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Ethical aspects of directly observed treatment for tuberculosis: a cross-cultural comparison

Mette Sagbakken1*, Jan C Frich2, Gunnar A Bjune3 and John DH Porter4

Author Affiliations

1 Department of Nursing, Faculty of Health Sciences, Oslo and Akershus University College, PB 4, St. Olavs Plass, Oslo, 0130, Norway

2 Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, PO Box 1089, Oslo, Blindern, 0318, Norway

3 Department of Community Medicine, Institute of Health and Society, University of Oslo, PO Box 1089, Oslo, Blindern, 0318, Norway

4 Department of Clinical Research/Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK

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BMC Medical Ethics 2013, 14:25  doi:10.1186/1472-6939-14-25

Published: 2 July 2013



Tuberculosis is a major global public health challenge, and a majority of countries have adopted a version of the global strategy to fight Tuberculosis, Directly Observed Treatment, Short Course (DOTS). Drawing on results from research in Ethiopia and Norway, the aim of this paper is to highlight and discuss ethical aspects of the practice of Directly Observed Treatment (DOT) in a cross-cultural perspective.


Research from Ethiopia and Norway demonstrates that the rigid enforcement of directly observed treatment conflicts with patient autonomy, dignity and integrity. The treatment practices, especially when imposed in its strictest forms, expose those who have Tuberculosis to extra burdens and costs. Socially disadvantaged groups, such as the homeless, those employed as day labourers and those lacking rights as employees, face the highest burdens.


From an ethical standpoint, we argue that a rigid practice of directly observed treatment is difficult to justify, and that responsiveness to social determinants of Tuberculosis should become an integral part of the management of Tuberculosis.

Tuberculosis; Directly Observed Treatment; Ethics; Socially Disadvantaged