Ethical issues in the treatment of hepatitis C.

Four million Americans are infected with hepatitis C virus (HCV), making it the most common blood-borne infection in the United States. Members of disadvantaged groups such as prisoners and those with psychiatric disorders have a higher prevalence of HCV infection than the general population. Ethical, clinical, economic, and social barriers often prevent these patients from receiving the effective antiviral treatments now available. These barriers to care have received little attention in the literature, and yet, knowledge of the ethical and social justice aspects of HCV treatment can enhance the quality of gastroenterologists' patient care. This article analyzes 5 clinical-ethical arguments frequently presented for limiting patient access to HCV treatment: risk/benefit balance, justice, compliance, cost-effectiveness, and discrimination. Appropriate psychiatric and substance use intervention can result in a favorable cost-effectiveness and risk/benefit balance for treating members of disadvantaged groups. Although members of disadvantaged populations might exhibit higher rates of psychiatric side effects and poorer compliance with antiviral regimens, collaborative care can improve adherence and reduce adverse effects. The principle of justice might warrant treatment of these populations if the rate of adherence and risk/benefit balance is not significantly different than in other populations. Discrimination against persons with hepatitis C often reduces access to care among prisoners and other stigmatized groups. This analysis suggests that if gastroenterologists and mental health and substance abuse professionals actively collaborate, access to antiviral therapy for HCV can, in many cases, be safely and effectively expanded to disadvantaged populations.