Case2) TB case (How to prevent infection to other people)


(Case)

Case2)  35 year old,male
  The patient was pointed out the several 10`20 mm diameter nodules
in left upper lobe in his regular health check in his factory.
He came to the local local clinic hear his factory with the health check
report. The physician consulted him to the hospital to take chest CT.
CT report showed nodules with vomica and lung tuberculosis was highly
suspected. (see X-ray and CT in my Japanese Web pagej
  The physician of the local medical clinic referred the patient to the
hospital for tuberculosis because he worried about the discharge
of the tuberculous bacilli from the patient's cough.
  But the patient didn't go to the hospital. So the local physician
telephoned the patient 3 months later, and said that it should be needed
not only for your health but also for your family and coworkers in your
factory. But he said "I am well and my factory is very busy"
So the local medical doctor telephoned the manager of the factory about
his condition and the need of hospitalization. But the manager said "He
seemed health and I cannot force him the hospital admission."
  Three years later the local medical doctor saw 29 years old man who
worked in that factory. He came to the clinic with the report from the
public health center. The report said that the former patient was
finally admitted to the hospital for tuberculosis one month's ago.
The patient's sputum showed Gafky No 6.(highly risk of infection to
the neighbors ) and one family member and this 29 years old man's
tuberculin reaction was positive and the first infection was suspected
and therapy for tuberculosis should be started.
  The physician regretted he could not prevent the new case.

(Question)

1)What should this physician do 3 years ago?
2)In these days the human rights of the patient was respected, but the
human rights of the infected patient also should be respected.
3)In Japan the prevention of tuberculosis law cannot force the patient
to admission except for the case the tuberculosis sputum discharge
was probed. The community health nurse can visit the patient and advise
the patient to take therapy. But if the patient doesn't want to take
medication, there is no compulsory measure.
What do you do in these cases in your country?

1998.9.24.
Masashi Shirahama, M.D.
Director, Mitsuse National Health Insurance Clinic
Lecturer, Department of General Medicine, Saga MEdical School
2615 MItsuse, Kanzaki Gun, Saga Ken, 842-0301 Japan
HQC00330nifty.ne.jp



(Comment)

Thomas R. McCormick

Box 357120 UW School of Medicine
Seattle, WA 98195-7120

The case of the man with TB:
1) This reveals an important conflict--the rights of the individual,
versus the rights of the population-at-large.
2) In the doctor-patient relationship, the doctor must protect the
confidentiality of the patient in all cases, unless legal exceptions are
built into the law.
3) Because TB is infectious-air-borne illness, the public is at risk.
Therefore the doctor and (all of us) should seek to change public policy
(laws) so that the law mandates treatment, even if the patient doesn't
wish treatment. An alternative, if the patient is noncompliant, may be to
place the patient into an asylum where the public is protected.
4) In other words, this is a case-study that presents a compelling
argument for public health policy laws, especially in the days of
drug-resistant strains of TB and the risk to innocent people.
 



Tomoko Matsuo
(Ph.D.student in University Heidelberg.Germany,
Ph.D.student in Kyusyu university, Legal Philosophy)

Case 2  Patient's misunderstanding about his disease

Q 1

The doctor should have tried to harder three years ago to admit the
patient to hospital. Here the public health could be in danger. The
medical doctor is as we know responsible not only for the individual
patient but also for the public health. So he must protect the public
from its danger in terms of public health.

In this case, the problem lies not in the patient's autonomy but in
his misunderstanding or lack of understanding about his disease and
condition.So we have to scrutinize, what caused this kind of
misunderstanding. To consider it, two factors come up, one is the
doctor's way of explanation, the other is the patient's situation.

About the way and intent of explanation by the doctor we don't have
much information. According to the script it can be taken that the
doctor informed his patient of his doubt of tuberculosis, the
necessity of further examinations and the risk of infection of other
people around him.
In spite of this information the patient implicitly rejected the
doctor's instruction and didn't take further action. The manager also
did not put much weight on the doctor's information about his worker.
At first the question comes up if the explanation was adequate enough
to persuade the patient and his manager into undergoing further
examinations? Even if the patient was aware of the symptoms, even if
the company where he was employed was very busy, if he had felt his
health at stake, then naturally he would have gone into hospital. So
would the manager have agrred. Because they have their own interests
in it.

Secondly, we must search the other factor of misunderstanding.
Supposed that the doctor had informed his patient thoroughly ,
notwithstanding the patient didn't obey the doctor's instruction. For
what reason would the patient not go to the hospital? Here some
reasons can be considered, besause of his understanding capacity or
his financial situation, for example he has a family to be supported,
or reasons for what he can not be free from his work. However, the
doctor and other medical staff must look for the reasons for
patient's hesitation and make efforts to change his mind. The later
the treatment will be, the worse his general condition will get,
including his economical situation and the risk of infection to
others. It would be take more time and  more costs to cure his
disease. So it is necessary for the doctor to explain the condition
of the patient in the long run.

Further it comes to me, if and how the patient's family was informed
of his condition. The family could be influenced strongly in regard
to both, infection and house hold. The family members should know
about his disease, so they can do something to change the patient's
attitude.

Q 2

Endangered public health and right of patient to be respected

In this case the right of patient is confronted with the public
interest. Medical doctors must put fundamentally on the latter and
try to keep it from dangers, if it is at stake. Nevertheless, he can
not force his patient to obey treatment without legal authorizing.
However here he must be confronted with his duty of confidentiality.
On the other hand,  we must consider to avoid stigmatization of the
patient, for instance as in case of AIDS and hepatitis B and so on.
We have learned a lot from this kind of problem recently, haven't' we?
stigmatization is caused from lack of understanding about the disease
by public. When the doctor informs the third party in need, he must
consider danger of stigmatization and discrimination, and try to give
adequate information without unnecessary anxiety against the patient
in order to protect both the public health from its risk and patient
from severe disease and stigmatization.



Yoo-seock Cheong
Lecturer of Bioethics, Instructor of Department of family medicine, Dankook
university, College of Medicine, Korea

In the case of the 35 year old man with tuberculosis, there's
a major conflict between a person's autonomy and social
security.

A physician should usually respect his patient's decision, but
most moral principles don't approve ofdecisions that are harmful
to innocent people. In Korea, we do not have legal obligation to
treat these kinds of patients. There is only a duty to notify the
government when a physician detects some kinds of infectious
diseases.

Unfortunately, innocent victims resulted in this case.
In Korea, it is very important responsibility of factory managers
to keep their factory workers healthy. The factory manager in
this case may be blamed in our society. Physicians in Korea do
not have any compulsion to force their patients to be treated
against their will.

Personally, I think the most important point is a physician's
attitude in persuading his patient. If the patient was well
enough informed about his and his family's risk, he should be
blamed.



Howard Brody
Department of Family Practice and Center for Ethics and Humanities
in the Life Sciences, Michigan State University, East Lansing, MI USA.

I would have to do some research to find out the exact status of public health
law in the U.S. but it is my impression that in a case like this, the individual
could be impelled by law to be studied and to accept treatment. The factory
manager could not bypass this process. This apparent interference with the
rights of the individual is viewed as justifiable because of the direct danger to
the health of others, as the final outcome of this case so graphically illustrates.
The general theory of respect for autonomy, upon which the heavy emphasis
on the rights of the individual patient in U.S. ethical thinking is based, makes
an important distinctions between self-regarding and other-regarding personal
decisions. It is generally felt that when I am making a decision which has
consequences principally for me alone, then no one should interfere with my
right to make and carry out that decision. But when my decision has important
consequences for others, and could cause them serious harm, then my "right"
to non-interference is no longer worthy of respect. (It seems obvious that the
distinction is not hard and fast and that many decisions are somewhere in
between the extremes of "self-regarding" and "other-regarding." How ethical
decisions are made within families might be an important area where this
distinction breaks down.)



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