HLTH 5023 Module 3 Public Health Ethics Analysis Example

Lawful Is Not the Same as Justified: Applying Five Justificatory Conditions to a Health Officer's Plan to Compel Tuberculosis Treatment

Student Name

American College of Education

HLTH5023: Legal and Ethical Issues in Public Health

Module 3 Assignment

Instructor Name

October 19, 2026

The Measure and the Ethical Question

The first module established that a county health officer may lawfully require a man with infectious pulmonary tuberculosis who stopped treatment to resume it, and may ultimately seek a court order to confine him if he refuses, provided due process is followed. The second module showed how courts now demand that restrictions be tailored and that less restrictive options be considered. This module asks a different question: even where each step is legal, is it ethically justified, and under what conditions?

The measure under review is the department's planned escalation: first, supported directly observed therapy where the man is staying; second, a written order requiring daily observed therapy; and third, a petition for confinement in a hospital unit until he is no longer infectious. The man, who has been homeless for two years and drinks heavily, has said he stopped because the medicines made him sick and because the nurse's visits embarrassed him in front of others at the shelter.

The Framework

Childress et al. (2002) mapped the terrain of public health ethics by identifying general moral considerations that public health actions engage, among them producing benefits, preventing harms, distributing benefits and burdens fairly, respecting autonomous choices, protecting privacy and confidentiality, disclosing information truthfully and building trust. Because these considerations often conflict, they proposed five justificatory conditions that must be met when a public health goal is pursued at the cost of another consideration such as liberty: effectiveness, proportionality, necessity, least infringement and public justification. The framework does not produce answers mechanically; it structures the argument so that each claim can be examined.

Effectiveness

The first condition asks whether infringing a person's liberty will actually achieve the public health goal. Here the goal is to render the man noninfectious and cure him, protecting people at the warming center and preventing drug resistance. Completing a full course of treatment accomplishes both, and the national treatment guideline developed jointly by three national bodies favors directly observed therapy for routine treatment and emphasizes case management (Nahid et al., 2016). Directly observed therapy therefore meets the effectiveness condition. Confinement is effective in a narrower sense: it guarantees observed doses and isolation while he is infectious, but it does nothing about the reasons he stopped and may not secure completion after release, which for drug-susceptible tuberculosis typically requires months of therapy.

Proportionality and Necessity

Proportionality asks whether the expected benefits outweigh the moral costs of the infringement. The risk the man poses is real: he is sputum-positive and sleeping in a crowded shelter. The benefit of treating him is large both for others and for himself. Supported observed therapy imposes a modest burden, some loss of privacy and routine, and is clearly proportionate. A written order adds legal pressure but little additional burden. Confinement is a severe deprivation of liberty, proportionate only if he is still infectious and all lesser measures have failed.

Necessity asks whether the infringement is required to achieve the goal, or whether a less coercive approach would work as well. His stated reasons, side effects and public embarrassment, point to changes that could restore voluntary adherence: adjusting how and when medicines are taken with food to reduce nausea, observing doses at a pharmacy, a clinic or by video rather than in front of others at the shelter, and offering practical support such as meals and transportation. Before the department concludes that a man will not cooperate, it should be sure it has removed the reasons he gave for stopping. Only if these fail does compulsion become necessary.

Least Infringement

Where compulsion is justified, the least infringement condition requires the department to choose the option that restricts liberty, privacy and dignity as little as possible while still achieving the goal. Several choices follow. Directly observed therapy should occur in the most private setting he will accept. If an order is needed, it should require daily observed doses rather than confinement, and it should be written in plain language. If confinement becomes necessary, it should be in a hospital or medical setting, not a jail, should last only while he is infectious, should include treatment for alcohol use if he wishes, and should end with a plan for completing therapy in the community. Gostin and Wiley (2016) note that the least restrictive alternative principle, which appears in tuberculosis case law and many state statutes, turns this ethical condition into a legal requirement as well.

Public Justification and Fairness

The fifth condition requires public health officials to explain and justify infringements openly, both to the person affected and to the public. The department should tell the man exactly what it is asking, why and what will happen next, in terms he can understand, and should document its reasoning for review. It should also be prepared to explain its tuberculosis control practices publicly, since trust in the department's fairness affects whether others with symptoms come forward.

Fairness raises a further point. People experiencing homelessness are more likely to be subject to compelled treatment, partly because stable housing makes voluntary adherence easier. A department that confines homeless patients while treating housed patients at home risks turning a public health measure into a penalty for poverty. The department should therefore treat housing support as part of tuberculosis treatment, for example by arranging a single-occupancy motel room for the infectious period, which is often less costly than hospital confinement and far less restrictive.

Weighing the Alternative of Doing Less

An ethics analysis should also ask what happens if the department does too little. If the health officer, reluctant to compel anyone, simply leaves messages and waits, the man may continue sleeping in a crowded warming center for weeks while infectious. People there, many of them older, ill or living with conditions that weaken immunity, would carry the risk of an infection they never agreed to accept. If his treatment remains interrupted, the bacteria may develop resistance, and any people he infects would then face a longer, harder and more toxic course of treatment. Inaction is therefore not ethically neutral; it shifts burdens onto others who have no voice in the decision. The justificatory conditions apply in both directions: the department must justify infringing the man's liberty, and it must equally be able to justify leaving others exposed. The escalation plan, followed carefully, is the department's attempt to meet both obligations at once.

Conclusion

The escalation plan can be ethically justified, but only if it is followed in order and each step is taken only after the one before it has genuinely been tried. Supported observed therapy that addresses his side effects and embarrassment meets all five conditions now. A written order may be justified if he refuses that support. Confinement is justified only as a last resort, while he remains infectious, in the least restrictive medical setting and with a plan for what follows. The framework's value is that it makes the department show its reasoning at each step, which is what distinguishes public health authority from mere power.

References

Childress, J. F., Faden, R. R., Gaare, R. D., Gostin, L. O., Kahn, J., Bonnie, R. J., Kass, N. E., Mastroianni, A. C., Moreno, J. D., & Nieburg, P. (2002). Public health ethics: Mapping the terrain. Journal of Law, Medicine & Ethics, 30(2), 170-178. https://doi.org/10.1111/j.1748-720X.2002.tb00384.x

Gostin, L. O., & Wiley, L. F. (2016). Public health law: Power, duty, restraint (3rd ed.). University of California Press.

Nahid, P., Dorman, S. E., Alipanah, N., Barry, P. M., Brozek, J. L., Cattamanchi, A., Chaisson, L. H., Chaisson, R. E., Daley, C. L., Grzemska, M., Higashi, J. M., Ho, C. S., Hopewell, P. C., Keshavjee, S. A., Lienhardt, C., Menzies, R., Merrifield, C., Narita, M., O'Brien, R., ... Vernon, A. (2016). Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America clinical practice guidelines: Treatment of drug-susceptible tuberculosis. Clinical Infectious Diseases, 63(7), e147-e195. https://doi.org/10.1093/cid/ciw376