need ethics help

[johndoe3344]

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First scenario:

Your 36-year-old patient has just tested positive for HIV. He asks that you not inform his wife of the results and claims he is not ready to tell her yet. What do you do?


The answer is that you have an obligation to tell the wife, because you must breach confidentiality when it concerns public safety or the safety of individual persons.


Second scenario:



A 22-year-old woman is admitted to the hospital with a headache, stiff neck and photophobia but an intact mental status. Lab test reveal cryptococcal meningitis, an infection commonly associated with HIV infection. When given the diagnosis, she adamantly refuses to be tested for HIV.



Should she be tested anyway by the medical staff?



The answer is that she shouldn't be tested because it should only be done with the informed consent of the patient.


But my question is, don't the answers to the first and second scenario contradict one another? Shouldn't we force testing in the second scenario so that her husband or sexual partner or whatever knows about the risks?

 

[NotSur]

First scenario:

Your 36-year-old patient has just tested positive for HIV. He asks that you not inform his wife of the results and claims he is not ready to tell her yet. What do you do?


The answer is that you have an obligation to tell the wife, because you must breach confidentiality when it concerns public safety or the safety of individual persons.


Second scenario:



A 22-year-old woman is admitted to the hospital with a headache, stiff neck and photophobia but an intact mental status. Lab test reveal cryptococcal meningitis, an infection commonly associated with HIV infection. When given the diagnosis, she adamantly refuses to be tested for HIV.



Should she be tested anyway by the medical staff?



The answer is that she shouldn't be tested because it should only be done with the informed consent of the patient.


But my question is, don't the answers to the first and second scenario contradict one another? Shouldn't we force testing in the second scenario so that her husband or sexual partner or whatever knows about the risks?

I say no. In the latter, you don't know if she has current sexual partners and until you know that she has HIV, I don't think you're morally bound to test her to make sure. Otherwise, physicians would be bound to test anyone who they think exhibits sexually risky behavior in case they are spreading diseases to their partners.

 

[afugazzi]

Either way, if these questions were actually posed to you as ethical dilemmas, then by their very nature you should be able to argue either way. If you have an argument that makes sense to you that contradicts the standard answers, you can voice it.

 

[BerlinDude]

I'm very curious to know where you got the "answers" to these scenarios.


But aside from that, this is the problem with what passes for "ethics" in medical school. As you go through your education, you are going to learn that there are very clear answers to what you do in these situations, and that it doesn't depend on what some hippie med school professor thinks is the "right thing to do", it's based on what the law in your state is.

Screw ethics, they're meaningless. Find out your legal obligations as a physician practicing in your state, and follow those rules. Everything else is unimportant.

What are you talking about? The law (usually) derives from ethics, not what "some hippie med school professor thinks is the right thing to do".

OP, I agree with both your answers.

 

[afugazzi]

I didn't say anything about one "deriving" from the other. I don't care about that.

What I'm saying is that classes and students kick around these scenarios, making arguments for one side or the other, talking about principles of justice and autonomy, and it's just pointless. The answer has already been decided by the law and the State Board of Medicine. I

In real life, you pick the wrong side, all the fancy philosophical arguments in the world aren't going to prevent you from getting your license pulled, a lawsuit filed, and maybe even criminally charged.

And BTW, for #1 - you (or the testing laboratory) notifies the State Board of Health, who then notifies the wife.

for #2, you don't run an HIV, but you do run a CD4 count (along with whatever other testing for causes of immunocompromised states are indicated), which basically makes an empiric diagnosis for you, since you have to have full-blown AIDS before the crytococcal meningitis shows up. You tell the patient all indications are that she as AIDS, and offer her further testing and treatment. She either pulls herself together and comes around, or she leaves and never comes back. Easy day.

Actually, it's not always true that if you pick the wrong side as determined by law you will be the worse off. For example, before Dr. Kevorkian finally got convicted (most likely because he had the audacity to violate his patient's privacy by filming the assisted suicide), he was arrested and tried several times for killing his patients, and each time he was let off. The law was very clearly against him, but the jury's morals aligned with his own in each case, so he got a not guilty verdict.

So at least in cases where a jury determines your ultimate guilt or innocence, you can break the word of the law, but as long as what you're doing is ethical in the jury's eyes, get in no trouble.

 

[Rendar5]

^ lol.

Yeah, the answer to question 1 is actually wrong. You do not break confidentially. You arrange for an anonymous message to the wife that tells her she has been exposed and should get tested. This is doen through the Department of Health generally as said above. The alternative is, you speak with the husband and ask if you could speak to the wife with him in the room to discuss the situation and as support. If he wants this, it takes 5 minutes out of your day. If you're in a setting where that's not feasible, offer him the services of an HIV counselor to talk with him and hsi wife at the same time. You do not breach confidentiality in this situation, just as you wouldn't breach confidentiality if someone who has the flu to protect the spouse and parents/children.