Keywords

Public Health Ethics Issue

In T.C. Boyle’s 2017 short story, “The Fugitive,” the public health practitioners treating the protagonist, Marciano, for tuberculosis (TB) override his right to decide his own treatment plan.Footnote 1Marciano‘s struggles show an inherent conflict in public health ethics between protecting the community from infectious disease and respecting a person’s right to autonomous decision making. This conflict remains unresolved at the end of the story for two reasons. First, public health practitioners failed to elicit Marciano’s illness narrative and his views on the treatment plan. They treated him merely as a case of multi-drug resistant TB due to noncompliance, rather than as a human being with goals, values, and beliefs about what makes life worth living. Second, by neglecting to elicit his perspective, public health practitioners were unaware of how social determinants of health affected his compliance with the recommended treatment. More specifically, they failed to recognize how Marciano’s concerns about avoiding stigma and keeping his job affected his decision making. To avoid these failures in the future, we recommend that public health officials adopt a narrative-based approach to policymaking and training public health practitioners. Doing so will help public health officials build trust in healthcare institutions, thereby increasing compliance with public health measures. In this chapter we will explore Boyle’s story as a way to frame concerns about the effectiveness, utility, proportionality, and necessity of the public health measures taken in this case.

Background Information

The control of infectious diseases like TB relies on the public’s cooperation. Effective clinical management of these diseases requires that patients temporarily give up some of their rights (Martini et al. 2018; Dye et al. 1998). These rights include the right to bodily freedom and integrity, privacy, and self-determination. But sometimes, patients who are infections refuse to give up these rights voluntarily. Public health officials then must resort to more coercive measures, including involuntary isolation and compulsory treatment, in order to halt the spread of the infectious disease. Many levels of government have delegated this use of police powers to public health departments, which permits them to examine, detain, and treat individuals over their objections. However, the affected individual’s constitutional rights to due process and equal protection limit these powers (Matthews et al. 2007).

If caught early enough, treatment for most types of TB does not require isolation. Doctors typically prescribe four oral antibiotics for 8 weeks, followed by a two or three drug regimen to complete a total of 6–9 months of therapy (Sterling 2019). However, patients must take the medications according to a strict schedule, which can be challenging for them. Drug-resistant strains of TB develop when this schedule is not followed, as in Marciano’s case. Treatment regimens for these mutant strains can last 1 year or longer, depending on the level of resistance, and typically require a mix of oral and intravenous antibiotics administered in a facility.

If public health practitioners understand what factors might impede the patient from receiving treatment—it could be a patient’s work schedule or a side effect she feels from the medication—they may be able to adjust and treat the illness more effectively. Identifying these barriers, however, can be difficult. It’s true that when patients are asked, many describe these barriers in fine detail. But this isn’t always the case. The only way to ensure these obstacles are identified is through attention and listening. Unfortunately, these skills can erode during a public health career that focuses mainly on statistics and science. Literary works—stories—offer a way to heighten these listening skills.

Approach to the Narrative

Brushing up on their skills of close reading can help public health practitioners thoughtfully engage with a story’s thematic content and cultural context. Close reading requires “laser concentration on the formal characteristics of a text … awareness of the complexity of the reader/text transaction…and [of] how acts of reading change the world” (Charon et al. 2017). These skills easily translate into attentive listening to patients’ stories, which can help public health practitioners communicate better. For instance, T.C. Boyle’s story “The Fugitive” illustrates how necessary public health interventions pit patients against public health practitioners. Attentive readers of stories like this one become attuned to their core features: plot, characters, setting, voice, and theme. They ask questions like, “Where and when is this story taking place?” As they become familiar with the characters in the story, they ask, “Who is telling this story and why are they telling it?” As the action unfolds and the story progresses, they seek to understand the characters better, as they would real people. Readers start to see the story unfold in their imaginations, and in doing so, develop narrative competencies, including a broader perspective and a wider moral imagination. With practice, close readers develop the ability to narratively transport themselves into a character’s world. They begin to imagine themselves in the character’s shoes. As they read more complex stories, they ask, “Why did that character make those choices? What might have happened if they chose differently?” Developing narrative competencies can help readers appreciate the sources of the conflicts in stories and imagine a more satisfying and ethically justifiable ending for the characters involved. This vicarious experience of decision making within a fictional world prepares them for making real-world decisions. Public health practitioners who become close readers can easily imagine the barriers and burdens that individual patients face, which helps them design ethically appropriate and effective public health interventions (Montello1997).

As part of our close reading of “The Fugitive,” we draw from Martha Montello’s concept of a “mattering map” (Montello2014; Goldstein 1983). A mattering map is a metaphorical means for schematizing a character’s internal and external struggles by showing how underlying personal values inform the character’s choices. Readers can identify which values conflict at different points in the story by organizing the map according to key plot points and their significance to the character. To construct a mattering map, we must identify values, beliefs, expectations, and relationships that affect a character’s motivations to pursue important goals. Taken together, these elements reveal what matters “overwhelmingly” to a character.

In key moments in the story, the values underlying Marciano’s decisions become apparent. Mapping out these plot points helps the reader understand how illness threatens his livelihood, restricts his choices, and interferes with his relationships. Below is Marciano’s map (Fig. 16.1). As the story progresses and readers complete their inventory of what matters to the character, the integrity or “wholeness within the value system” becomes apparent (Montello2014). There is harmony or balance among the values and between the values and the other elements that constitute the character’s moral universe. However, the map itself can lose integrity when these values conflict or goods (romantic relationships, income, respect, health, etc.) that the charactervalues cannot be obtained. When this happens, readers may temporarily or permanently “erase” some elements of the map to signify that they are not driving the character’s motivations. At those points, other values may matter more to the character and thus motivate him to make different choices. In Marciano’s case, because he desires to maintain job security above all else, he defends his right to make his own decisions about whether to accept treatment that would interfere with his livelihood. Throughout the story, this principle of autonomy coexists in harmony with other values, such as his health, personal safety, and socioeconomic stability. But the map is disrupted when Marciano is coerced into receiving TB treatment. His core value—freedom of choice—is limited by external forces, and thus, its value diminishes on his map. Successful treatment will restore that value, but at the moment, Marciano feels his autonomy doesn’t matter because he’s powerless to exercise it in a meaningful way. As the story progresses, readers construct and reconstruct parts of Marciano’s map multiple times as he responds to challenges to his value system (Fig. 16.2).

Fig. 16.1
An illustration of Marciano's mattering map shows that job security is of the highest importance. It is a big circle, and around it at the top are the possibilities of cure, which are slightly bigger than freedom of choice and movement; at the bottom, there's safety and stability around the same size as the possibilities of cure.

Marciano’s mattering map before being detained for treatment. Shape and text size indicate degree of importance to Marciano

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Fig. 16.2
An illustration of Marciano's map depicts that cure possibilities are most important, followed by job safety, safety, and stability, and freedom of choice is least important.

Marciano’s mattering map after being detained for treatment

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To construct his mattering map, we must look at Marciano’s story “backwards, forwards, and sideways” (Lindemann2014). Looking backwards in time at what led to the current situation, we see how the illness experience created ruptures in his life story. In stories, as in life, it is generally the case that “one thing happens because of another,” but sometimes the unexpected happens (like catching TB), which causes a rupture or a break in the expected sequence of events that composes the “plot” of our life stories (Montello2014). Looking sideways, we explore how TB generally affects people socially. Some patients with infectious diseases like TB may face stigma attached to the illness, social factors that heighten risk of infection and transmission to others, assumptions about the health of immigrant populations, and the conflict between preserving individual libertyrights and the health of populations. Finally, by looking forward into the future, we consider possible treatment trajectories and the consequences they will have for Marciano.

Summary of the Narrative

We meet Marciano in the opening scene of “The Fugitive,” in a clinic somewhere in California. Marciano’s doctor is giving him instructions through a public health caseworker, Rosa, who also serves as a translator. Marciano hasn’t been following the doctor’s orders and will be given one final chance to follow the treatment plan, which includes wearing a mask in public and taking oral and intravenous medications. If he doesn’t follow the plan, he will be incarcerated and forced to comply with treatment. Marciano wants to be cured but doesn’t want to bear the treatment-related burdens. He faces numerous barriers to following through with treatment. He is frustrated by the requirement to wear a mask in public because it makes him feel uncomfortable and draws unwanted attention. Moreover, it’s difficult for him to manage his clinic appointments because they interfere with his work schedule. Ultimately, these and other challenges prove to be too much for Marciano, and he fails to complete the treatment plan. In response, the public health practitioners detain him and prepare to send him to a prison colony for treatment. He attacks them and escapes. As the story concludes, his fate remains unknown. Will the authorities find Marciano and incarcerate him again? Will he infect others? The ambiguous ending forces us, the readers, to consider how things might have turned out differently had Marciano and the public health practitioners developed a therapeutic instead of an adversarial relationship.

Close Reading in Action

We need to understand how Marciano experiences his illness in order to see how public health practitioners can make better and more ethically appropriate treatment decisions. TB has ruptured his life in many ways, but the circumstances of his life before his illness made accepting treatment even more difficult for Marciano. He was born to Mexican parents in California and was subsequently deported with them before he “had a chance to learn English or go to school here or anything else” (Boyle 2017, 245). He decides to return to California, where he finds a job as a gardener and amateur exterminator. Yet, he still wrestles with his decision to trade the safety and security of being “at home” with his family in Mexico for the pursuit of a better life in the United States. Nonetheless, all seems to be going well for him until he contracts TB from an unknown source. The narrator doesn’t share too many details about Marciano’s initial illness experience with us, but it’s clear that at some point he seeks treatment. He even manages to continue working while taking his medication, at least initially. Being able to work while undergoing treatment seems to heal some of the ruptures caused by the diagnosis. This is why work matters overwhelmingly to Marciano: when he works, he isn’t Marciano the patient as much as he’s Marciano the gardener. He experiences a number of unpleasant side effects, however, which make him nauseous and itchy “as if there were something under his skin clawing its way out” (Boyle 2017, 235). His illness also affects his ability to enjoy sexual relationships as the visible symptoms of his illness—the look of consumption— leave him feeling unattractive. Throughout the story, his constant cough, sometimes in the middle of conversations, embarrasses him. Beyond brief interactions with his co-workers and roommates, he becomes socially isolated.

Marciano’s actions and thoughts show that he values social connection and avoiding embarrassment. He knows that imprisonment will only isolate and embarrass him further. Taken together, the physical symptoms and the social dysfunction he experiences create multiple ruptures in his life story. 

A conflict with his case manager, Rosa, only widens these ruptures. As a day laborer with no family in the area and no close friends, Marciano is desperate for any form of social connection. He believes he’s found this with Rosa. What Rosa fails to recognize is that Marciano misreads her sympathy. He takes her kindness as flirtation. His desire for a cure isn’t simply a desire to avoid the public health authorities. He also wants to impress Rosa. On Marciano’s mattering map, his strong desire to be cured stands only slightly above his desire to be intimate with Rosa and his yearning for social connection.

As the story progresses, we see that Marciano is indeed sexually attracted to Rosa. She notices this and encourages him to take the medications to win her affections (Boyle 2017, 243). While we don’t gain insight into Rosa’s mind or her thoughts about Marciano, we can imagine her incentive to entice him into treatment. For example, one could speculate that she uses his interest in her as a source of leverage to convince him to accept the treatment plan. If this is the case, then it raises a question about the use of emotional manipulation as a tool for promoting the public’s best interests: should public health authorities be allowed to do this? It’s also possible that she found his leering distasteful but decided not to take herself off the case because she decided their therapeutic alliance was invaluable and that she could handle his advances. Taking herself off the case would also risk wasting time and endangering the public.

Marciano’s fantasies of a romantic relationship evaporate when Rosa catches him not wearing his mask. She then orders the authorities to haul him away to jail. For Marciano, cooperating with Rosa initially represents the possibility of a better life for him and the potential to heal multiple ruptures in his life story. As reflected on his mattering map, Marciano’s desire for social connection, intimacy with Rosa, and a potential cure for his illness supported the choice to cooperate. Once she becomes aware that he would never meet her expectations, Rosa reveals herself as an enforcer of the state’s will and a threat to his liberty. This conflict comes as a result of Rosa’s failure to understand Marciano’s story and to connect that story with goals that matter “overwhelmingly” to him. Rosa could have talked him through his experience of stigma. She could have made her expectations clearer. She could have communicated more clearly about the nature of their relationship. But alas, she misses multiple opportunities to do so.

What Rosa fails to understand is the significant difference between her expectations and Marciano’s when it comes to the treatment plan. When he is treated initially, he feels better in a shorter time than expected. This unexpected return to health causes him to think he is cured and impels him to stop the medication. Once he has achieved what matters to him, there seems to be no need to continue subjecting himself to the medication’s harmful side effects. Were Rosa aware of Marciano’s motivations, she could have explained that he had not yet reached his goal of being treated and would be risking his ability to return safely to work by ending treatment prematurely. Instead, he resorts to secretly selling the pills to make some extra money, all the while demonstrating to Rosa that he’s taking them as expected. When he turns in the empty pill bottles each week, he simply claims that he took them. And so, he accomplishes two major goals at once: he continues to gain favor with Rosa, and he maintains his financial stability. However, Rosa never asks him about any of this or why he is having trouble taking his medications and wearing the mask. She fails to understand that he genuinely wants to be cured but is facing “their contempt and their antiseptic smells and their masks and their dictates and their ultimatums” in addition to the awful effects of both the treatment and the disease (Boyle 2017, 236). Beyond these challenges, he is also at the mercy of numerous psychosocialfactors that are affecting his health and his decision making.

Social Determinants of Health

While researchers have attributed specific illnesses to social conditions for centuries, the idea that a person’s health depends on circumstances out of his or her control—including the political, socioeconomic, and cultural environment, also known as social determinants of health—has only gained traction in the last 20 years. England’s sanitary revolution in the nineteenth century made the connection between public health measures and personal health evident. New sewer systems prevented cholera outbreaks and reconfigurations of hospital spaces, as recommended by Florence Nightingale, saved patients from the germs their doctors carried (Kisacky 2017). In response to an urbanizing and industrializing world, the United States developed a decentralized public health infrastructure in the late 1800s (Starr 1982). But it would take more than 100 years for the idea that these social factors play as much of a role in a person’s health as individual choices to take shape in the medical literature.

The 2010 Affordable Care and Patient Protection Act, or Obamacare, was the first piece of health care legislation to identify social determinants as major contributors to a person’s health (HCERA 2010; PPACA 2010).Footnote 2 The law’s focus on population health spurred researchers to study how psychosocial factors, like the location of a hospital or forms of payment, affect groups of people. As of yet, these studies have shown more promise than effect. While most doctors acknowledge the contribution of social determinants to healthcare, a 2016 study in the Annals of FamilyMedicine showed that few have adopted these principles in their practice (Solberg 2016). Today, we are at a turning point with regard to the social determinants of health and medicine’s acceptance of this idea. Given the profession’s reticence to accept social determinants of health, it is at least somewhat understandable that public health guidelines, interventions, and enforcement strategies brought to bear on Marciano’s case did not account for the social determinants that influenced his decision not to continue with the treatment plan. These include his lack of job security, low socioeconomic status, social isolation, poor English fluency, and stigma related to others’ fear of infection. Taken together, these challenges place Marciano at a disadvantage when it comes time for him to make decisions about whether to adhere to the treatment plan. No matter which path he chooses, he will continue to face tradeoffs that could widen the ruptures already present in his illness experience.

Labeling Marciano’s behavior as “noncompliance” provides public health practitioners with an excuse to dismiss his choices as mere defiance. As Poirier and Brauner note, “language not only reflects but in turn can affect” how caregivers are taught to think about patients (1988). Reframing Marciano’s behavior and choices as the products of social determinants that already limited his life choices can help bridge communication gaps and identify psychosocial needs. Also at play are the values, beliefs, and desires that inform the construction of his mattering map. Although he desires to be cured, the treatment conflicts with other goods that matter most to him, namely, his independence and ability to earn a living. He “missed the job—and the money… he wanted to be back there again, under the sun, working, just that, working” (Boyle 2017, 238). Marciano’s dependence on a steady source of income crucially informs his decision making. Starting work too late in the day because he had to spend the morning in the clinic may cause him to lose his job. For Marciano, losing his job, which would be reflected as a significant erasure on the mattering map, would be too great a loss to endure. It’s not simply a job for him, but a way to demonstrate his value and independence. Knowing that he will have to continue to tolerate these intrusions at a stage in life when “thirty months was like a lifetime sentence, and even then, there were no guarantees,” Marciano refuses to risk his job security (Boyle 2017, 238). Not only would he face daily intrusions into his work life as well as irritating and debilitating side effects, but also he would have to face these challenges with little hope for a cure if he failed to complete the regimen. For Marciano, being cured at the cost of his job and independence strikes the wrong balance between what matters and what matters overwhelmingly.

To communicate the burden of the choices Marciano faces, Boyle draws on the symbolism of a wild animal trapped in a cage moments before extermination. As he broods on the brief chapter in his life between TB flare-ups, Marciano recalls an occasion when, as part of his gardening duties, he had the distasteful job of checking and cleaning the animal traps. He comes across a live raccoon who had wandered onto the estate of one of his patrón’s clients. His patrón instructs him to drown the raccoon in a garbage can. Marciano reluctantly complies. Later, with the authorities hunting him down, Marciano imagines himself in the raccoon’s place. He closes his eyes and “all he could see was the glint of a metal trap, bubbles rising in clear cold water, and the hands of the animal fighting to get out” (Boyle 2017, 252). Finding himself in a no-win situation, Marciano realizes that his illness has trapped him within an impersonal and uncaring system that provides only the illusion of autonomous choice.

Infectious Disease Management and Stigma

As Marciano’s story and our construction of his mattering map demonstrate, infectious disease management strategies that ignore stigma likely will fail to reduce disease incidence rates. Sociologist Erving Goffman defines stigma as a “dynamic process of devaluation that significantly discredits an individual in the eyes of others” (1963). Stigma related to health behaviors can exacerbate existing health inequalities. Marciano faced stigma from both external and internal sources. No matter what he did, he couldn’t hide his illness from others. As he walked around with a soiled surgical mask and halted conversations to cough violently, Marciano endured a number of negative reactions. These responses compounded his preexisting concerns about how others viewed him.

Unbeknownst to the public health authorities who detained Marciano, he deeply resented wearing the surgical mask in public because it “made him feel like he had a target painted on his back—or his face, actually, right in the middle of his face” (Boyle 2017, 233). Although an American citizen, he assumes that wearing the mask in public will likely reinforce misconceptions about non-English speakers and undocumented immigrants. As the mattering map we have constructed shows, he values the safety and security of feeling “at home,” but knows that some view him as unwanted or alien. He also embodies some of the stereotypes often attached to recent immigrants from Latin America. His appearance, native language, and field of work all mark him as someone who may have crossed the border recently. He internalizes these assumptions about how others view him, perhaps as someone to be avoided as both socially inferior and a potential threat to their health, which negatively impacts his own feelings of self-worth. In the United States during the twentieth century, persons who appeared to be “foreign-born” were associated with disease and infestation (Markel and Stern 2002; Molina 2011). Sadly, these associations have continued to frame this discourse into the twenty-first century (McCauley et al. 2013). Anti-immigrant advocates and others use this disenfranchising rhetoric of contagion to argue for restricting the flow of immigrants by labeling them as undesirable threats to public health (Alexander 2009). This larger public discourse around contagion and immigration underlies some of the stigmaMarciano faces.

Ultimately, Marciano responds to perceived stigma by discarding any obvious signs of illness, thus deflecting the dehumanizing gaze of his fellow citizens. Instead of wearing the mask as instructed, he throws it away and drinks beer in a pub with other customers, thus increasing the risk of infecting those around him. This decision to remove the mask in the bar makes him appear more threatening to those who know about his condition and ultimately leads to his incarceration. Nonetheless, his choice is justifiable according to his core values, given the importance that he attributes to both maintaining social connections and avoiding stigma.

Stigmatizing rhetoric colors Rosa’s instructions to Marciano. She tells him, “You’re highly contagious, and if you were to cough without the mask on, the bacteria could get into the air and infect your roommates, and you wouldn’t want that, would you?” (Boyle 2017, 234). She describes him as “contagious,” not the disease as contagious. He causes infection, not tuberculosis. In Rosa’s view, if Marciano doesn’t wear the mask, then it’s his (and only his) fault. In her view, refusing to wear the mask or take his medicine means that he wants to sicken his roommates. The way Rosa uses “contagion” here stigmatizes Marciano and raises the question of whether shame and guilt are the best strategies for achieving compliance. What alternatives might public health practitioners have for reframing the stigmatizing rhetoric around infectious disease and the public health interventions associated with controlling its spread?

Public relations campaigns to normalize wearing masks in public may be effective at reducing stigma. Patients could be encouraged to incorporate the mask into their wardrobes as a fashionable accessory, rather than as a medical apparatus. The masks themselves could be designed to be more aesthetically pleasing while retaining their primary function. One of Marciano’s chief complaints about the mask is that it is too conspicuous. Perhaps it could be redesigned to be less noticeable and more comfortable. Acknowledging that these concerns about appearance are valid and should be addressed would help reduce the stigma related to wearing the mask in public, thus preserving a value that Marciano ranks highly. As part of this campaign, public health officials could also emphasize that patients shouldn’t be blamed for contracting infectious diseases like TB. Instead, they should be seen as unwilling hosts to a dangerous disease that is contagious. Reframing mask-wearing as a heroic act of compassion for others could also shift the public’s view of that behavior from stigmatizing to praiseworthy. In light of the COVID-19 pandemic, this strategy may gain even more traction with the general public as awareness of the value of masks to prevent the spread of infectious diseases has grown considerably (Fisher et al. 2020).

Incarceration and Compulsory Treatment

Historically, public health authorities have restricted the liberty of both symptomatic and asymptomatic patients in very limited circumstances. The constant threat of incarceration and compulsory treatment looms over Marciano, undermining his trust in his caretakers. Trust is one of the values on Marciano’s mattering map. As someone whose only consistent social contacts are public health practitioners, losing trust in them poses a significant threat to the integrity of his core values. Only after he’s caught defying their orders via video and community surveillance--in a manner akin to an Orwellian regime--does Marciano attempt to assert his rights as an American citizen to due process. Unfortunately for him, he is unaware that states also have constitutionally protected rights. In this case, they have the right to compel treatment when citizens pose a risk to public health (California Health and Safety Code; Barry et al. 2016). At the story’s climax, Marciano, in an act of desperation, escapes incarceration and compulsory treatment by spitting on Rosa and everyone else in the room. It is a harsh action, as Marciano knows that he is infecting them with his “living death” (Boyle 2017, 246). As he sprays Rosa and the other shocked public health practitioners with his bloody sputum, he thinks to himself, “see how they like being condemned and ostracized and locked up without a trial or a lawyer or anything” (Boyle 2017, 246). Understanding what drove him to make this choice is important for considering the potential consequences of overzealous monitoring and pursuit of noncompliant patients.

Trust forms an essential component of the therapeutic alliance between doctors and patients. Historically, marginalized populations have had numerous reasons not to trust medical authorities. From Marciano’s perspective, the public health doctor in charge of his care is callous and uncaring. As he listens to a stern warning about the consequences of not complying, the “doctor’s eyes… looked at him as if he were less than human, something to step on in the street and crush, angry eyes, hateful, and what had he done to deserve this? He’d got sick, that was all—and couldn’t anybody get sick?” (Boyle 2017, 235). It is clear from this interaction that Marciano feels that he is being unfairly blamed for contracting TB. He doesn’t feel respected by the doctor, nor does he feel that the doctor trusts him. These suspicions are confirmed by subsequent interactions with Rosa and other public health practitioners. Towards the end of the story, he realizes that she was “part of the system and the system was against him” (Boyle 2017, 246).

Although public health practitioners commonly use surveillance methods to ensure compliance, doing so raises some concerns about privacy. These methods typically include face-to-face counseling, text reminders, monthly check-ins at home, follow up appointments at clinics, or directly observed therapy (Pradipta et al. 2020). Rosa is able to confront an unmasked Marciano at his home because she has been tracking him since he left the clinic. After his arrest, she counters his claim of innocence: “Don’t even give me that. We have you on the feed from the security camera at the 7-Eleven making a purchase without your mask on—and there was testimony from the bartender at Herlihy’s that you were in there without a mask, drinking, and on the very day you gave me your promise” (Boyle 2017, 245). Rosa’s use of terms like “testimony” and video evidence suggests she is more concerned with law enforcement than Marciano’s health. Her actions show that she is already convinced he will not comply with the treatment plan before he leaves the clinic. Revealing her suspicions to Marciano would have damaged their relationship even further, making future compliance even less likely. The use of these intrusive methods of monitoring to ensure adherence raises questions about whether and in which cases would resorting to measures that may infringe on patients’ privacy rights be ethically supportable.

Questions for Discussion

Incarcerating Marciano and obtaining a court order to force him to take the required medication would protect the public from a potential source of multi-drug resistant TB. If the use of force is effective in curing him of TB and ensuring that he cannot spread it to others, then both society and Marciano stand to benefit. However, these benefits need to be balanced against the loss of individual liberty, especially if due process isn’t followed. It is unclear whether the use of state power to place him in custody is actually warranted or simply being exercised in his case because Marciano lacks the resources needed to contest this use of power.

  1. 1.

    What considerations should be taken into account before public health officials exercise their police powers to confine and forcibly treat persons who are infected with TB?

  2. 2.

    Did Rosa exceed the boundaries of appropriate public health interventions? If so, in what way? Were her actions justified?

  3. 3.

    How would the principle of justice as fairness apply to this case? Is it fair to place Marciano in custody and compel him to complete an extended course of treatment?

  4. 4.

    How might a mattering map be useful for interviewing patients? What questions might public health practitioners ask in order to learn what matters overwhelmingly?

  5. 5.

    What role should public health practitioners play in addressing stigma related to infectious diseases? How responsible should they be for dispelling myths around public health interventions that may be stigmatizing or for mitigating their effects?

  6. 6.

    Considering the range of social determinants of health that affected his adherence in the first place, what would appropriate recompense for the restriction of Marciano’s liberty look like?

  7. 7.

    How might public health practitioners or others help lower the barriers to adherence that Marciano faces?