Question

Mr. Abdullah attended the genito-urinary clinic of the local hospital. He is seen by the doctor who informed him that he is HIV positive. He started a course of treatment. During patient history taking, Mr. Abdullah shares to the nurse that he married two years ago and they are expecting they are first born in two months’ time. Prior to his marriage, Mr. Abdullah had a series of sexual partners. The nurse counsels him to contact his sexual partners to inform them of his status.

On his subsequent visit, the nurse learns that Mr. Abdullah has not told his wife about his condition. The nurse explains to him that steps should be taken to assess whether his wife is HIV positive and whether the baby is at risk so that necessary treatments may be started. However, despite the nurse’s counsel and explanation, Mr. Abdullah refuses to tell his wife. He threatens the nurse that if she will attempt to communicate with his wife in any way or tell her of his diagnosis without his consent, he will stop his treatment regimen and will sue her for breach of confidentiality because this is a privileged communication.

What is the legal and ethical dilemma surrounding this scenario?

What is the “right” thing to do for the nurse in the case of Mr. Abdullah? Defend your answer focusing on the legal and ethical aspects of your decision.

What would you recommend to prevent this situation from occurring in

Answer 1

It is clear that the ethical principles of respect for people, justice and beneficence provide essential guidance in health care. In addition, the utilitarian perspective and the ethic of caring also provide vital guidance to medical behavior. Notably, these enable the clinicians to interact with HIV positive patients and those with infectious diseases in a sustainable manner. Ethical concerns such as confidentiality, end of life, informed consent, vaccine research, research design and conflict of interest characterize the interaction between patients with infectious illnesses such as HIV and clinicians.

Patients need to be informed of their legal rights prior to testing. Pretest procedures and counseling need to be upheld. With regard to HIV vaccine research, it is important that the trials be carried out on a population that is globally representative. Finally, it would be important for the researchers carrying out medical research about infectious diseases to be guided by fundamental clinical ethics.

Healthcare providers contribute to the misconceptions (Gostin, 2000). Patients are not informed about the implications of the research. Loyalty by patients makes them to avoid informing themselves of the necessary procedures. Patients at times provide information in return for better services from the healthcare in future. Healthcare providers undertaking research place greater emphasis on financial benefits rather than the interests of the patients.

The value of respect for persons demands that the decisions and autonomy of other individuals be upheld. In addition, this principle postulates that persons that lack autonomy and those that are unable to make independent decisions be protected. Justice requires that all persons irrespective of their status be treated in a fair manner. The ideal state of justice is characterized by equal distribution of the burdens and benefits within the society.

The former places emphasis on the consequences of the activities and postulates that clinical behavior can only be morally acceptable if its consequences are desirable and enhance the greatest good for the majority of the population. The latter on the other hand judges the activities based on the effect that they have on relationships.

Over time, various ethical concerns have arisen from the interaction between HIV positive patients and clinicians. Confidentiality is one such issue that has been considered to be very important in this regard. Generally, the law provides that all medical information be treated with a high degree of confidentiality. However, Gostin et al (1997) shows that the sensitive nature of information related to HIV and other infectious diseases has prompted various states to adopt relevant laws that offer additional protection to the same. These laws prevent disclosure of information related to HIV without prior authorization. However, as indicated earlier, there are different contexts that might require that such information be disclosed without the knowledge and/ or authorization of the patients. Basically, such steps are considered ethical as they seek to enhance the greatest good for the greatest percentage of a population.

To begin with, the law allows the healthcare personnel to report HIV infections to relevant public heath authorities. Gostin (2000) contends that the advantages of this reporting basically outweigh the risk discrimination of the infected individual. Usually, the name of the individual is not provided during reporting. However, epidemiological studies show that in order for intervention measures to yield optimal results, there is need to encourage provision of name based information during reporting. Nonetheless, it has been argued that this has the capacity to increase the risk of discrimination and therefore should be avoided. This position is also held by the Centers of Disease Control and Prevention that ensure that testing of HIV is made anonymous.

Another scenario that breeches confidentiality but is not punishable by law is when the healthcare providers disclose the status of a patient to persons that may be at risk of infection. In this regard, Gostin and Webber (1998) ascertain that the right of a patient to be accorded confidentiality is often in conflict with the right of the partner to be notified accordingly. Despite the fact that confidentiality is instrumental in avoiding discrimination, it needs to be appreciated that the implications of failing to inform a non suspecting partner can be far reaching. In order to avoid conflicts, the patients are usually advised during counseling to reveal their status to their sex partners.

Another exception with regard to confidentiality of information that is HIV related concerns the healthcare workers that are infected with the disease. This particularly affects the workers who perform exposure prone procedures. In this respect, Singer et al (2006) cites the US law that demands that the status of these workers be reviewed by the expert panel. This then makes a decision regarding whether to prevent the infected workers from performing such procedures or to inform the patients about their infection. The equivalency policy that demands that the healthcare workers disclose their status has been increasingly adopted by various states.

From an ethical perspective, disclosure of HIV status by the health workers and enforcement of some form of restrictions is in line with the best interests of the patients. However, various studies of whom Lurie and Wolfe (1999) are represented argue that this contravenes the privacy of health workers and enhances discrimination especially when the patients are informed. However, it should be appreciated that the benefit of the uninfected patient outweighs the risk of discrimination of a heath worker by the same. To address these concerns, a more viable approach would be for the council of experts to place restrictions but avoid informing the patient, unless under special conditions.

Another ethical issue regarding HIV positive patients and those with infectious diseases is informed consent before testing. Basically, various clinical tests that involve testing of the blood samples of the patients do not require consent. However, the realization that testing for HIV had various negative implications led to the need for informed consent. The specific psychosocial risks that are presented by HIV testing include restriction of lack of access to insurance, healthcare or housing, possibility of rejection by family, friends and/ or close relatives and discrimination during employment. Thus special procedures that seek the consent of the patient such as pretest counseling and need for specific informed consent from the patient are a prerequisite. These measures ensure that the patient is psychologically and emotionally prepared to deal with the implications of the results.

Essentially, the information that needs to be availed to the patient prior to testing include the benefits and risks of testing, risky behaviors, measures undertaken to prevent transmission, the nature of the test and confidentiality of the test. These are always coupled with an informed consent from the patient. In their review, Varmus and Satcher (1999) indicate that most states require that the patient provide a written consent. However this provision has various exceptions. In some instances, prisoners are persons that are accused of sexual crimes are often tested without consent. In addition, some states have made the testing mandatory for new born babies. In his study, Kass et al (1996) indicates that this also reveals the status of the mother.

Notably, prenatal testing is also undertaken without consent from the mother. Fundamentally, early detection is instrumental in preventing mother to child transmission. Initially, prenatal testing was undertaken after a pretest counseling and informed consent. However, changes were proposed and currently, all pregnant mothers undergo a routine prenatal HIV testing. However, the revised edition of this law by the US Public Health Service presented a need for informed consent, although it is not clarify whether this needs to be verbal or written. Connor et al (2004) ascertains that the proposals that seek to make HIV testing mandatory for pregnant mothers are compounded by different complexities.