Ethical Dilemma in TB Case

Case Study: Risk to Public Health

Ann Singer was first diagnosed with tuberculosis (TB) in February and immediately began treatment. In June of that year she was diagnosed with multidrug-resistant tuberculosis (MDR-TB), a strain of TB that is resistant to treatment using “first-line” drugs that are usually effective against TB. She was advised by county public health officials not to fly via commercial airlines because she would be putting others at risk. She was scheduled to be married in June, and then take an extended honeymoon throughout Europe. Despite the public health risk, she decided to go through with her plans. When she was in Paris, France, she was contacted by a representative from the United States Centers for Disease Control and Prevention (CDC), who advised her that it was discovered that she had extremely drug-resistant tuberculosis (XDR-TB). XDR-TB is very contagious and is extremely difficult to treat. Mrs. Singer was told that she was put on a no-fly list, and the only way she could fly back to the United States would be to charter a private plane. Mrs. Singer then booked a commercial flight that left earlier than the one she originally booked, flew to Denmark, and then to Canada, where she and her husband rented a car and drove to the United States. Despite an alert attached to her passport, she was not detained at the Canadian border. Mrs. Singer then voluntarily checked into a Denver hospital for treatment.

All passengers on all flights with Mrs. Singer were identified, contacted, and required to undergo TB testing. French public health officials asserted that the United States did not contact them in a timely fashion. The case made national and international news. Mrs. Singer considered suing the CDC for revealing her name and breaching her privacy.

Discussion Questions

1. How were the interests of Mrs. Singer and population health involved in this case?
2. There was no evidence of team-based care in this case. How do you think team-based care could have affected this case?
3. How could cooperation among healthcare professionals involved in this case (nationally and internationally) have been improved?
4. Do you think Mrs. Singer had a trusting relationship with the public health representatives? Explain why or why not and how this may have affected the outcome.
5. Is there an ethical dilemma present in this case? How would you manage the dilemma?
6. Did the various people involved in this case act with honesty and integrity in their relationships? Explain.

1. In this case, the interests of Mrs. Singer and population health were in conflict. Mrs. Singer’s interest was to fulfill her personal plans, including her wedding and honeymoon, which she pursued despite her diagnosis of MDR-TB and later XDR-TB. On the other hand, the interest of population health was to prevent the spread of these highly contagious and drug-resistant forms of tuberculosis to others, both within the United States and internationally. Public health officials advised her not to fly via commercial airlines due to the risk she posed to other passengers, highlighting the tension between her individual desires and the broader public health concern.
2. Team-based care could have played a crucial role in managing this case more effectively. A multidisciplinary team of healthcare professionals, including physicians, public health officials, infectious disease specialists, and legal experts, could have collaborated to ensure better communication, decision-making, and coordination. This team could have developed a more comprehensive and patient-centered approach to address Mrs. Singer’s medical needs, her desire for personal events, and the protection of public health.
3. Cooperation among healthcare professionals involved in this case, both nationally and internationally, could have been improved through better communication and information sharing. Timely and accurate notification of French public health officials about Mrs. Singer’s condition would have allowed for quicker contact tracing and containment efforts. Establishing clear protocols and lines of communication between different healthcare systems and jurisdictions is essential in managing cases with public health implications.
4. Mrs. Singer’s trust in public health representatives may have been compromised due to the revelation of her name and the breach of her privacy. Trust is crucial in public health interventions, and the disclosure of personal information without consent can erode trust between individuals and healthcare authorities. Building and maintaining trust should be a priority for public health officials to ensure compliance with public health recommendations and prevent individuals from taking actions that could endanger public health.
5. There is an ethical dilemma present in this case. On one hand, there is the principle of individual autonomy, where Mrs. Singer has the right to make decisions about her life, including her wedding and honeymoon plans. On the other hand, there is the principle of beneficence, which requires healthcare professionals and public health officials to act in the best interests of public health and prevent the spread of a highly contagious and drug-resistant disease. Managing this dilemma involves finding a balance between respecting individual autonomy and protecting public health. In this case, public health officials prioritized the latter, given the potential risk to others.
6. The actions of various people involved in this case raise questions about honesty and integrity. Mrs. Singer’s decision to book a commercial flight despite being on a no-fly list may be seen as a lack of integrity regarding her responsibility to prevent the potential spread of a dangerous disease. Additionally, the disclosure of her name by the CDC could be considered a breach of privacy. On the other hand, public health officials were acting in the interest of public health and may argue that their actions were ethically justified to protect the broader community. The ethical evaluation of the actions of each party may vary depending on one’s perspective on individual rights versus public health imperatives.