Doctor confidentiality, HIV, and what feels right

I don’t have a fully formed opinion on the following issue, because I can see both sides of the argument.

But as sometimes happens, vigorous debate amongst good debaters may help me reach a more solid conclusion.

An opinion piecein today’s Washington Post discusses a doctor whose patient was urged by her long-term partner to seek medical care for her ongoing fatigue and persistent cough. The patient initially refused an HIV test because, she said, she wasn’t at risk.

The test was eventually done and came back positive. She was devastated, and brought in her long-term partner, fearing she had infected him. His test was also positive, and he asked to be treated as well. Alone, the doctor asked him about any previous medications and he revealed he had been taking an AIDS cocktail – in other words, he had been an HIV carrier for years, knew he was an HIV carrier, and withheld this information from his partner. As the physician relates:

She goes on:

The opinion piece concludes with the speculation that this dilemma arises mainly from the stigma still associated with HIV; if doctors managed the disease like a chronic condition, like diabetes or high cholesterol, and tested for it regularly, HIV’s stigma would vanish.

Should doctors’ confidentiality include an exception in similar cases?

It should be illegal (if it isn’t) to knowingly put someone at risk for a potentially fatal disease (however well controlled it is these days). A doctor who is aware of criminal activity planned ought to be compelled to report it, and the appropriate authorities should deal with it, including removing the danger (i.e., telling the potential victim).

I don’t think HIV positive patients should be stigmatized. That, however, doesn’t make this difficult for me. I would require zero soul searching, I think, to answer the question, “Gee, should I try to interfere in this guy deliberately putting that other person’s life at risk?”

I think that in the first case, the doctor-patient confidentiality should control. The damage has been done. No disclosure can undo that.

In the second case, she is knowingly putting her boyfriend at the risk of infection of a deadly disease. The doctor should have a duty to disclose it to prevent future harm.

It’s pretty similar for attorneys, no? You can’t rat out your clients for prior bad acts, but you may (shall in some states) disclose confidential information to prevent future death or serious bodily harm.

HIV is a reportable disease. The physician should report the results to the department of health. The ball is then in their court.

Further, I don’t think the stigma is an appropriate analogy. If diabetes or high cholesterol could be passed on through sexual contact, then the same rules should apply. Since they aren’t, there is no dilemma on keeping a patient’s diabetes secret from his/her partner.

Exactly. An attorney could breach confidentiality to prevent a future crime, but not to reveal a past one.

Back in 1970, when I got married, I was required to take a blood test. I assume for syphilis. Do state laws currently require an AIDS blood test? I would hope so.

These sound like great matters of discussion for a college ethics class.

I tend to agree with the answer jtgain gave - report the second case to prevent further infection. But I’m not at all sure that would be the “correct” legal answer.

I think almost every state has eliminated the blood test requirement.

I didn’t have to get a blood test in PA in 2003. I think most states are doing away with blood tests. I think the original idea was that since people would certainly not fornicate, they would be having sex for the first time on the wedding night and would need to be sure that nobody was infecting anyone.

Today, we realize that is ridiculous. The couple getting married has probably had more sex than they will for the rest of their lives, so any infection has already happened. No point in a blood test.

Not merely should: already does in places. This is not a “private matter” of an individual. We locked up Typhoid Mary, not because she was some evil witch, but because she was too damn stupid not to go around getting other people sick. And, unfortunately, selfish and stupid people have frequently do get others sick because they don’t consider the consequences.

HIV, as with any infectious disease, is a valid and legitimate public health issue. It’s an extremely serious disease which took a couple decades to get halfway under control. Given that infection rates are rising in some communities, it’s become increasingly obvious that some view their sickness as merely a minor obstacle on the road to personal fulfillment.

I don’t expect doctors, per se, to be handling the more delicate aspects of this issue. But public health agencies do exist, and doctors should (and should be legally required to) update them whenever neccessary if and when they have a reasonable suspicion that a patient may be, through neglect or apathy, spreading diseases.

If someone is being treated for HIV and uses a condom for vaginal intercourse, what are the chances they’ll transmit the disease to their partner in a given sexual encounter?

Some quick googling confirms this, and I agree. Any further action should be by the government. However, I think a doctor should strongly council his patient to reveal the condition to his or her sexual partner(s). And if there are any legal implications of the patient not doing so, the doctor should advise about that as well.


Cecil answered this very question:

I seem to recall that he revisited the question, armed with more statistics that basically confirmed his original numbers. But I can’t find it, so maybe not.

Edit: note the date of the column; Cecil noted that the statistics used were old.

Well, let’s look at the rationale for physician/patient confidentiality: reducing the patient’s incentive to provide his physician with false or incomplete information, to ensure appropriate care is provided.

Does it apply here? Well, maybe. The infected partner withheld information from the physician despite the privilege, but maybe he wouldn’t have come in at all otherwise.

HIV is treated differently for disclosure purposes than any other illness in emergency services.

I work in a 9-1-1 center outside the US (so HIPPA does not apply) and routinely ask about “any other medical conditions the ambulance crew should know about.” I can relay any information to the medical crew except HIV status, even if the patient explicitly instructs me to inform the ambulance crew.

Of course the EMTs should always use universal precautions. That isn’t really the issue in my mind. The problem is that this non-disclosure policy sets HIV apart from all other illnesses. It’s something not to be talked about. And as the old slogan says, Silence = Death.

Isn’t the timeline of her infection relevant to her course of treatment?

I’m not so sure. Was a crime committed? Why shouldn’t it be reported? If a physician saw evidence of sexual abuse, he wouldn’t say, “Well, the damage is done, let’s move on.” Is this different (in that sense)?

Depends on the state. It’s not a crime everywhere.

Interesting topic!

I would like to add a few questions:
When in the relationship should one be legally responsible for disclosing such information to a partner?
What about other STDs?