When is the use of suboptimal treatment in functionally untreatable multi-drug resistant tuberculosis morally permissible?

摘要

Multidrug-resistant tuberculosis (MDR-TB) is well recognised as a seriousthreat to controlling and ending the TB epidemic. Treatment is timeintensiveand costly. Current treatment guidelines recommend the useof at least four effective drugs plus pyrazinamide for a period of 18–24months. There are, however, situations in which this is not feasible. Thismay be due to severe patterns of drug-resistance, poor tolerance to themedications, or supply chain issues. In this paper, I use the termfunctionally untreatable MDR-TB to refer to such situations. Patientsmay be assigned to waiting lists until appropriate medications areavailable, and many die while awaiting treatment. Clinicians face aserious ethical dilemma in these cases, and some may choose to treattheir patients with suboptimal regimens in the interim. While thispractice may alleviate symptoms and even cure some patients, it isknown to extend drug-resistance, limiting further the availability ofefficacious anti-TB medicines. This paper explores the relevant ethicalconsiderations faced by clinicians providing MDR-TB treatment, andhow this differs from formal ethical principles and guidance. It outlinesextreme situations in which suboptimal regimens may be considered,and requisite conditions to be fulfilled by stakeholders for this to bemorally permissible.