Case Study 2

Chris van Buren is a 29-year-old man who returned to Toronto from a trip to South Africa eight
months ago. Shortly after returning, he developed a cough, fever, and weight loss. After
extensive medical tests, he was diagnosed with multi-drug resistant (MDR) tuberculosis (TB).
After a period of treatment in hospital, he was released to continue treatment at home for at least
another six months. His treatment consists of a burdensome regime of four different antibiotics.
He has been instructed not to leave the house until tests confirm that his sputum is clear of all
traces of TB.
From the start, there have been issues with Chris’s compliance with his treatment. In hospital he
repeatedly left his room without permission to smoke cigarettes outside. At one point, hospital
staff posted a security guard outside his room. After release, he has been observed twice in a
local shopping mall. Because Chris lives alone, public health officials have arranged for daily
delivery of food and medication. In his defence, Chris noted that he needed to buy clothes and
that he was careful to wear a mask to avoid infecting others. The public health officer is
considering ordering that Chris be detained in a locked hospital ward until his treatment is
completed.
MDR TB is tuberculosis that is resistant to at least two drugs in the standard treatment regimen.
As a result, it is treated with more expensive second-line drugs that are associated with more side
effects. Additionally, it may require treatment for longer periods to ensure that the TB is
eliminated. Public health officials are anxious to prevent the spread of drug-resistant TB in the
community because of the difficulty in treating it and the worry that fully resistant strains of TB
may emerge.

Question 1:
What moral question do you think most important in this case? Phrase this as a question in
your response. Your question should focus on the ethics of the case (rather than medical details,
legal questions, etc.). Information from Module 1 will help you develop a moral question. This
should be one sentence/question.

Is it ethical for Chris to be ordered by public health officials to be in a locked hospital ward to
ensure compliance of his treatment, considering the potential risk to public health by his actions
and his own rights?

Question 2:
What is your position on the moral question you described above? Provide your thesis
statement which directly responds to the moral question and clearly expresses your view, which
will frame your following analysis. This should be one sentence.

In this case, it is ethically justifiable for Chris to be detained in a locked hospital ward
considering it is essential to protect the public’s health, reduce the risk of transmission of MDR
tuberculosis, and ensure the effectiveness of Chris’s treatment, regardless of the limitations on
Chris’s freedom.
Question 3:
Select two of the following concepts that you think are important to defending your thesis as
stated above. Define these terms in your own words, using our textbook and course materials to
support your descriptions when needed. For each term, you might write a few sentences.
The terms you can choose from are: Public health, nudging, paternalism, libertarianism, negative
rights, positive rights

The first concept I believe is present in this case and will help to prove my thesis statement is
Public Health. Public health is focused on preventing illness and promoting the wellbeing in
populations, not individuals. Relating to our case, by detaining Chris in a locked hospital ward
this is helping to assure the health of the public by protecting them against the transmission of
MDR tuberculosis due to Chris not isolating himself as instructed throughout his treatment.
Assuring public health is a group effort amongst the government and populations themselves
(Fice Module 9, p. 4). As learned in Module 8 of our course, public health initiatives are
preventative and protective, both of which apply to keeping Chris in a locked hospital ward.
Doing so protects the public around Chris and prevents transmission of the disease (Fice Module
8, p. 3).

The second concept in this case is nudging. Even though it can be heavily argued that nudging is
morally unethical due to its’ effect on a person’s autonomy, as explained in our course module,
Navin argues that nudging can be justified if the benefits outweigh opposing on a person’s
autonomy (Fice Module 8, p. 12). Nudging is a concept where someone’s autonomous decisions
are influenced by changing the environment in order to guide someone to make a certain
decision (Fice Module 8, p. 12). In this case nudging could be argued as morally permissible due
to the fact that the benefits of nudging Chris to stay home and away from the public outweighs
his autonomous decisions to go to the mall and buy clothes for himself. Nudging could be
beneficial in this case, as if it is successful and Chris stays home, this would prevent from public
health officials detaining Chris in a locked hospital ward. Examples of nudging in this case could
include informing Chris on the risks of not complying to his treatment plan, how dangerous for
the public it could be that he doesn’t stay home and explaining how completing the treatments
successfully will be beneficial for him eventually, even if it is hard now.

Question 4:
Do you think a libertarian might use something like Brennan’s clean hands principle to argue
in favour of detaining Chris? Why or why not? Explain the principle and whether it might be
applied in this case. Briefly explain whether you think this supports or opposes your own thesis.
Aim to respond in about two paragraphs.

Libertarianism emphasizes someone’s negative rights. Negative rights are seen as a person’s
freedoms or liberties and are protected against interference from others, including the
government (Fice Module 8, p. 7). Basically, negative rights focus around removing constraints
on a person’s actions. Even though detaining Chris goes against his negative rights, which
Libertarians would usually not support, they may be inclined to adopt Brennan’s clean hand
principle in this case study. This is because Brennan’s clean hand principle implies that there is
sometimes moral obligation not to participate in collectively harmful activities or unacceptable
risks of harm (Schulenk et all, 264). Therefore, I believe Libertarians would use Brennan’s clean
hand principle in this case because the actions taken by Chris does not benefit society and instead
imposes risk of harm.

I believe Brennan’s clean hand principle supports my thesis because it provides valuable
reasoning as to why Chris should be detained in a locked hospital ward throughout his treatment.
Even though it goes against Chris’s negative rights, it is justified by the fact that it is keeping the
health of the public safe and preventing harm onto others. Brennan’s clean hand principle
explains how ethical considerations must be considered always even in situations where
someone’s freedom or autonomy is restricted, such as this case with Chris. In arguing in favour
of Chris’s detention in a locked hospital ward, the clean hand principle emphasizes that the
benefits to society outweigh the restrictions on Chris’s freedom throughout his treatment.
Therefore, the detention of Chris in this case is not just about ignoring Chris’s negative rights,
but instead, is considered necessary and an appropriate response to a potential threat to public
health. A Libertarian would be in favour that the clean hand principle in this case reinforces the
idea that ethical decisions should prioritize the greater good.

Question 5:
Could public health officials nudge Chris to stay home instead of detaining him in a hospital
ward? What might that nudge look like in this case, from your perspective? Do you think a
nudge would be a more ethical alternative? At what point do you think public health officials
might be justified in intervening more, beyond just a nudge? Reflect on some of these questions
in two paragraphs.

I believe public health officials could nudge Chris to stay home and adhere to his treatment plan
rather than detaining him. If the nudges were successful. A nudge in this case could be providing
Chris with education or persuasive information about how it would be beneficial for Chris to stay
home, the risks that could be caused by his non-compliance, and how it could harm the health of
the public around him if he kept leaving home. Officials could ensure supports were in place for
Chris including regular check ins form healthcare workers, beyond just dropping him of
necessities, providing an online counseling service to provide support to him and to reinforce the
positive reasonings behind Chris staying home. Providing positive reinforcement could also
nudge Chris towards complying with his treatment plan.

In this case nudging could be considered a more ethical alternative, considering it is less abrasive
and harsh in terms of influencing Chris’s behaviour, compared to detention. Nudging would be
more respectful to Chris’s autonomy while still encouraging compliance to the treatment plan.
However, if nudging is unsuccessful and Chris’s non-compliance continued to pose increased
risk of harm to the public, I believe it is justified for public health officials intervening more
drastically. Including detaining Chris in a locked hospital ward. It is necessary to weigh out the
risk and benefit in respecting individual freedom and protecting the health of the public, affected
by the severity of the threat and the effectiveness of lesser alternatives.
Question 6:
In this case study, we saw that treatments for multi-drug resistant tuberculosis are expensive.
Indeed, the Centre for Disease Control (CDC) writes that the cost for treating MDR TB can
range from $20,000 to $500,000. In Module 9, we discussed whether there is a right to health
care. We saw that, if we think there is such a right, there might be a social obligation to provide
people with some form of health care. But not everyone agrees such a right exists. Do you think
that the cost of Chris’s treatment of MDR TB should be covered by a publicly funded health care
system? Use one of the readings from Module 9 to support your view, making sure to summarize
the relevant argument(s). Provide a response in about a paragraph or two.

As a person with a deep sense of empathy and compassion for others I feel that Chris’s treatment
should be covered by the publicly funded health care system. As such an expensive treatment
may be unattainable for Chris. As well as, ensuring Chris receives the proper treatment also
helps to protect the public by ensuring the disease is controlled and not transmitted throughout
the community Chris lives in. As explored in our textbook reading, the Commission, who are the
Presidents for the study of Ethical Problems, argue four distinct points that give health care its
special importance. 1. Well-being 2. Opportunity 3. Information 4. The interpersonal and social
importance of healthcare (Fice Module 9, p. 7). Following these points presented by the
Commission, Chris is entitled to wellbeing which is promoted by preventing or relieving pain,
suffering or illness (Fice Module 9, p. 7). Therefore, providing the treatment to Chris’s MDR
tuberculosis, we are supporting Chris’s wellbeing. Secondly, by providing the expensive
treatment for Chris we are also supporting Chris’s ability for opportunity. Once he is treated, he
will be able to live a normal life again, without restrictions. Third, providing Chris information
towards his treatment may help Chris to refrain from going outside of his home, protecting the
public as well as Chris. Fourth, the social importance of healthcare shows the solidarity in the
face of suffering and death (116). Meaning, that because all human beings are vulnerable and all
humans are at risk to suffering from illness, pain and eventually death, healthcare acts as an
outlet to expressing empathy and compassion to one another (Fice Module 9, p. 7). Therefore,
providing Chris the treatment through publicly funded health care, we as a community are
working together to better the lives of others by alleviate the suffering of those in need (Fice
Module 9, p. 7). It is a positive thing for the community in many ways.

Question 7:
Pick one of your answers to any question above and try to imagine a possible objection that
someone might raise against an element of your argument. We’re assuming that person is
reasonable and charitable and has a strong objection to something you’ve said. In your answer
here, explain what part of your answer the objection targets. Then, describe the objection and
how it poses a problem for some element of one of your answers. Finally, you will give a
response to that objection in defense of your view and thesis overall. Provide your answer in
about two paragraphs.

This objection is aimed towards my answer in question 6 that based off empathy, compassion
and solidarity Chris is not entitled to publicly funded healthcare to treat his MDR tuberculosis.
The person argues that although the characteristics of empathy and compassion are admirable in
healthcare, they should not be the basis for treating Chris. They argue individuals who put
themselves at risk, such as the case in traveling to another country unvaccinated, should be
responsible for their own healthcare and treatment costs, especially when those treatments are so
expensive and could put undue strain on the public healthcare system. They also arguing that
allocating so much money towards Chris’s treatment takes away from the resources that other
people in the community could benefit from. This argument poses a problem in my statement
above suggesting that providing the treatment for Chris will help to alleviate his suffering as well
as others in need. This is because, providing these funds may instead increase suffering for
someone else. This could be caused by the steep funds going to Chris and redirecting them out of
someone else’s hands. Maybe the cost of Chris’s treatment means someone else will be unable to
afford theirs due to resource allocation challenges in the system.

I argue, as someone in favour of providing Chris the expensive treatment through public funding,
by emphasizing the societal benefits in this case. Again, there is a scale present in this case. Both
risks are present with the further transmission of disease or resource challenges in the
community. This isn’t just an issue regarding compassion and empathy amongst the community.
By providing the treatment for Chris we are working as a community to ensure health risks are
minimized. It’s important to create an equal society where everyone, regardless of economic
status, has access to the necessary medical care. By supporting Chris’s treatment, it is not just an
empathetic approach but a realistic one. It is imperative that the public is protected by further
transmission of MDR tuberculosis. By investing in the health of individuals we contribute to the
overall wellbeing of the population.

Question 8:
Based on your responses to the questions above, conclude the assignment by articulating
what you think we should do in a case like this one. Give some reasons to support your view.
You can refer back to some of your previous answers to support your view. Aim to defend your
thesis in about a paragraph.

I believe we should detain Chris in the locked hospital ward for both his safety and the publics.
Due to MDR tuberculosis being contagious to others and dangerous to Chris’s health, it is very
important for Chris not to be leaving his home and entering into public settings. Especially if the
very expensive treatment is being provided by public funding for Chris, it acts as an incentive
for Chris to respect the strict regimen of the treatment. While it is important to recognize the
restrictions of Chris’s freedom and rights, the risk to the community, which is the larger group
in this case, outweighs the limitations. In this case, a temporary restriction to Chris as an
individual can be seen as the more reasonable and responsible measure to balance the risks
and the welfare of the community and Chris’s health.