You are about to meet the Lemont family. The physician knows that Janice’s husband, Mike, recently discovered that he is human immunodeficiency virus (HIV) positive. He has been having bisexual relations for some time now. Mike has told the physician that he is happy with Janice and does not want to give up his family life, but has found it difficult to ignore his bisexual tendencies. The physician advised Mike that he had to tell Janice about the HIV as she would need to be tested. He had offered to to tell Janice for him but Mike wanted to do it himself. Janice is now in the physician’s office.
Consent and confidentiality
Reflective exercise 1
The exercises focus on ethical, communication and cultural issues. There are no absolutely right or wrong answers but some answers are better than others.
Read the options and the questions arising from them. To see how the option would occur in the physician-patient relationship, three of them have videos. Use the questions associated with each option to guide your decision making. After completing the exercise, you can read the commentary on the exercise and/or consult some resources.
You have told Janice that she needs the routine antenatal tests.
Commentary on option 1
Ordinarily, formal consent is not required for low-risk procedures such as routine blood tests. The patient’s obvious agreement to the procedure is sufficient. Perhaps in this instance you want to avoid causing Janice anxiety, because she could very well test negative. While the desire to do no harm (non-maleficence) is commendable, your privileged knowledge in this situation (about Mike) may make this option deceptive. In fact, it could be seen as an example of “therapeutic privilege.” Such paternalistic behaviour is rarely acceptable.
Given the implications of HIV testing, even in a low-risk situation (which this is not), such a test cannot be considered “routine” in the same sense as a hemoglobin or blood glucose test can. One could argue that even with routine tests, if there are important implications for the patient, it would be advisable for the physician to explain why the test is being done and its possible consequences. A patient who is told what the physician is thinking and the reasons for his recommendations is more likely to feel cared for and more willing to participate in their care.
Commentary on option 2
While it might differ by province and territory, guidelines recommend that all pregnant women be screened for HIV and receive counselling for this process. What is discussed during counselling will depend upon the patient’s circumstance. Janice, for instance, does not indulge in high-risk sexual behaviour and therefore the physician must obtain formal written or verbal consent before ordering the test. The physician is expected to inform the woman that the test will be done, to provide counselling and to include the test unless she explicitly opts out. Consider the implications for the physician in how the request for testing for HIV is presented to the patient. Is there sometimes a difference between legal adherence to guidelines and ethical behaviour? In this case, is Janice giving truly informed consent?
Commentary on option 3
You are caught between your duty of confidentiality to Mike and your duty to provide the best care for Janice (beneficence). In telling Janice to speak to Mike about HIV, are you not violating your confidentiality to Mike? Also, in suggesting that they talk, are you abandoning your duty of care to both? Might they seek care elsewhere, and in this circumstance, will that caregiver know of Mike’s status? Sexual conduct is a potentially sensitive topic with a couple. Although you have no reason to suspect abuse will occur in this case, you always have to remember that raising the topic may cause domestic violence. Screening for that possibility or suggesting that the couple come in to talk to you together may be better options.
For additional information, consult the Canadian Medical Association’s Code of Ethics.
Commentary on option 4
With this choice, you have placed a duty to warn above that of confidentiality. This might be appropriate if Mike refused to tell Janice of his HIV status and you were concerned that she remained at risk. Guidelines indicate that if the physician believes that a clear and immediate danger to another individual or society is present, then there is a duty to warn. In this case, is this requirement present? What beneficence will occur to Janice if you tell her? What harm might come if you tell her? This action should only be taken if you have exhausted all other options.
The case continues
The physician decides simply to say that he will request routine blood tests and asks that Janice make a return appointment for the following week.
Click on the audio button to hear the telephone conversation between the physician and Mike. Next view the video.
Dr. Randall: Mike, it’s Dr. Randall here. I’m calling because I just saw Janice and I’m wondering if you’ve told her about the HIV yet?
Mike: Well, no actually. I’ve tried but I didn’t know how to tell her …
Dr. Randall: Are you aware of Janice’s condition?
Mike: You mean that she might be … pregnant?
Dr. Randall: Yes. You know that she might be at risk and the baby also. If Janice is positive she has to have treatment as soon as possible to protect the baby.
Mike: I didn’t know there was treatment. I guess I’m just feeling sick that I might have put the baby at risk. I can’t even think about what it means if Janice …
Dr. Randall: Mike, this is a very difficult situation but there are things we can do. Is there something I can help you with? Would you like me to help you tell Janice?
Mike: Ummm, I don’t know … I should be able to … yeah, I guess I would like that, thanks.
Dr. Randall: Janice is scheduled to come back for her test results tomorrow at 11:00. Can you join her?
Mike: I’ll be there. Thanks Dr. Randall.
After the telephone conversation, Dr. Randall meets with Mike and Janice in his office.