Bovine tuberculosis is the most economically important animal health policy issue in Britain. The problem of what to do about badgers has plagued successive governments since a dead badger was discovered with bovine TB in 1971. Successive Labour governments oversaw the Randomised Badger Culling Trial from 1998 to 2006. Despite the RBCT recommendation against culling, the 2010–2015 Coalition government implemented pilot badger culls. This paper provides an account of the evolution of bovine TB and badger control policy, focusing on (...) the 1997–2010 Labour, the 2010–2015 Coalition and the 2015-present Conservative governments. Interviews with bovine TB policy stakeholders supplement discussion of the development of bovine TB policy. The paper discusses the science and politics of bovine TB policy, in which there are different badger control policies in Westminster, Welsh and Scottish governments. Badger control is a highly polarised issue, and the Coalition and Conservative governments have been heavily criticised for a culling policy opposed by the independent scientific community. Recent governments have defended badger culling on the basis of veterinary advice and experience in countries such as New Zealand. The paper concludes with two key recommendations to inform controversial animal health and welfare policy issues such as bovine TB. First, mandatory Animal Welfare Impact Assessment provides objective data on the impacts of policy options on cows and badgers. Second, robust ethical analysis, conducted by independent experts using established moral frameworks, should be applied to animal health and welfare issues for the benefit of decision makers. (shrink)

Bovine tuberculosis is an important animal health policy issue in Britain, which impacts farmers, the public, domestic farmed cattle and the wild badger population. The Westminster government’s badger culling policy in England, which began in 2013, has caused considerable controversy. This is in part because the Independent Scientific Group advised against culling, based on the Randomised Badger Culling Trial. Those opposed to badger culling support more stringent cattle-based measures and the vaccination of badgers. This paper argues for ethical analysis (...) of public policy options which impact sentient species. It provides a summary Animal Welfare Impact Assessment of a do-nothing approach, badger culling, and badger vaccination. A utilitarian analysis is then applied to these policy options considering human wellbeing and animal welfare. The analysis compares a badger culling policy that achieves a 19% reduction in bovine TB incidence, a badger vaccination model achieving a 12.5% reduction, and a do-nothing approach. Policy options are assessed over 9 years and a longer timeframe, and uncertainty is considered. The analysis finds that non-culling approaches, particularly badger vaccination, result in greater total utility, compared to badger culling. Badger culling causes 30% reduction in the badger population in England as well as substantial harms due to the culling process. Culling is opposed by public opinion and is associated with considerable risks and uncertainty. In contrast, non-culling approaches, such as cattle-based measures and badger vaccination, are supported by public opinion and are not associated with such risks. (shrink)

Bovine tuberculosis is the most important animal health and welfare policy issue in Britain. Badgers are a wildlife reservoir of disease, although the eight-year Independent Scientific Group Randomised Badger Culling Trial concluded with a recommendation against culling. The report advised government that bovine TB could be controlled, and ultimately eradicated, by cattle-based measures alone. Despite the ISG recommendation against culling, the farming and veterinary industries continued to lobby government for a badger cull. The 2005–2010 Labour government followed the ISG (...) advice and decided against a cull. The 2010–2015 Coalition and the 2015-present Conservative governments have followed a badger culling policy. This paper investigates whether a virtuous government would cull badgers. It provides an overview of virtue theory in the context of government animal health and welfare policy. Bovine TB and badger control policy options are then analysed in the context of the virtues of justice, wisdom, integrity, loyalty, curiosity, trust, empathy, compassion and aesthetics. Justice is the first virtue of government, and badger culling is seriously problematic from a virtue perspective given that five badgers are culled per cow that avoids slaughter as a result. Analysis based on other virtues strongly suggests that government should not cull badgers. The paper concludes that a virtuous government would not cull badgers as part of policy to control bovine TB in cattle. (shrink)

Bovine tuberculosis is an important and controversial animal health policy issue in England, which impacts humans, cattle and badgers. The government policy of badger culling has led to widespread opposition, in part due to the conclusions of a large field trial recommending against culling, and in part because badgers are a cherished wildlife species. Animal rights theorists argue that sentient nonhumans should be accorded fundamental rights against killing and suffering. In bovine TB policy, however, pro-culling actors claim that badgers (...) must be culled to avoid the slaughter of cattle. The first part of the paper compares AR theories of Regan, Francione, Cochrane, Garner and Donaldson and Kymlicka in the context of wildlife species. The second part of the paper applies these AR theories to bovine TB and badger control. AR theories are applied to badger control policy options of do nothing, badger culling, and badger vaccination. We conclude that AR theories are strongly opposed to badger culling. In general, culling is prohibited due to a badger’s right to life and its rights against suffering. The AR theories support a do-nothing, i.e. non-culling, non-vaccination approach to badger control. In the case of the AR theories of Regan and Francione, this is based on abolitionist positions with respect to farming. For Cochrane, Garner, and Donaldson and Kymlicka, the do-nothing policy option is preferred because badger vaccination causes a degree of suffering which generally is not for the individual’s benefit. (shrink)

Tuberculosis en América Latina y el Caribe: reflexiones desde la bioética Tuberculose na América Latina e no Caribe: reflexões da bioética The objective of this article is to analyze the conditions of access to health services by people with tuberculosis in Latin America and the Caribbean, reflecting on the public health aspects involved from a bioethical perspective. A literature review of the context of tuberculosis in LAC based on epidemiological data was performed. The results were analyzed from (...) its relationship with the social determinants of health and the ethical principles that guide medical practice. Tuberculosis is a pressing public health problem in the region because of its family, social, economic and health impact. It mainly affects vulnerable individuals and populations. Health services violate ethical principles. Tuberculosis is a serious ethics and public health problem in the region that causes death, disability and increased poverty. It is imperative to ensure the right to health services and to understand the individual and public health consequences of non-adherence to treatment. It is important that national tuberculosis control strategies include principles of dignity and non-discrimination of the sick, changes in the social determinants of the disease, and respect for the ethnicity, language culture and identity of patients. Para citar este artículo / To reference this article / Para citar este artigo Muñoz del Carpio-Toia A, Sánchez-Pérez HJ, Verges de López C, López-Dávila LM, Sotomayor-Saavedra MA, Sorokin P. Tuberculosis en América Latina y el Caribe: reflexiones desde la bioética. pers. bioét. 2018; 22: 331-357. DOI: 10.5294/pebi.2018.22.2.10. (shrink)

CAPPE LPO Box 8260 ANU Canberra ACT 2601 Australia Tel: +61 (0)2 6125 4355, Fax: +61 (0)2 6125 6579; Email: michael.selgelid{at}anu.edu.au ' + u + '@' + d + ' '//--> Abstract This article reviews ethically relevant history of tuberculosis and recent developments regarding extensively drug resistant tuberculosis (XDR-TB). It argues that tuberculosis is one of the most important neglected topics in bioethics. With an emphasis on XDR-TB, it examines a range of the more challenging ethical issues (...) associated with tuberculosis: individual obligations to avoid infecting others, coercive social distancing measures, third-party notification, health workers' duty to treat contagious patients, and international justice. In each of these cases, key philosophical questions are highlighted and the need for empirical research/information is demonstrated. CiteULike Connotea Del.icio.us What's this? (shrink)

Coercion, the act of compelling someone to do something by the use of power, intimidation, or threats, has been deemed a necessary weapon in the public health armamentarium since before public health fell under the remit of physicians and out of the grip of “sanitarians” and civil engineers. This article examines the ethics of detention in the pursuit of public health and uses a contemporary example, detention of poorly compliant individuals with tuberculosis, to highlight the moral dilemmas posed, and (...) examine whether recently proposed approaches are just. In particular I focus upon the public health response to non-infectious individuals who fail to comply with treatment . Our response to them helps clarify contemporary attitudes to recalcitrant, often marginalised, individuals who pose an uncertain threat.Globally tuberculosis control is failing. The World Health Organisation recently called this public health threat a global emergency.1 Transmission occurs through often casual contact from individuals who have pulmonary disease. Although there is much that is uncertain regarding the infectiousness of this ancient disease, we do know that those who are smear-positive, that is who have organisms of Mycobacterium tuberculosis visible in stained respiratory secretions, are considerably more infectious than those who do not.2, 3 Compliance with effective treatment rapidly makes previously infectious patients non-infectious. Standard treatment for fully drug-sensitive tuberculosis usually lasts for six months. Erratic adherence to chemotherapy, however, may result in relapse and the development of drug-resistant disease which is considerably more difficult to treat.In the 1980s and early 1990s New York City witnessed an epidemic of tuberculosis and, of particular concern, a marked increase in drug-resistant and multidrug-resistant strains. In the early 1990s the threat of a virtually untreatable, casually communicable, …. (shrink)

During the mid-nineteenth century the annual tuberculosis mortality in the penitentiaries at Auburn, N.Y., Boston, and Philadelphia exceeded 10 percent of the inmate population. At the beginning of the sanatorium era, 80 percent of the prison deaths were attributed to TB. As the mountain air was “commonly known” to be healthful, the first prison sanatorium was opened in the mountains near Dannemora, N.Y. in 1904. It served to isolate contagious prison inmates until the advent of effective chemotherapy for the (...) disease in the 1950’s. Early antibiotic therapy for TB was such a great success that the public health aspects of TB in prisons remained dormant for the next 40 years.In 1991, a correctional officer from Auburn Correctional Facility in Auburn, New York died as a result of multidrug-resistant TB. He had been posted to care for hospitalized patients, from whom he acquired his disease. This death, and the transmission of TB infection to health care workers in the same hospital, brought the nature and extent of modern inmate medical care into finer focus. (shrink)

During the mid-nineteenth century the annual tuberculosis mortality in the penitentiaries at Auburn, N.Y., Boston, and Philadelphia exceeded 10 percent of the inmate population. At the beginning of the sanatorium era, 80 percent of the prison deaths were attributed to TB. As the mountain air was “commonly known” to be healthful, the first prison sanatorium was opened in the mountains near Dannemora, N.Y. in 1904. It served to isolate contagious prison inmates until the advent of effective chemotherapy for the (...) disease in the 1950’s. Early antibiotic therapy for TB was such a great success that the public health aspects of TB in prisons remained dormant for the next 40 years.In 1991, a correctional officer from Auburn Correctional Facility in Auburn, New York died as a result of multidrug-resistant TB. He had been posted to care for hospitalized patients, from whom he acquired his disease. This death, and the transmission of TB infection to health care workers in the same hospital, brought the nature and extent of modern inmate medical care into finer focus. (shrink)

Conocida esta enfermedad por el nombre de tisis, algunos países tenían registros de las muertes producidas por la tuberculosis, aunque después de la revolución industrial del siglo XVIII, se hicieron frecuentes los registros debido a la alta mortalidad. Las causas fueron varias: las malas condiciones de trabajo, las casas insalubres y atestadas de seres humanos, la dieta poco variada, entre otras. Se va a definir la imagen idealizada de la tuberculosis por el estudio de diversos poemas de autores (...) que plasmaron el pensamiento general de esa época, un muestreo de una enfermedad que se sigue manifestando, pero sin el concepto añadido de belleza romántica. (shrink)

This paper explores the notion of reciprocity in the context of active pulmonary and laryngeal tuberculosis treatment and related control policies and practices. We seek to do three things: First, we sketch the background to contemporary global TB care and suggest that poverty is a key feature when considering the treatment of TB patients. We use two examples from TB care to explore the role of reciprocity: isolation and the use of novel TB drugs. Second, we explore alternative means (...) of justifying the use of reciprocity through appeal to different moral and political theoretical traditions. We suggest that each theory can be used to provide reasons to take reciprocity seriously as an independent moral concept, despite any other differences. Third, we explore general meanings and uses of the concept of reciprocity, with the primary intention of demonstrating that it cannot be simply reduced to other more frequently invoked moral concepts such as beneficence or justice. We argue that reciprocity can function as a mid-level principle in public health, and generally, captures a core social obligation arising once an individual or group is burdened as a result of acting for the benefit of others. We conclude that while more needs to be explored in relation to the theoretical justification and application of reciprocity, sufficient arguments can be made for it to be taken more seriously as a key principle within public health ethics and bioethics more generally. (shrink)

Research Ethics, Volume 18, Issue 4, Page 265-280, October 2022. Concerns around comprehension and recall of consent information by research participants have typically been associated with low health and research literacy levels. In genomics research, this concern is heightened as the scientific and ethical complexities of genetics research, such as biobanking, genetic susceptibility, data sharing, and incidental findings may be more difficult for potential research participants to understand. However, challenges to research participants’ comprehension of consent information may be compounded by (...) factors beyond health and research literacy levels. To identify factors that may impact research participants’ understanding and recall of consent information, we designed a qualitative study to explore whether participants enrolled in a tuberculosis genetics study in Cameroon understood the objectives of the study, the risks and benefits and certain key aspects of the study such as biobanking and data sharing. The results showed that research participants had limited understanding and/or recall of the TBGEN-Africa study goals and methods. Some participants were of the opinion that TBGEN-Africa was not a genetics study because tuberculosis is not an inheritable condition. Factors that may have hindered understanding and/or recall of study information are diagnostic misconception, and information overload and situational vulnerability. There is a need for improved practices to support research participants’ understanding of consent information in genetics studies including designing the consent process in ways that minimize psychological distress and diagnostic/therapeutic misconception. (shrink)

In little more than a decade, the AIDS epidemic has exerted a profound effect on morbidity and mortality among young adults and children in many parts of the world. One of the more dramatic aspects of AIDS is that it seems to have arisen almost spontaneously as a new epidemic, spreading rapidly within at-risk populations in a way that is unprecedented for the serious infectious diseases of recent memory. Tuberculosis, on the other hand, had only recently been considered a (...) disease of historical importance but of diminishing relevance to current public health priorities, especially in industrialized countries. Over the past decade, however, and in parallel with the AIDS epidemic, there has been a resurgence of tuberculosis in many of the same populations most affected by HIV infection. This has had important implications for clinical practice, public health, and the development of appropriate health policy. A number of elements have converged to promote the development of HIV-related tuberculosis, including biologic, social, and environmental factors. These will be discussed both to provide a context for understanding the relationship between the two epidemics, and as a basis for suggesting strategies for tuberculosis control in the AIDS era. (shrink)

In little more than a decade, the AIDS epidemic has exerted a profound effect on morbidity and mortality among young adults and children in many parts of the world. One of the more dramatic aspects of AIDS is that it seems to have arisen almost spontaneously as a new epidemic, spreading rapidly within at-risk populations in a way that is unprecedented for the serious infectious diseases of recent memory. Tuberculosis, on the other hand, had only recently been considered a (...) disease of historical importance but of diminishing relevance to current public health priorities, especially in industrialized countries. Over the past decade, however, and in parallel with the AIDS epidemic, there has been a resurgence of tuberculosis in many of the same populations most affected by HIV infection. This has had important implications for clinical practice, public health, and the development of appropriate health policy. A number of elements have converged to promote the development of HIV-related tuberculosis, including biologic, social, and environmental factors. These will be discussed both to provide a context for understanding the relationship between the two epidemics, and as a basis for suggesting strategies for tuberculosis control in the AIDS era. (shrink)

“Recognizing that prisons disproportionately confine sick people, with mental illness, substance abuse, HIV disease among other illnesses; and that prisoners are subject to further morbidity and mortality in these institutions, due to lack of access and/or resources for health care, overcrowding, violence, emotional deprivation, and suicide.… condemns the social practice of mass imprisonment.”After decades of steady decline, tuberculosis has emerged as a significant public health threat in the United States. The rising rates of tuberculosis cases, an increasing proportion (...) of which are resistant to standard chemotherapies, are linked to the many scourges threatening our communities: the explosion of poverty, drug use, violence, the HIV epidemic, and the concomitant rise in congregate housing including homeless shelters, residential drug treatment programs and incarceration facilities. Jails and prisons have disproportionately high rates of tuberculosis infection and have been implicated as points of tuberculosis spread and, as such, are a critical point for tuberculosis control interventions. (shrink)

A striking and unexplained feature of granulomatous inflammation is its anatomical association with the lymphatic system. Accumulating evidence suggests that lymphatic tracks and granulomas may alter the function of each other. The formation of new lymphatics, or lymphangiogenesis, is an adaptive response to tumor formation, infection, and wound healing. Granulomas also may induce lymphangiogenesis which, through a variety of mechanisms, could contribute to disease outcomes in tuberculosis and sarcoidosis. On the other hand, alterations in lymph node function and lymphatic (...) draining may be primary events which attenuate the risk and severity of granulomatous inflammation. This review begins with an introduction of granulomatous inflammation and the lymphatic system. A role of the lymphatic system in tuberculosis and sarcoidosis is then hypothesized. With a focus on lymphangiogenesis in these diseases, and on the potential for this process to promote dissemination, parallels are established with the well‐established role of lymphangiogenesis in tumor biology. (shrink)

Reflecting on his scientific career toward the end of his life, the French-educated medical researcher René Dubos presented his flowering as an ecological thinker as a story of linear progression—the inevitable product of the intellectual seeds planted in his youth. But how much store should we set by Dubos’s account of his ecological journey? Resisting retrospective biographical readings, this paper seeks to relate the development of Dubos’s ecological ideas to his experimental practices and his career as a laboratory researcher. In (...) particular, I focus on Dubos’s studies of tuberculosis at the Rockefeller Institute in the period 1944–1956—studies which began with an inquiry into the tubercle bacillus and the physiochemical determinants of virulence, but which soon encompassed a wider investigation of the influence of environmental forces and host–parasite interactions on susceptibility and resistance to infection in animal models. At the same time, through a close reading of Dubos’s scientific papers and correspondence, I show how he both drew on and distinguished his ecological ideas from those of other medical researchers such as Theobald Smith, Frank Macfarlane Burnet, and Frank Fenner. However, whereas Burnet and Fenner tended to view ecological interactions at the level of populations, Dubos focused on the interface of hosts and parasites in the physiological environments of individuals. The result was that although Dubos never fully engaged with the science of ecology, he was able to incorporate ecological ideas into his thought and practices, and relate them to his holistic views on health and the natural harmony of man and his environment. (shrink)

Approximately one in two hundred persons in the Marshall Islands have active tuberculosis. We examine the historical antecedents of this situation in order to assign ethical responsibility for the present situation. Examining the antecedents in terms of Galtung’s dialectic of personal versus structural violence, we can identify instances in the history of the Marshall Islands when individual subjects made decisions with large-scale ecologic, social, and health consequences. The roles of medical experimenters, military commanders, captains of the weapons industry in (...) particular, and industrial capitalism in general are examined. In that, together with Lewontin, we also identify industrial capitalism as the cause of tuberculosis, we note that the distinction between personal versus structural violence is difficult to maintain. By identifying the cause of the tuberculosis in the Marshall Islands, we also identify what needs be done to treat and prevent it. (shrink)

This paper argues for the inclusion of ethnography as a research methodology for understanding the effects of public health policy. To do this, the implementation of DOTS (Directly Observed Therapy, Short-course) is explored in the context of Nepal. A brief history of DOTS and its implementation in Nepal is outlined, and the way it has been represented by those within the Nepal Tuberculosis Programme (NTP) is described. This is followed by an outline of the research done in relation to (...) this, and the ethnographic methods used. These ethnographic data are then interpreted and analysed in relation to two specific areas of concern. Firstly, the effects around the epidemiological uses of is explored; it is argued that a tightening of the definitional categories so necessary for the programme to be stabilized for comparative purposes has profound material effects in marginalizing some from treatment. Secondly, the paper examines some of the implications and effects relating to the way that the component was implemented. The discussion explores how current debate on DOTS has been played out in some medical journals. It argues for the importance of ethnography as a method for understanding certain questions that cannot be answered by particular, and increasingly dominant, research ideologies informed by randomized controlled trials. This raises important issues about the nature of in debates on the relationship of research to policy. (shrink)

From the mid nineteenth to mid twentieth century sanatoria loomed large in the popular consciousness as the space for the treatment of tuberculosis (TB). A review of the historiography of sanatoria at the beginning of this paper shows that the nursing contribution to the care of TB patients is at best ignored and at worst attracts negative comment. Added to this TB nursing was not viewed as prestigious by contemporaries, leading to problems attracting recruits. Using a case study approach (...) based on surviving archival material, this paper sets out to provide a glimpse of the work of TB nurses in a rural sanatorium at Westwood, Queensland, Australia. For the nurses geographical isolation was compounded by professional stagnation, which created a working environment influenced by friction and discord among the staff. It reveals how despite this, nurses coped with working in hostile conditions, to make the long stay of their patients, separated from their families and familiar life style more bearable. (shrink)

Mycobacterium tuberculosis is the causative agent of pulmonary tuberculosis which has infected one third of the mankind and causes 2–3 million deaths worldwide each year. The persistence of the infection ensues from the ability of M. tuberculosis to subvert host immune responses in favor of survival and growth of mycobacteria in macrophages. The mechanisms by which M. tuberculosis manipulates the host immune system have only recently come to light. These activities are attributed to lipoarabinomannans (LAM) and (...) their precursors lipomannans (LM), two predominant glycolipids of M. tuberculosis cell wall. LM are able to skew anti‐mycobacterial immune responses into un‐protective ones, while LAM evoke immunosupression upon binding to macrophage and dendritic cell receptors specialized in binding to “self” host components. A newly emerging idea implicates plasma membrane rafts in LM and LAM signaling. Depending on acylation patterns, the glycolipids may either directly incorporate into the raft membrane via mannosylphosphatidylinositol anchors or interact with raft‐associated proteins to affect the assembly of receptor signaling complexes. BioEssays 30:943–954, 2008. © 2008 Wiley Periodicals, Inc. (shrink)

We extend recent conversation about the ethics of human challenge trials to tuberculosis (TB). TB challenge studies could accelerate vaccine development, but ethical concerns regarding risks to trial participants and third parties have been a limiting factor. We analyse the expected social value and risks of different challenge models, concluding that if a TB challenge trial has between a 10% and a 50% chance of leading to the authorisation and near-universal delivery of a more effective vaccine 3–5 years earlier, (...) then the trial would save between 26 400 and 1 100 000 lives over the next 10 years. We also identify five important ethical considerations that differentiate TB from recent human challenge trials: an exceptionally high disease burden with no highly effective vaccine; heightened third party risk following the trial, and, partly for that reason, uniquely stringent biosafety requirements for the trial; risks associated with best available TB treatments; and difficulties with TB disease detection. We argue that there is good reason to consider conducting challenge trials with attenuated strains like Bacillus Calmette-Guérin or attenuatedMycobacterium tuberculosis. (shrink)

Reflecting on his scientific career toward the end of his life, the French-educated medical researcher René Dubos presented his flowering as an ecological thinker as a story of linear progression—the inevitable product of the intellectual seeds planted in his youth. But how much store should we set by Dubos’s account of his ecological journey? Resisting retrospective biographical readings, this paper seeks to relate the development of Dubos’s ecological ideas to his experimental practices and his career as a laboratory researcher. In (...) particular, I focus on Dubos’s studies of tuberculosis at the Rockefeller Institute in the period 1944–1956—studies which began with an inquiry into the tubercle bacillus and the physiochemical determinants of virulence, but which soon encompassed a wider investigation of the influence of environmental forces and host–parasite interactions on susceptibility and resistance to infection in animal models. At the same time, through a close reading of Dubos’s scientific papers and correspondence, I show how he both drew on and distinguished his ecological ideas from those of other medical researchers such as Theobald Smith, Frank Macfarlane Burnet, and Frank Fenner. However, whereas Burnet and Fenner tended to view ecological interactions at the level of populations, Dubos focused on the interface of hosts and parasites in the physiological environments of individuals. The result was that although Dubos never fully engaged with the science of ecology, he was able to incorporate ecological ideas into his thought and practices, and relate them to his holistic views on health and the natural harmony of man and his environment. (shrink)

TB human challenge studies could accelerate TB vaccine development by reducing uncertainty in early-stage vaccine testing, selecting promising vaccine candidates for large-scale field trials, and identifying an immune correlate of protection. However, ethical concerns regarding the exposure of trial participants and bystanders to significant risk have been a limiting factor for TB human challenge models. We analyze the expected social value and risks of different types of TB human challenge models, and conclude that given the massive public health burden of (...) TB, challenge models with even scant probabilities of expediting TB vaccine authorization have enormous expected humanitarian value, saving between 33,000 and 1,375,000 lives over the next ten years. We argue that attenuated M.tb challenge trials can be conducted ethically, and discuss the benefits and drawbacks of conducting virulent M.tb challenge trials. (shrink)

This article critically examines current responses to multi-drug resistant tuberculosis and argues that bioethics needs to be willing to engage in a more radical critique of the problem than is currently offered. In particular, we need to focus not simply on market-driven models of innovation and anti-microbial solutions to emergent and re-emergent infections such as TB. The global community also needs to address poverty and the structural factors that entrench inequalities—thus moving beyond the orthodox medical/public health frame of reference.

With attention to the experiences, agency, and rights of tuberculosis patients, this symposium on TB and ethics brings together a range of different voices from the social sciences and humanities. To develop fresh insights and new approaches to TB care and prevention, it is important to incorporate diverse perspectives from outside the strictly biomedical model. In the articles presented in this issue of the Journal of Bioethical Inquiry, clinical experience is married with historical and cultural context, ethical concerns are (...) brought to bear on global health, and structural analyses shed light upon the lived experience of people living with TB. The relational and reciprocal dimensions of care feature strongly in these discussions, which serve as a poignant reminder that behind each of the yearly deaths from TB is a deeply personal story. No single discipline holds a monopoly on how to care for each of these people, but strong cases are made for support from mental health and social workers in addressing the kaleidoscope of needs in TB prevention. As the World Health Organization moves towards the goal of eliminating TB globally by 2050, attending to the needs of TB patients serves global interests to lower disease burden and to develop better integrated communities worldwide. (shrink)

Prominent tuberculosis (TB) actors are invoking solidarity to motivate and justify collective action to address TB, including through intensified development and implementation (D&I) of technologies such as drugs and diagnostics. We characterize the ethical challenges associated with D&I of new TB technologies by drawing on stakeholder perspectives from 23 key informant interviews and we articulate the ethical implications of solidarity for TB technology D&I. The fundamental ethical issue facing TB technological D&I is a failure within and beyond the TB (...) community to stand in solidarity with persons with TB in addressing the complex sociopolitical contexts of technological D&I. The failure in solidarity relates to two further ethical challenges raised by respondents: skewed power dynamics that hinder D&I and uncertainties around weighing risks and benefits associated with new technologies. Respondents identified advocacy and participatory research practices as necessary to address such challenges and to motivate sustained collective action to accelerate toward TB elimination. We present the first empirical examination of bioethical accounts of solidarity in public and global health. Our study suggests that solidarity allows us better to understand and address the ethical challenges that arrest the D&I of new TB technologies. Solidarity lends credence to policies and practices that address the relational nature of illness and health through collective action. (shrink)

Planning of effective responses to the recent resurgence of tuberculosis in the United States, and particularly in New York City, requires review of our knowledge of the factors that led to the decline of tuberculosis in the U.S. and other countries during the nineteenth and the first three-quarters of the twentieth century, and the recent changes in these same factors and the rise of new factors that have contributed to its resurgence. Because the analysis of the impact of (...) all of these factors in both the remote and the recent past is controversial, it is important to use a well-defined framework to organize the analysis. The framework we will use is shown in Table 1. To the classic epidemiologic triad of Agent, Host and Environment it adds the category of Health Services. In this paper we redefine both the classic and new categories using current disciplines and concepts applicable to tuberculosis. (shrink)

Planning of effective responses to the recent resurgence of tuberculosis in the United States, and particularly in New York City, requires review of our knowledge of the factors that led to the decline of tuberculosis in the U.S. and other countries during the nineteenth and the first three-quarters of the twentieth century, and the recent changes in these same factors and the rise of new factors that have contributed to its resurgence. Because the analysis of the impact of (...) all of these factors in both the remote and the recent past is controversial, it is important to use a well-defined framework to organize the analysis. The framework we will use is shown in Table 1. To the classic epidemiologic triad of Agent, Host and Environment it adds the category of Health Services. In this paper we redefine both the classic and new categories using current disciplines and concepts applicable to tuberculosis. (shrink)

Controlling the movement of potentially infectious bodies has been central to Australian immigration law. Nowhere is this more evident than in relation to tuberculosis, which is named as a ground for refusal of a visa in the Australian context. In this paper, I critically examine the “will to knowledge” that this gives rise to. Drawing on a critical analysis of texts, including interviews with migrants diagnosed with TB and healthcare professionals engaged in their care, I argue that this focus (...) on border policing, rather than resettlement and the broader social determinants of health that drive current rates of TB, paradoxically renders migrants diagnosed with TB as liminal subjects in the post-arrival phase. This raises ethical issues about who “matters,” as well as dilemmas about what constitutes adequate care for the “Other,” both of which go to the heart of the political economy of migration. (shrink)

Bovine tuberculosis is a controversial animal health policy issue in England, which impacts farmers, the public, cattle and badgers. Badgers act as a wildlife reservoir of disease. Policy options for badger control include do nothing, badger culling, and badger vaccination. This paper argues for mandatory Animal Welfare Impact Assessment for all policy that significantly affects sentient animals. AWIA includes species description, and AWIA analysis stages. In this paper, AWIA is applied to impacts of bovine TB policy options on cattle (...) and badgers. Over 4 years, 85,000 badgers will be culled to prevent the slaughter of ~17,750 cattle over 9 years. Hence, about five badgers are culled for every cow which avoids slaughter. The AWIA analyses the impact of badger vaccination on cows and badgers based on a set of stated assumptions. The AWIA estimates badger vaccination to reduce the number of cows slaughtered by 11,600, i.e. a 12.5% reduction. Additional to the harm of killing, culling has greater welfare impacts on badgers compared to non-culling options. Actors in animal health and welfare policy were interviewed about the concept of AWIA. Policy actors supported the idea of AWIA to provide objective data to feed into policy making. The paper concludes with the proposal that AWIA is a necessary stage of just policy making where sentient animals are impacted by government policy. (shrink)

There is a nationwide resurgence of tuberculosis in the country’s urban centers; New York City stands at the forefront of this resurgence. The root causes are increased homelessness, drug addiction and poverty, all symbols of deteriorating social and economic conditions in the city. The inadequate level of public health resources devoted to TB has also contributed to its spread. Still, even with these factors, it is questionable whether the escalating number of TB cases in this country would have occurred (...) without the reservoir of immunosuppressed persons, who are less resistant to the disease, created by the AIDS epidemic. The fear and urgency of this public health crisis, which has been emerging since the beginning of the last decade, are fueled by the rise of TB strains resistant to the first-line drugs and by the disease’s contagiousness. (shrink)

There is a nationwide resurgence of tuberculosis in the country’s urban centers; New York City stands at the forefront of this resurgence. The root causes are increased homelessness, drug addiction and poverty, all symbols of deteriorating social and economic conditions in the city. The inadequate level of public health resources devoted to TB has also contributed to its spread. Still, even with these factors, it is questionable whether the escalating number of TB cases in this country would have occurred (...) without the reservoir of immunosuppressed persons, who are less resistant to the disease, created by the AIDS epidemic. The fear and urgency of this public health crisis, which has been emerging since the beginning of the last decade, are fueled by the rise of TB strains resistant to the first-line drugs and by the disease’s contagiousness. (shrink)

Background Tuberculosis is a major cause of morbidity and mortality globally. Recent scholarly attention to public health ethics provides an opportunity to analyze several ethical issues raised by the global tuberculosis pandemic. Discussion Recently articulated frameworks for public health ethics emphasize the importance of effectiveness in the justification of public health action. This paper critically reviews the relationship between these frameworks and the published evidence of effectiveness of tuberculosis interventions, with a specific focus on the controversies engendered (...) by the endorsement of programs of service delivery that emphasize direct observation of therapy. The role of global economic inequities in perpetuating the tuberculosis pandemic is also discussed. Summary Tuberculosis is a complex but well understood disease that raises important ethical challenges for emerging frameworks in public health ethics. The exact role of effectiveness as a criterion for judging the ethics of interventions needs greater discussion and analysis. Emerging frameworks are silent about the economic conditions contributing to the global burden of illness associated with tuberculosis and this requires remediation. (shrink)

This case study examines the ethical dimensions of isolation for patients diagnosed with tuberculosis in Australia. It seeks to explore the issues of resource allocation, liberty, and public safety for wider consideration and discussion.

Tuberculosis (TB) is one of the world’s leading causes of death due to infection and efforts to control TB would be substantially aided by the availability of an improved TB vaccine. There are currently nine new TB vaccines in clinical development, and the first efficacy trials are due to commence in 2009. There are many complex ethical issues which arise at all stages of TB vaccine development, from the need to conduct trials in developing countries to informed consent and (...) the process of ethical review. While it is important that these issues are discussed, it may also be timely to consider the challenges which may arise if a vaccine in clinical development proves to be highly effective. We examine a number of scenarios where decisions on the deployment of a new TB vaccine may impact on the rights and liberty of the individual. (shrink)