The ethical values articulated in the Guidance on Ethics of Tuberculosis Prevention, Care and Control reflect many of the principles incorporated in frameworks used by ethicists in assessing the justification of public health interventions.
These frameworks include a loose set of moral considerations such as producing benefits, preventing harms and maximizing utility, and, to a great extent, they overlap [18–20].  point to five “justificatory conditions” that need to be assessed when considering ethical concerns in public health interventions.
Even when a proposed policy satisfies the first three justificatory conditions, “least infringement” is a condition underlining the need to minimize the infringement on general moral considerations.
For example, when a policy infringes on a patient’s autonomy, the least restrictive alternative should be sought; or when a policy infringes on a patient’s privacy, the least intrusive alternative should be sought.
While DOTS programmes have significantly contributed to a decline in TB prevalence and TB mortality, socio-economic development is still the main reason behind the decline in TB incidence in different regions of the world .
Directly observed treatment (DOT) is one component of DOTS.It involves observing patients during their intake of medication.A systematic review of 11 randomized and quasi-randomized controlled trials that compared DOT conducted by a health worker, family member, or community volunteer with self-administration of treatment at home found no evidence that DOT, when compared with self-administration, had any quantitatively important effect on cure or treatment completion for TB in low-, middle- and high-income countries .Research in Addis Ababa, Ethiopia [14, 15], and in Norway [16, 17], indicates that DOT gives rise to a series of ethical issues in practice.The aim of this paper is to highlight and discuss ethical aspects of the practice of DOT from a cross-cultural perspective, drawing on results from research in Ethiopia and Norway.Further, no significant difference in clinical outcomes was found between DOT given at a clinic and DOT given by a family member or community health worker, or for DOT given by a family member compared with a community health worker .The impact of DOT on patients’ autonomy has been questioned .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.Nevertheless, studies investigating the effect of DOTS on TB incidence, treatment completion and cure do not provide convincing evidence of the value of DOTS as the main strategy in efforts to control TB.In areas where there has been a significant decline of TB, it has been difficult to separate the effect of DOTS from the effect of general socio-economic development .