D594 Task 1 Leadership and Ethics Case Example

The Patient Who Went Back to Work: Leadership, Public Health Ethics and Negotiation When a Man With Infectious Tuberculosis Stops Treatment in a Composite County

Student Name

Leavitt School of Health, Western Governors University

D594: Public Health Leadership and Administration, Task 1

Course Instructor

Month Day, Year

The Patient Who Went Back to Work: Leadership, Public Health Ethics and Negotiation When a Man With Infectious Tuberculosis Stops Treatment in a Composite County

The Situation

Ridgeway County Health Department is a composite department whose tuberculosis program has two nurses and an outreach worker. Three weeks ago, Mr. Eduardo Ruiz, a composite 44-year-old line cook, was diagnosed with infectious pulmonary tuberculosis. He began treatment in the hospital and went home under a home isolation agreement, with a nurse visiting daily to watch him take his medicines. After ten days he stopped answering the door. The outreach worker learned that he had returned to work at a busy restaurant. At home are his wife and their three children. As the program manager, I must lead a worried team, resolve an ethical dilemma and reach a decision the patient will actually follow.

Leading the Team

The team is divided. One nurse wants the health officer to seek a court order immediately; the other thinks pressure will drive Mr. Ruiz further away. The outreach worker, who speaks Spanish and knows the restaurant community, fears that a heavy response will make other patients hide their symptoms. Morale is low, and each person is partly right.

I would use an adaptive leadership approach, which distinguishes technical problems with known solutions from adaptive challenges that require people to change their assumptions and learn (Heifetz et al., 2009). The medicine for tuberculosis is a technical matter; getting this patient to take it, without losing the community's trust, is adaptive. Applying that approach means naming the conflict openly at a team meeting, asking each member what they are trying to protect, and giving the work back to the team: the outreach worker will lead the first contact, the nurses will design a treatment schedule that fits a cook's hours, and I will prepare the legal option with the health officer in case it is needed. Holding steady, rather than rushing to the most dramatic option, is itself a leadership task.

The Ethical Dilemma

The dilemma sets Mr. Ruiz's liberty and privacy against the health of his coworkers, customers and family. Clinical ethics, which centers on the individual patient, is not enough here; public health ethics also recognizes the community's claim to protection. Childress et al. (2002) proposed five conditions that should be met before public health overrides individual rights: the measure must be effective, the benefit must outweigh the infringement, the infringement must be necessary to achieve the goal, it must be the least restrictive option available, and the decision must be explained publicly and honestly.

Applied here, protecting others is a strong justification: infectious tuberculosis spreads through the air in shared indoor spaces, and incomplete treatment risks drug resistance. But necessity and least infringement point away from immediate confinement. Mr. Ruiz has not refused treatment in principle; he stopped because of reasons the department has not yet addressed. A court order now would be more restrictive than necessary and might not even work, since a patient who feels coerced can still hide.

Legal Authority

State public health law gives the county health officer authority to order a person with infectious tuberculosis to complete directly observed treatment, to remain in isolation and, as a last resort and with a court hearing, to be detained for treatment. Due process protections apply at each step. The law therefore allows a stepped response, and the ethical analysis says to start at the lowest step that can work.

The Negotiation

The negotiation draws on interest-based bargaining as Fisher et al. (2011) describe it: keep the relationship apart from the dispute, look beneath what each side demands to what each side needs, create several possible solutions before choosing one, and settle hard points by a standard both sides accept. The outreach worker arranged a meeting at a neutral place, a community center, and served as a mediator the patient trusted.

The positions were simple: the department wanted him in isolation taking medicine; he wanted to work. The interests beneath them were more useful. Mr. Ruiz needed income, because he had no paid sick leave and his family depended on his wages. He feared that staying away would cost him his job. He was nauseated by the pills taken on an empty stomach at the time the nurse came, and he worried, wrongly, that the health department shared information with immigration authorities. The department needed him to take every dose and to stay away from others only until he was no longer infectious.

Options followed from those interests. The department assured him in writing that it does not share patient information with immigration authorities. The nurse changed his dose time to evening, with food and an antinausea medicine. Instead of daily visits at his door, he could take doses on video through his phone; in a randomized trial, video-observed treatment led to more fully observed doses than in-person observation (Story et al., 2019). The department connected him with emergency cash assistance and a food bank for the remaining weeks of isolation. With his permission, the outreach worker called the restaurant owner, sharing only that an employee needed a short medical leave for a treatable infection and would be cleared by the health department to return. The owner, whose interest was keeping a reliable cook and avoiding an outbreak among staff, agreed to hold his job.

The objective criterion was infectiousness. Both sides agreed that he would return to work when his sputum tests showed he was no longer infectious under the department's standard criteria, not on a date chosen by either side. The agreement was written in Spanish and English and signed. The health officer's order remains prepared but unused, and the agreement states plainly that it will be issued if doses are missed for three consecutive days.

Conclusion

The case required three skills at once. Adaptive leadership kept a divided team working together. Public health ethics justified protecting the community while insisting on the least restrictive effective measure. Interest-based negotiation turned a patient in hiding into a partner in his own treatment. The legal authority to compel treatment remained available, but the department did not need to use it because it first addressed the reasons treatment had stopped.

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

Fisher, R., Ury, W., & Patton, B. (2011). Getting to yes: Negotiating agreement without giving in (3rd ed.). Penguin Books.

Heifetz, R. A., Grashow, A., & Linsky, M. (2009). The practice of adaptive leadership: Tools and tactics for changing your organization and the world. Harvard Business Press.

Story, A., Aldridge, R. W., Smith, C. M., Garber, E., Hall, J., Ferenando, G., Possas, L., Hemming, S., Wurie, F., Luchenski, S., Abubakar, I., McHugh, T. D., White, P. J., Watson, J. M., Lipman, M., Garfein, R., & Hayward, A. C. (2019). Smartphone-enabled video-observed versus directly observed treatment for tuberculosis: A multicentre, analyst-blinded, randomised, controlled superiority trial. The Lancet, 393(10177), 1216-1224. https://doi.org/10.1016/S0140-6736(18)32993-3