The difficult question of if and when to treat those infected with hepatitis C virus (HCV) can be evaluated from a myriad of perspectives, including public health concerns, risk/benefit in corrections, legal issues, ethical issues, and personal physician-patient responsibility. The discussion that follows reflects the opinions of the author.
Reflecting these concerns, public health resources have been directed to the prevention of infection and disease. The goals of the National Hepatitis C Prevention Strategy are "to lower the incidence of acute hepatitis C in the United States and reduce the disease burden from chronic HCV infection," through:
Up to one third of those with HCV in this country have been incarcerated. Correctional health care workers see two discrete HCV epidemics in prisons and jails -- one that is decades old and the other that is comprised of "rapid progressors, i.e., patients who have not been infected for the traditional two to three decades that are required to show problems with this disease."2 HIV has a clear role in the more rapid progression of HCV disease in co-infected patients. In some prison systems, HCV has become the single largest cause of death,3 reminiscent of the situation of HIV a decade ago.
Although prisoners have a constitutional right to healthcare, correctional healthcare standards vary significantly from state to state. Some argue that to treat HCV aggressively would draw scarce resources away from other essential correctional healthcare programs. Prison budgets are at the whim of the respective state legislatures (and the U.S. Congress in the federal system), and must compete with all other healthcare initiatives. Few states have appropriated recurring funding for HCV care as they have for the treatment of HIV. Some prison systems have chosen to ignore the issue because with an average length of stay of less than three years,4 it is unlikely that while incarcerated, a patient with HCV will develop sequelae that will lead to an economic burden for the penal system.
However, some large systems, particularly in the South, have average lengths of stays that approach a decade.5 These systems are more likely to face the economic consequences of therapeutic nihilism. Paradoxically, most of these systems have been among the least aggressive when it comes to HCV treatment.
There are currently pending lawsuits involving correctional facilities concerning failure to treat HCV;6 most of these cases are progressing at a very slow pace. It is still unclear whether or not the plaintiffs will prevail in these cases. Last year at the "Management of Hepatitis C in Prisons 2003" meeting (San Antonio, TX), healthcare providers discussed various approaches to developing effective guidelines for HCV treatment in corrections but failed to achieve a definitive consensus on management of this infection.7 It is therefore unlikely that the courts will intervene and require a particular approach to treatment.
One area in which correctional systems may be vulnerable is by requiring an inmate to have a specific amount of time left on their sentence to be considered for treatment. The justification for this requirement has been that it is necessary to allow the patient to be able to complete a full course of therapy prior to release. In the same way that one cannot withhold cancer treatment because the regimen may not be completed prior to discharge, there is a requirement to initiate treatment for eligible patients and then refer the patient to non-correctional resources once the inmate has reached the end-of-sentence. In this sense, requiring a specific period of time left to serve may be more legally risky than having a policy of not treating HCV at all.
Systems that have policies that do not offer treatment for HCV claim:
Systems with policies for treatment of HCV in place claim:
As with most ethical dilemmas, all sides have compelling arguments. In addition, most issues fall into grey areas.
Irrespective of our practice setting, each of us has a responsibility to our individual patients. This responsibility exceeds that of "what is good for most of the population." This unique relationship is one reason why physicians understand the global problem of antibiotic overuse, but continue to excessively prescribe in their own practices. The legal issues notwithstanding, (which in the correctional setting include malpractice and licensure actions, as well as allegations of deliberate indifference and Civil Rights infraction) there is the matter of patient trust. Your patient expects you to do what is best for him or her. Your final decision is based on your background of knowledge, your ethical framework and the interaction between you and your patient at that particular moment in time.
This kind of subjectivity is the nemesis of managed care companies. As physicians, we claim it is part of the art of medicine. It is one of the major reasons there is not uniformity of decision-making among physicians or, more importantly, even for a single physician seeing patients with similar problems. Most of us would comfortably say medicine is an art as well as a science and explain it that way. Should it not be our unique physician/patient relationship that determines whether to treat or not to treat? After all, it is our name on the prescription and our irrevocable, non-delegable responsibility for the patient.
David Thomas, M.D., J.D., holds a Chair at the Department of Surgery, Division of Correctional Medicine, NovaSoutheastern University, College of Osteopathic Medicine. Disclosures: Nothing to disclose.