An ethical road map to universal DOT

Fair to whom? That’s the big question

A working group known for helping formulate public health policy for AIDS patients had convened to look at a radical new concept some of its members found disturbing: universal directly observed therapy (DOT) for tuberculosis patients.

True, outbreaks of multidrug-resistant TB were grabbing headlines across the nation; but even the threat of MDR-TB didn’t seem to justify the proposed new policy, some experts say.

"I remember the day I read about an outbreak in a New York state prison," says Ronald Bayer, PhD, professor of public health at Columbia University School of Public Health in New York City. "They were calling for everyone to be tested, and the word ‘consent’ never once appeared. It was startling."

Yet Bayer and some of his colleagues in the group changed their minds. Why? Bayer cites the following reasons:

• The public health consequences of MDR-TB were a terrible burden, and must be avoided.

• Trying to identify in advance those who would be compliant would fail, and would probably discriminate against the poor and against people of color.

• DOT was only minimally intrusive — it wasn’t, after all, "like going to prison," Bayer decided, and represented a much better option than, for example, forcible hospitalization.

• Reports were surfacing that DOT actually benefited recipients, who often developed good relationships with outreach workers.

• To those who argued that patients should be given the benefit of doubt, Bayer concluded, "there wasn’t time: by then, another person might have been exposed to an incurable disease."

Without MDR-TB threat, do arguments hold?

Now that the threat of MDR-TB has paled, some who oppose universal DOT say it’s time to re-evaluate the argument.

Those who favor universal DOT, however, contend that many of the arguments first raised for it still apply.

By treating everyone the same, universal DOT is not only fair, these defenders say, it also makes it easier for administrators to frame the policy as positive instead of punitive.

So says Stephen Weis, DO, senior consultant with Tarrant County (Fort Worth), TX, and professor of internal medicine at the University of North Texas Health Science Center in Fort Worth.

Weis says the message is this: "TB is a very bad disease, one for which you must take a lot of pills for a very long time; and that to do this, we have people trained to help you."

Nonsense, say opponents of universal DOT; and nonsense for two reasons.

First, they declare, it’s wrong to assume most people probably won’t be adherent (or, in other variations of the same argument, that most people’s behavior can’t be predicted).

Second, they say, it’s wrong to conclude, based on either assumption, that the fair (or sensible) thing to do is give everyone DOT.

"Most people do take their medication by themselves, as long the meds are available and the people know what’s going on," says George Annas, JD, professor of health law at the Boston University School of Public Health. Thus, universal DOT isn’t "fair"; rather, it’s a policy that inconveniences most people to account for an unreliable few.

DOT is easy — for administrators

Administrators resort to the fairness argument, Annas says, because it disguises their true motives, which spring from the fact that universal DOT is easy — for program administrators, that is. How typical, Annas says with a sigh. "People in public health would rather bother 100 people than let one through," he says. "In truth, neither system gives you 100% unless you lock everyone up."

Not everyone opposed to universal DOT subscribes to Annas’s optimistic view of human behavior.

"Neither in TB nor anywhere else is there any indication demographics predicts compliance," says Esther Sumartojo, PhD, MSc, behavioral scientist in the division of HIV/AIDS at the Centers for Disease Control and Prevention (CDC) in Atlanta. "It’s simply not true to say a banker will be compliant and a homeless guy won’t."

Even so, that doesn’t mean universal DOT is the remedy, Sumartojo says.

"It seems to me universal DOT is an easy out — a medical solution to what’s really an interpersonal and social issue," she says. "What you really need to do is give people some compelling reason to take their meds."

The way to do that is simple, she adds: "Give people good service." That, and continue to monitor them on a regular basis, taking into account the fact that behaviors may change over time, and even the best patient needs his behavior reinforced and maintained from time to time.

Special Report: Directly Observed Therapy