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Ethics, Autonomy and the Treatment of Tuberculosis in Impoverished Patients in India
By Kelsey Whittier
Tuberculosis is a highly contagious airborne disease which is transmitted through emitted aerosol droplets of people infected with active tuberculosis. This mode of TB transmittance contributes to its high prevalence and rate of transmission in areas characterized by overcrowding, poor ventilation and populated by immunocompromised individuals. As observed while visiting the slums and clinics of Mumbai, these are the exact conditions which are found in urban India. Consequently, tuberculosis is the leading cause of infectious disease death in India, killing roughly 500,000 people a year. Furthermore, the emergence of multi-drug resistant strains of tuberculosis is complicating treatment regimes, as well as posing a serious threat to the health of the public. One of the primary causes of multi-drug resistance is non-adherence on the part of patients to medically prescribed drug regimes. Several relevant ethical issues are broached surrounding this non-adherence and the status of tuberculosis as an infectious disease; specifically, the proper understanding of autonomy in these circumstances and the role of the state in compelling non-adherent patients to comply with their treatments. The concept of autonomy within bioethics was largely developed with regard to non-infectious diseases or procedures which primarily affected only the individual patient. These current bioethical interpretations of autonomy do not readily apply to infectious diseases such as tuberculosis due to their contagious nature and the position of a patient as both a victim and a vector. This paper examines the moral value of various understandings of autonomy within the context of tuberculosis in urban India by applying rights-based ethics, deontology, the ethics of care and utilitarianism to the situation. The ethical permissibility of the state to compel non-adherent tuberculosis patients to follow their drug regimes is also analyzed based upon the bioethics of patient autonomy.
"Play rocks with us!" Marea exclaimed. A simple children's game allowed some respite from the overwhelming sights common on the dirty streets of the Mumbai slums. After several games of "rocks," with stray dogs circling us and half-naked children tentatively begging for rupees, Marea and her entourage of slum children ran off to their make-shift huts. By most accounts, Marea was an encouraging sight among the generally depressing state of the slums. She was happy and relatively well-fed, spoke fluent English and seemed surprisingly well-educated given her surroundings. However, it was her surroundings that were the issue. The slums consisted of row upon row of continuous shacks, made from any materials available, and situated in a way reminiscent of tooth-pick buildings; remove one vital component and the whole construction tumbles down. More problematic than the architectural shortcomings is the fact that the slums contain no sewage system, are poorly ventilated and overcrowded - a potent combination that provides optimal breeding conditions for communicable diseases.
Among the plethora of possible illnesses exists a particularly silent and prevalent killer. Tuberculosis is an airborne infectious disease which is widespread among impoverished communities. This paper will examine various interpretations of the moral value of personal autonomy within the context of the victim/vector paradox as seen in an impoverished environment such as urban Mumbai, India. Rights-based ethics, deontology, the ethics of care and utilitarianism will be employed in this examination. Based upon these i nterpretations of a patient's autonomy, an analysis of the ethical permissibility of the state to compel non-adherent patients with active tuberculosis to follow their drug regimes will be made. Based upon this analysis, this paper will contend that a utilitarian approach is appropriate due to the nature of the disease.
II. Epidemiology and Treatment of Tuberculosis in Urban India
Tuberculosis (TB) is an infection caused by the bacteria Mycobacterium tuberculosis which primarily invades the lungs causing pulmonary TB. TB is transmitted through aerosol droplets of people infected with active tuberculosis; a patient's cough, sneeze or spit can be highly contagious and potentially lethal to those in close proximity, especially individuals in prolonged contact with the infected patient. The mode of TB transmittance especially contributes to its high prevalence and rate of transmission in areas characterized by overcrowding and poor ventilation and populated by immunocompromised individuals. So as Marea ran towards the coughs echoing out of her crowded shack situated in the center of her slum community, we wondered, not if, but the extent to which she had been exposed to the bacterium and whether her immune system would be strong enough to fight the disease for her.
As our visits to both the Municipal Tuberculosis Hospital and Kasturba Infectious Disease Hospital in Mumbai made painfully clear , tuberculosis presents a major public health issue to the urban areas of India, and has, according to epidemiological studies, done so for at least the past four and half decades.1 Tuberculosis is the leading cause of infectious disease death in India, killing roughly 500,000 people a year. 2 According to the World Health Organization, India accounts for roughly 20% of the global incidence of TB (with roughly 16% of the world's population), which translates to about 1.8 million cases occurring each year.3 Approximately 30-50% of the total Indian population, without regard to class, is infected with the TB bacilli; and the annual rate of [new] tuberculosis infection (ARTI), which is a measurement of the probability of contracting the infection within the span of a year, is estimated at 1-2%. Furthermore, this statistic is an under-representation of the disease situation in urban areas, in which there exists a significantly higher risk of infection than in the rural regions of India.4 Without taking into account multi-drug resistant strains, which will be discussed later, there are two categories of pati ents infected with tuberculosis: those who have been exposed to the bacilli but who have asymptomatic latent tuberculosis and those patients with active tuberculosis who can transmit the bacteria to others. Most of those infected with the tuberculosis bacilli have latent tuberculosis and at the present time pose no threat to their surrounding community because they are incapable of transmitting the bacteria. However, patients with latent TB need to be treated in order to prevent the disease's progression to active TB. Without this preventive treatment, there is a roughly 10% chance that a patient's latent tuberculosis will progress to active TB, and this statistic is greatly elevated when solely considering malnourished and immunocompromised patients, such as the members of Mumbai slum communities.5 This paper will focus on those patients who have progressed to an active tuberculosis state and are therefore capable of transmitting the disease. These patients, when left untreated, pose an immediate and potentially devastating threat to their communities.
An additional issue to be considered when examining the epidemiology of TB in India is the complicating factor of new multi-drug resistant (MDR) strains of tuberculosis. MDR-TB is a type of tuberculosis which is resistant to the usual antibiotics used for treatment and is generally defined as "resistance to two or more of the primary drugs used for the treatment of tuberculosis."6 This resistance occurs when the bacteria develop the ability to endure antibiotic attack and confers this resistance to their progeny. Resistance is conferred via genes carried in small, DNA-containing organelles called plasmids. These plasmids can pass from parent to progeny as well as between bacteria. 7 As the levels of resistant bacteria grow, so does the spread of MDR-TB throughout the population.8 However, though one can initially contract a MDR strain of tuberculosis, "on an individual basis, inadequate treatment or improper use of the anti-tuberculosis medications remains an important cause of drug-resistance tuberculosis."9 The proportion of TB patients who contracted MDR-TB, as opposed to individuals who developed MDR-TB, varies between 0.5% and 5.3%; however, when looking exclusively at individuals with previously treated, but probably improperly treated, cases of TB this rate ranges from 8% to 67% of the total TB population.10 The striking disparity between these two statistics may indicate that current treatment regimes are not fully successful and it is likely that patient adherence (or lack thereof) is a key factor in this failure.
The Revised National Tuberculosis Control Program (RNTCP) was created in 1992 after a joint evaluation by the Government of India, the World Health Organization and the Swedish International Development Agency found that the Indian National Tuberculosis Program (NTP) was inadequate in its treatment of tuberculosis. The current public health treatment plan in India, the WHO recommended Direct Observed Therapy, Short-Course (DOTS), was established as a model in 1993 by the RNTCP.11 Following favorable treatment success rates at a model DOTS center, the program was expanded to the general public in September of 2002.12 The program initially sorts patients into three categories. Category I consists of newly diagnosed patients with sputum smear positive TB, those patients who are seriously ill with sputum smear negative TB and extrapulmonary TB patients; category II consists of patients who have been previously treated; and patients classified as category III present with sputum smear negative or extrapulmonary TB and are not seriously ill.
The primary goals of "antituberculosis chemotherapy are to kill tubercle bacilli rapidly, prevent the emergence of drug resistance, and eliminate persistent bacilli from the host's tissues to prevent relapse. To accomplish these goals, multiple antituberculosis drugs must be taken for a sufficiently long time."13 The treatment regime afforded by the DOTS program calls for the prescription of drugs dependent on a patient's category; category I patients are initially treated intensively with four drugs, and later treated with two drugs during a four month continuation phase. Category II individuals are treated initially with five drugs during an intensive phase lasting two months, followed by a one month period of treatment with four drugs and a subsequent continuation phase of five months treatment with three drugs. Category III patients are treated with an intensive phase of two months with three drugs and a continuation phase of four months with two drugs.14 These drug regimes are administered under the direct supervision of treatment supervisors and faculty at DOTS centers, at least for the initial intensive phase of the treatment.
The DOTS treatment and control strategy, established by WHO, combines five elements vital for successful implementation; political and government cooperation, the resources and ability to diagnose TB cases using sputum microscopy, standardized short-course drug therapy given under direct observation, constant supply of quality drugs to patients with reliable distribution techniques, and recording and reporting of patient outcomes in order to assess the overall effectiveness of the program.15 Although these protocols clearly outline procedures within ideal conditions, the DOTS strategy, which is now said to be available for about 87% of the Indian population, has reported cure rates consistently over 80%.16 However, though the medical treatments are physically ingested under direct supervision (at least in the initial phases), it is largely the responsibility of the individual patients to report to the DOTS or treatment centers. Based upon our experiences at the tuberculosis clinic in Mumbai and through speaking with the specialists employed there, it has become clear that many patients fail to consistently report to the centers, thus presenting the issue of non-adherence. This non-adherence poses a threat to the community in two regards. First, non-adherent patients with active tuberculosis continue to be a vector of the disease and thus are readily able to spread the harmful bacilli. Secondly, and even more troublesome, non-adherence promotes the development of MDR-TB which can also be spread to the community and for which treatment is not as readily available. Therefore, an active TB patient's non-adherence to a drug regime is detrimental, not only to themselves, but also to the greater community.
There are many complicating factors that may contribute to this non-adherence and which negatively affect a community's ability to implement a DOTS program that is effective. These include, but are not limited to, high rates of poverty and illiteracy, poo r accessibility to health care facilities and a lack of education on healthcare matters. Each of these provides barriers, whether monetary, environmental or knowledge-based, which inhibit a patient's ability to fully adhere to a treatment regime. For example, a tuberculosis patient within the slums of Mumbai may travel to a DOTS center and begin treatment; however sometime within the lengthy treatment process the patient may be unable to come to the center. This could be because she needs to stay at home and care for children, or is needed for work, or is not able to spend the money on the taxi or rickshaw needed to get to the DOTS center. Due to these obstacles, a patient may be unable to continue treatment, and thus be non-adherent. Many of these factors are external to the patient and require an in depth analysis of the socioeconomic factors and governmental responsibilities related to public health concerns. However, there also exist individual factors and decisions which inhibit the effective treatment of tuberculosis, and thus present an increased threat of infection to the public. The effective treatment of TB, given its highly infectious nature as well as the possible obstacles to successful treatment internal to the individual, raises some intellectually stimulating and important applicable ethical issues which were largely ignored by early bioethical theorists due to a variety of reasons.
III. Distinguishing Features and Ethical Importance of Infectious Disease
As an infectious disease, there is little research or commentary on the ethics surrounding tuberculosis. Bioethics emerged as a field of study, primarily in Western countries, during the late 1950's through 1970's. During this time, infectious disease was regarded by many public health officials as a problem of the past, thus little attention was given to the topic in the early texts (see Francis 2005 for an analysis of nineteen texts published before the advent of HIV/AIDS and their lack of attention to infectious disease). This triumphant stance, though short-sighted, was understandable; by the late 1950's the polio vaccine had been developed by Jonas Salk and later refined by Albert Sabin, tuberculosis levels were low in developed countries due to improved sanitation and public health, and the HIV/AIDS epidemic had yet to emerge.17 So widespread was the opinion that infectious diseases had been "almost completely conquered" that in 1972 the United States Surgeon General Jesse Leonard Steinfeld declared that "it [was] time to close the book on infectious disease," as a public health problem.18 The absence of infectious disease as a serious consideration for early bioethicists left the field ill-equipped to deal with the unique conceptual issues which surround communicable diseases. Specific characteristics of communicable diseases, such as the fact that a patient is both a "victim and a vector," that the illness can be rapid and acute rather than chronic, and that they are vastly more prevalent in impoverished and malnourished populations, present relevant ethical issues that are not necessarily compatible with the prominent bioethical approaches which have dealt almost exclusively with autonomy and informed consent within the realm of chronic illnesses or individual choices.19 Issues such as abortion, euthanasia, cloning, and stem cell research have received the bulk of the attention and resources within bioethics, all of which are topics which are largely non-applicable to the majority of the world's population. This situation mirrors the "10/90 divide" observed in the funding of medical resources; "less than 10 percent of [medical] research funds are spent on the diseases that account for 90% of the global burden of disease diseases affecting large proportions of humanity are given comparatively little attention."20
The ethical attention given to infectious diseases grew with
the emergence of HIV/AIDS in the 1980's. However the nature
of HIV transmission, direct contact with body fluids such as
blood, vaginal secretions or semen, makes its ethically relevant
concerns significantly different from those of the more readily
acquired tuberculosis. It is impossible to approach tuberculosis
with the same frame of mind and ethical tools as are used when
examining the ethical issues raised in HIV/AIDS. Many of the
aggravating issues related to the spread and treatment of tuberculosis
are due to the fact that an individual can act as a vector by
simply breathing and coughing in his everyday surroundings,
a concern that is not relevant to HIV/AIDS.
Nevertheless, it is possible to examine the ethics of an infectious
disease, such as tuberculosis, with regard to an individual
non-adherent patient. There are various reasons for non-adherence
to a medically prescribed drug regime. As previously mentioned,
many of these causes are external to the patient and prevent
a patient's access to and ability to acquire the drugs. Educational
shortcomings, due to governmental deficits such as lack of funding,
which render the patient ignorant to the causes and progression
of the disease and importance of the treatment should also be
considered external; an individual should not be faulted for
a lack of educational resources or information provided to them.
However, especially with the advent of DOTS therapy, patients
are being given increasing levels of information and access
to medical treatments, and many of the reasons for non-adherence
are shifting to those more commonly seen in developed countries
in patients with a variety maladies and drug regimes. Patients
may become lazy or inattentive, or just decide that they are
feeling better and that they do not wish to continue drug therapy.
That patients would discontinue drug therapy simply when overt
symptoms cease could be considered an issue of educational and
The primary characteristic of infectious diseases that separates it from other medical issues is the fact that an infected individual is both a "victim and a vector."24 This distinguishing feature, particularly pronounced in the case of tuberculosis due to its highly contagious mode of transmittance, "places us [those infected] in the position of putting others at risk, whether or not [they] want to be in this position."25 This feature is also what raises infectious diseases' unique ethical questions with regards to non-adherence, autonomy and the role of the state. Neither abortion nor euthanasia, stem cell research nor cloning possess this peculiar paradox which makes the patient also the perpetrator. Therefore the traditional ethical conceptualities of patient autonomy and the role of the state are largely irrelevant.
IV. The Definition of Autonomy in Regards to Tuberculosis Patients
Beauchamp and Childress describe personal autonomy as "at a minimum, self-rule that is free from both controlling interference by others and from limitations, such as inadequate understanding, that prevent meaningful choice."26 This explanation encompasses the two major conditions of autonomy: liberty and agency. Informed consent is centrally related to the concept of au tonomy in that it is generally required as a way to respect and protect the autonomous choices of individuals, and when related to the medical field, to respect the individual's choices of medical treatments. Broken down into its components, "the information component refers to disclosure of information and comprehension of what is disclosed. The consent component refers to both a voluntary decision and an authorization to proceed."27 This informed consent standard assumes that patients are competent and able to understand their choices, as well as the ability to appreciate how each choice may coincide with their established ethical values. However, both of these ideals, patient autonomy and informed consent, "focus myopically on the significance of the treatment decision for the individual patient."28 For example, within the realm of reproductive rights and assuming that an unborn fetus is not an individual person or autonomous moral agent, a woman's decision to undergo an abortion is her own autonomous decision; a decision that is assumed to physically and directly affect no one else. Her autonomous decision is hers alone, and she need not take into account the opinions or wishes of others.
However, this is not the case with infectious diseases. The information provided to a patient determined to be capable of autonomous choice- such as the nature of the condition, treatment options and side effects- are all related to the individual patient and how it affects that individual. Autonomy gives no consideration to the effects of the condition and subsequent treatment on the patient's friends, family and acquaintances. However, the victim/vector paradox demands that the issues of autonomy, and the related concept of informed consent, be examined in regard to "the extent to which the patient's decision about treatment- or nontreatment- may affect the health status of others."29 The communicable nature of tuberculosis highlights how, though we are autonomous agents, we are vulnerable to infection due to our relationships with others.30 It could therefore be argued that the state must take these distinctive characteristics of tuberculosis into consideration when dealing with non-adherent patients who pose a threat to their community at large.
A notably pertinent question concerning these issues is whether a patient (as a victim), once informed of his condition and its infectiousness, and who persists in non-compliance (thus exacerbating the patient's role as a vector) can be compelled by the state, as an arm of the moral community, to adhere to treatment. Debate should arise as to whether the patient has the ethical right to exercise his autonomy in the traditional sort of manner, and thus have the right to refuse treatment, even when doing so would increase the possibility of transmitting detrimental effects to others. This debate broaches the subject of whether the standard bioethical understanding of an individual's autonomy is relevant in regards to tuberculosis, where that patient is both a victim and a vector. The understanding of autonomy in regards to tuberculosis subsequently determines what action by the state is morally permissible in protecting the health of the community from a non-adherent tuberculosis patient.
Various ethical schools of thought would approach this difficult dilemma differently. Given that in the case of tuberculosis, an infected individual can spread the disease and threaten the health of whole communities, one approach emphasizes "public health measures required to protect other individuals and society from contagion [which] might involve surveillance, mandatory testing, mandatory vaccination or treatment, notification of authorities or third parties, isolation of individuals, quarantine or travel restrictions."31 Those that support this utilitarian approach would likely deem a patient's refusal of treatment or non-adherence to the treatment of tuberculosis as unethical because of its potentially harmful effects on others, and thus contend that state-enforced compulsory treatment is not only morally permissible, but also the state's duty. On the opposite end of the spectrum, are those that promote libertarian aims "to protect privacy and individual rights and liberties such as freedom of movement, and so on."32 Between these two extremes exists other schools of ethical thought such as deontology and the ethics of care. The challenge is to determine an understanding of autonomy that balances both the libertarian and utilitarian goals and from which a principle for the duty of the state in protecting the community from non-adherent active TB patients can be derived; this will be done by examining the ethics of individual autonomy in regards to tuberculosis in urban India under the framework of libertarian or rights ethics, deontology, ethics of care and utilitarian public health aims. This analysis will take place with regards to an adult individual with active TB who is non-adherent to his drug regime and living in the previously described enduring and overcrowded conditions characteristic of the slums of Mumbai, India.
V. Ethical Approaches to Autonomy
Rights-based theories of ethics (rights ethics) and morality, referred to as liberal individualism by Beauchamp and Childress and said to be promoting libertarian aims by Selgelid, concentrate on the protection of individual rights promoting freedom, liberty and expression. Since the time of philosopher Thomas Hobbes, we have used the language and theory of rights in both the moral and political realms to protect against injustices such as oppression, unequal treatment, intolerance and much more.33 These "rights," so ubiquitous in our Western culture, are defined as "justified claims that individuals and groups can make upon other individuals or upon society; to have a right is to be in a position to determine, by one's choices, what others should do or need not do."34 Claims of rights are based upon moral rules, and a claim, and its attendant right, is valid only if it is prescribed and justified by the relevant rules. Rights are generally viewed as prima facie claims, in that they can be justifiably overridden in certain circumstances. However, some theorists such as Ronald Dworkin, have presented more absolutist definitions which promote the ideal that some rights are so basic and ingrained that "ordinary justifications for interference with rights by the state, such as reducing inconvenience or promoting utility, are insufficient."35 In this view, some of the rights of individuals are placed above utilitarian, social-interest goals, and may not be infringed upon. The general rights ethics approach is not nearly this absolute; most theorists agree that rights can be justifiably overridden or infringed upon in certain circumstances, such as legitimate and demanding needs to protect the well-being and rights of others.
Another important distinction within the field of rights ethics
is between positive and negative rights. Positive rights are
justified claims "to receive a particular good or service
from others, whereas a negative right is a right to be free
from some action by another."36 It is generally easier
to justify negative rights, such as privacy or autonomy which
prevent others from acting so as to negatively affect an individual,
and therefore my focus is primarily on negative rights. Within
this rights-based, libertarian view of ethics, "the function
of morality is to protect individuals' interests (rather than
communal interests), and rights (rather than obligations) are
our primary instruments to this end."37 From the viewpoint
of theorist Robert Nozick, autonomy in this context is basic
to moral life in that "all persons have a right to be left
free to do as they choose,"38 and it is the obligation
of others' not to interfere with this right.
There are clearly large gaps in this approach, and it is very
rarely taken in regards to healthcare issues, especially when
dealing with infectious disease. The first issue that must be
considered is that when dealing with tuberculosis, due to the
individual's status as both a victim and a vector, the autonomous
choice of an individual, protected by rights, may violate the
rights of others. And though imposing limits on a patient's
autonomous choice would be considered an infringement of their
rights, it is also impermissible to allow the rights of one
person to violate the rights of another. Infectious disease
is distinctly different than other medical cases which generally
directly affect only the individual patient. If a man with congestive
heart failure fails to adhere to his medical regime, either
due to preferences or ignorance, his act is affecting no one
but himself. According to the libertarian ethics it is his right
to act as he pleases; he possesses the negative right to non-interference
in making his own autonomous decisions.
As the above description outlines, the Kantian concept of autonomy
is not congruent with the contemporary bioethical definition
of autonomy; Kant's autonomy is not "'What do I really
want, and is it best for me?'; rather, it is of moral autonomy
which applies universally, and asks the question 'Is this what
I ought to do?', morally speaking."47 Within the context
of infectious disease, a maxim or rule derived using rational
and impartial thought and which could be universalized, would
first have to be established. The obvious maxim would be that
everybody should adhere to their medical and drug regime; this
is rational and could easily be universalized. Patients who
then complied to this maxim, for the sake of duty, could then
be classified as autonomous a gents. They, as rational beings,
were capable of autonomy and bound by morality.
This approach is much more applicable to the realm of infectious
disease. It acknowledges the diverse array of factors that combine
to influence behavior. Furthermore, it emphasizes the fact that
no patient, especially a tuberculosis patient, is an isolated
individual; "contagious, infectious disease, moving quickly
from individual to individual, reminds us that we do not exercise
our agency on an island."52 Determination of autonomy cannot
pretend that we are fully rational, isolated beings and the
context of tuberculosis makes this point particularly pertinent.
However, the ethics of care does not fully explain autonomy
within infectious disease. The relationships which are emphasized
in this theory are caring, loving and intimate relationships
with individuals to which one is close. Infectious disease,
however, affects not just close relationships. The patient,
as both the victim and the vector, may infect others that are
strangers, as the result of accidental interaction, and a concept
of relational autonomy must reflect this vulnerability. Under
the concept of relational autonomy and with a consciousness
of the vulnerability of others, a state-enforced compulsion
to adhere to a medical regime would be morally acceptable. If
a patient with active TB is not adhering to their medical regime,
the individual is ignoring his role as a relational and connected
Beauchamp, Tom L. & Childress, James F. Principles of Biomedical Ethics (5th edition). New York; Oxford University Press, 2001.
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Francis, L. et al. "How Infectious Diseases Got Left Out-
and What This Omission Might Have
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Selgelid, M. "Ethics and Infectious Disease." Bioethics. (2005) 19(3): 272-289.
Sharma, S.K. et al. "DOTS centre at a tertiary care teaching
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Verweij, Marcel. "Obligatory Precautions Against Infection." Bioethics. (2005) 19(4): 323-335.
1 Chadha, V.K. "Tuberculosis epidemiology in India: a review." International Journal of Tuberculosis and Lung Disease. (2005) 9(10): 1072-1082. (1078)
2 Sharma, S.K. et al. "DOTS centre at a tertiary care
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3 Chadha, V.K. (1075)
4 Chadha, V.K. (1072)
5 "Tuberculosis." World Health Organization. March 2006. 3 June 2006.
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2006. 3 June 2006.
7 Lachmann, Peter J. "Public Health and Bioethics."
Journal of Medicine and Philosophy. (1998) 23(3): 297-302.
8 "Multidrug-Resistant Tuberculosis Fact Sheet." American Lung Association.
10 Chadha, V.K. (1072)
11 Sharma, S.K. (255)
12 Sharma, S.K. (251)
13 "Treatment for Tuberculosis." Center for Disease Control. 20 June 2003. 5 June 2006.
14 Sharma, S.K. (253)
World Health Organization. 2006. 27 May 2006.
16 Chadha, V.K. (1079)
18 Francis, L. et al. "How Infectious Diseases Got Left
Out- and What This Omission Might Have
19 Francis, L. et.al. (309)
20Selgelid, M. "Ethics and Infectious Disease." Bioethics. (2005) 19(3): 272-289. (273)
21 Selgelid, M. (278)
22 Selgelid, M. (278-279)
23 Selgelid, M.(286)
24 Francis, L. et. al. (308)
25 Francis, L. et. al. (311)
26 Beauchamp, Tom L. & Childress, James F. Principles of Biomedical Ethics (5th edition). New York; Oxford University Press, 2001. (58)
27 Beauchamp, T.L. & Childress, J.F. (79)
28 Francis, L. et al. (312)
29 Francis, L. et al. (312)
30 Francis, L. et al.
31 Selgelid, M. (277)
32 Selgelid, M. (278)
33 Beauchamp, T.L. & Childress, J.F. (355-6)
34Beauchamp, T.L. & Childress, J.F. (357)
35Beauchamp, T.L. & Childress, J.F. (357)
36Beauchamp, T.L. & Childress, J.F. (358)
37Beauchamp, T.L. & Childress, J.F. (360)
38Beauchamp, T.L. & Childress, J.F. (360)
39 Francis, L. et al. (316)
40 Francis, L. et al. (317)
41 Beauchamp, T.L. & Childress,J.F. ( 349)
42 Beauchamp, T.L. & Childress, J.F. (350)
43 Secker, Barbara. "The Appearance of Kant's Deontology
in Contemporary Kantianism: Concepts of Patient
44 Secker, Barbara. (46)
45 Secker, Barbara. (47)
46 Beauchamp, T.L. & Childress, J.F. (349)
47Secker, Barbara. (48)
48Secker, Barbara. (53)
49 Beauchamp, T.L. & Childress, J.F. (369)
50 Beauchamp, T.L. & Childress, J.F. (371)
51 Francis, L. et al. (320)
52 Francis, L. et al. (320)
53 Beauchamp, T.L. & Childress, J.F. (341)
54 Beauchamp, T.L. & Childress, J.F. (341)
55 Verweij, Marcel. "Obligatory Precautions Against Infection."
Bioethics. (2005) 19(4): 323-335. (323)
56 Verweij, Marcel. (328)
57 Verweij, Marcel. (329)
58 Francis, L. et al. (321)
59 Francis, L. et al. (316)
60 Verweij, Marcel.
Kelsey Whittier graduated from Santa Clara University in
2006. This paper was her senior thesis at SCU and was supported
by a Hackworth Grant that she received in the spring of 2005.