Modules

Consent and confidentiality

Part 1

Introduction

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 tell Janice for him but Mike wanted to do it himself. Janice is now in the physician’s office.

  • Dr. Randall: So Janice, how’s everything?

    Janice: Good. I’m a little bit tired though I suppose that’s early pregnancy.

    Dr. Randall: Pregnancy? You think you’re pregnant?

    Janice: I know I am. I feel pregnant and I haven’t had my period in two months oh and I took a bunch of drugstore tests.

    Dr. Randall: I didn’t realize you two were trying for another baby.

    Janice: Yeah.

    Dr. Randall: How do you both feel about it?

    Janice: Well we always thought we’d have another one eventually, a second one, you know, but I think Mike’s a little bit freaked out by it. Sam is finally sleeping through the night and I think he’s worried about sleepless nights again.

    Dr. Randall: Did Mike say he was freaked out?

    Janice: No, but he’s been acting a little bit withdrawn. Actually, I’m a little worried about him. I think he might be a bit depressed.

    Dr. Randall: Do you think he needs to talk to someone?

    Janice: You know Mike, he keeps things to himself.

    Dr. Randall: Well, let’s confirm that you are. We’ll do some tests. Well, what are your symptoms?

    Janice: The usual: tired, sore breasts, little queasy, and no period.

    Dr. Randall: Sounds like you are. Anything changed since your last pregnancy?

    Janice: No.

    Dr. Randall: You’re not a smoker?

    Janice: No.

    Dr. Randall: No. Any alcohol?

    Janice: No.

    Dr. Randall: Okay, how about street drugs?

    Janice: Please. I am taking my folic acid though.

    Dr. Randall: Excellent. Good. Well we’ll do the tests and if you’re worried about Mike, why don’t you just ask him to come in and he and I will talk.

    Janice: Okay, I’ll do that. Thank you.

    Dr. Randall: You’re welcome.

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.

What would you do?

Doctor: So Janice, as you know when a woman is pregnant there are certain routine blood tests that we do to make sure everything’s okay.

Janice: Yeah, I had them last time.

Doctor: Right. So the tests include hemoglobin, a white cell count. Oh, we did rubella last time so we don’t have to repeat that one. We’ll check your urine, you know, all the routine stuff and HIV.

Janice: HIV?

Doctor: It’s all part of the regular blood work.

Janice: That’s new?

Doctor: Well, we figure if we give it to everyone we can catch the people who really need it.

Janice: Okay.

Doctor: So Janice, as you know when a woman is pregnant there are certain routine blood tests that we do to make sure everything’s okay.

Janice: Yeah, I had them last time.

Doctor: Right. So, you know that the tests include a hemoglobin, a white cell count… oh we did rubella last time so we don’t have to repeat that one. I’ll check your urine. Well, you know all the routine stuff and HIV.

Janice: HIV? That’s new.

Doctor: Well. You know, it’s out there. It’s been around for a while actually and well do you have any reason to believe that you may be at risk for HIV?

Janice: No, I mean Mike and I have been together forever.

Doctor: And do you know for certain that Mike is monogamous?

Janice: Yes, as far as I know.

Doctor: Hey, it’s out there. It’s around. It might be a good idea for you two to have a talk about it.

Janice: Are you trying to tell me something?

Doctor: Janice, before we proceed there’s something that you and Mike need to discuss together.

Janice: What do you mean?

Doctor: I really can’t say but I’d really like to see the two of you together.

Janice: Is something wrong?

Doctor: I really can’t say right now.

Janice: Doctor I don’t understand why do I have to wait until Mike comes in?

Doctor: I’d really rather not say anything until I can get you both in the office together. Do you think you could ask Mike to come in with you?

Janice: Yeah, yeah I guess.

Doctor: Good, good.

Option 4

You tell Janice that, in addition to the routine antenatal tests, she needs an HIV test. You choose to tell her that Mike is HIV positive because you are obliged to for her own protection.

  • Which principal of physician-patient interaction are you following in this instance?
  • Why would you choose this course of action?

(There is no video for this option.)

Commentaries

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.

(See the commentary on the Tarasoff case.)

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.

  • Dr. Randall: Mike.

    Mike: Hi.

    Dr. Randall: Hi. It’s Dr. Randall. I’m calling because I just saw Janice and I was wondering if you’d told her about the HIV yet?

    Mike: Well, no actually. I’ve tried but I don’t know how to tell her.

    Dr. Randall: Are you aware of her condition?

    Mike: You mean that she might be pregnant?

    Dr. Randall: Yes. You know, she and the baby might be at risk. If Janice is HIV positive she needs treatment as soon as possible to protect the baby.

    Mike: I didn’t know there was treatment. 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: No, Mike this is a very difficult situation but there are things that we can do. Is there something I can help you with? Would you like me to help you tell Janice?

    Mike: I don’t know. I should be able to yeah, yeah, I guess I would like your help. Thanks.

    Dr. Randall: Okay Janice is scheduled to come in tomorrow at 11:00 for her test results. Do you think you can join her?

    Mike: I’ll be there. Thanks, doctor.

    Dr. Randall: No problem. Bye Mike.

After the telephone conversation, Dr. Randall meets with Mike and Janice in his office.

  • Dr. Randall: I’m glad you could both come in today.

    Janice: So, doc, what’s the good news?

    Dr. Randall: Well Janice, as you suspected, you are pregnant. Is this something I can congratulate you both on?

    Janice: Oh yeah I’m pretty happy about it. I don’t know how Mike’s feeling though?

    Mike: No, no, I’m happy. I just… There might be a problem.

    Janice: What do you mean?

    Mike: …

    Dr. Randall: Janice, one of the reasons I asked you to come in today is because there’s something important we need to discuss. You don’t know about this, and well I’m sorry to have to tell you but there are concerns with Mike’s health. Mike came in to see me for some blood tests a few weeks ago for his insurance and well, his results came back HIV positive.

    Janice: What? How? Why didn’t you tell me?

    Mike: I tried but I didn’t know how.

    Janice: Wait, wait a minute.

    Dr. Randall: Janice, there’s something else you need to know.

    Janice: No. This is what that HIV test was about. How dare you sit there and tell me this now when you knew last time I was sitting here! How dare you trick me!

    Mike: Janice. This has nothing to do with…

    Janice: The hell it doesn’t!

    Dr. Randall: Janice, it’s understandable that you’re upset.

    Janice: It’s understandable, you don’t know how I’m feeling.

    Dr. Randall: No, no I don’t, absolutely. I don’t but I can see that you’re upset. I’m just wondering if we can take a couple of steps back and I could give you the information you need, is that all right?

    Janice: Fine.

    Dr. Randall: All right. First, I’m truly sorry that you feel that I have betrayed you. It certainly wasn’t my intention. The problem is that I would have been breaching Mike’s confidentiality. He is my patient too. If I told you about his condition… I probably didn’t handle this very well. Looking back, I probably should have had you both come in and tell you about this before I actually did the test but many doctors test for HIV and pregnancy, I thought we were under time constraints and it would be prudent to act as quickly as possible.

    I know that you two are going to have a lot of things to discuss and I’m still here if you need me but if you prefer I can set up an appointment with a counselor.

    And Janice there’s something else I have to tell you. I got the results back for your blood tests and sorry but it’s not good news.

    Janice: Oh, no.

    Dr. Randall: You tested positive for HIV.

    Janice: No…

    Mike: Janice, I’m so sorry…

    Janice: So what, you’re just going to infect all of us now? What’s going to happen now? What about our babies?

    Dr. Randall: Listen, you’re going to have a lot of questions I know, but I’m here and I’ll give you as much information as I can.

    Janice: What are we going to do?

Knowledge check

    Select as many as you think apply.

 

Next: Part 2

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