AIDS and Confidentiality versus the Right to Know
In the summer of 1987, a pregnant woman was shot with a bow [Bioethics]. The arrow came from another man engaged in an argument with another person. Rescue workers from the city came to the aid of the bleeding woman. Both the child and the woman died.
This incident would have been just another case of urban violence but the twist in the story makes it memorable. After the incident occurred, it was later found that the woman was infected with the AIDS virus. A nurse, on her own judgment, decided to inform the workers that they had just been exposed to blood from a patient with AIDS. Soon after the story hit, legislation passed a law adding AIDS to the list of diseases that hospital workers are required to be informed about [Bioethics]. Many proponents to confidentiality spoke out saying that every patient is a potential AIDS patient, the burden is on the caregiver to protect themselves.
This raised many questions on the limits of confidentiality, who has the right to know, and who should inform sexual contacts of AIDS patients.
The rule of confidentiality prohibits medical workers from revealing information, obtained through medical treatment, about a patient to a third party [Bioethics]. This rule is a part of medical practice, medical education, and all major medical oaths and codes.
The main justification behind keeping confidentiality lies in the individual’s right, coming from autonomy, to control personal information and protect privacy [Bioethics]. It is particularly important in cases where if the information was revealed it could cause discrimination, loss of rights, or emotional harm. In the case of AIDS and HIV, many infected persons are subjected to discrimination, loss of employment, refusal of insurance, and refusal of housing [Bioethics]. Because of this, many physicians believe it is important to keep this information safeguarded. Also, many infected persons are from already socially discriminated groups [drugs users, homosexuals, prostitutes] it is especially important to protect this information.
Other justifications for confidentiality are of equal importance. The medical practice requires that a patient reveal intimate personal secrets to their physician. The trust of a physician's confidentiality is what allows a patient to reveal such secrets. If confidentiality were broken then physicians would be violating many medical oaths and codes.
If the guarantee of confidentiality were not there, some potential patients would be deterred from seeking medical attention. Some might fear that sensitive personal information could be revealed to third parties, thus exposing themselves to discrimination, loss of rights, etc. Many doctors who work with AIDS patients fear that breaches in confidentiality could prevent people in high-risk groups from seeking antibody testing and counseling [Bioethics].
Some believe that there are situations when confidentiality can be overridden for more important moral obligations-
*Situations involving a minor
*Incompetent patient who might suffer if certain information were not disclosed to a parent or guardian
*cases against threats of violence to a third party
*cases involving a sexually transmitted disease
*cases in which an identifiable third party could be harmed
[Bioethics]
In the above list, limits are put on confidentiality through the 'Harm Principle' [Bioethics]. It requires that an individual refrain from acts and omissions that may result in a preventable, wrongful harm to innocent others in the near future. However, not all acts that result in another's harm appear to be wrong.
Example> If one football team defeats another, the losing team has been harmed
Example> I use the last roll of toilet paper, the next person to use the toilet has been harmed
Neither of these examples was a representation of wrongful harm. What makes harm wrongful? Under the Vulnerability Principle states that the duty to protect against harm arises most often when someone is especially dependent upon another or in some fashion vulnerable to their choices and actions [Bioethics]. It is like the Harm Principle but more specific in that the controlling party [AIDS patient] has an obligation to let it be known. Here's another example.
Harm Principle> There is no intense obligation to inoculate other adults. [Bioethics]
Vulnerability Principle> There is a strong obligation to inoculate all children and a stronger obligation to inoculate our own children [Bioethics]
Because children are vulnerable and lack the skills required to protect themselves there is an obligation to protect them. If these children are your own, then the obligation intensifies. On the other hand, other adults have the capacity to protect themselves, thus there is not an obligation to protect.
Remember the story from the beginning? The hospital spokesperson argued that it was each individual's responsibility, if properly trained, to treat every patient as if he or she had AIDS. Considering the above paragraph this argument is very strong. The nurse that informed the workers of the status of the patient was not responsible for the prevention of harm. The workers were responsible for their own safety.
However, health care workers are routinely exposed to blood and blood is a major pathway for the AIDS virus [Bioethics]. A worker could be more careful and refuse to handle patients they suspect have the virus. This would, in turn, violate their professional responsibility to administer care. This puts health care workers in a different ethical situation than normal people. Normal people do not have a special obligation to protect people and they are not exposed to blood on a daily basis. In turn making health care providers especially vulnerable. In light of this, it seems as though the nurse who informed the workers of the status of the AIDS patient made the correct choice.
Some physicians are not exposed to blood on a daily basis. Does this change anything?
Example> A patient is diagnosed with AIDS and tells his physician that he does not intend to tell his fiancée that he is infected.
The fiancée is a known, unsuspecting third party. She is vulnerable to the infected patient since the patient's choices, actions, and omissions will put her in great harm. The patient has the obligation to protect his fiancée through breaking off the relationship, abstaining from sex, practicing 'safe sex', or informing his fiancée of his condition. However, what responsibility does the physician have in the above example?
Like the patient, the physician possesses information that could protect the fiancée and the only other person with this information has clearly stated that it will not be revealed. Thus, the fiancée is especially dependent upon the actions, choices, and omissions of the physician. By not persuading the patient to reveal the information or letting the fiancée know directly, the physician was acting in compliance with the patient to do the fiancée harm.
From what has been discussed so far, it seems that confidentiality in the cases of HIV/AIDS patients cannot be absolute. However, a few justified exceptions does not permit for an unrestricted disclosure of antibody status to any individual you demands it [Bioethics]. If any individual is especially vulnerable to harm, they should be notified. If someone faces a significant risk of exposure to an infection and the revelation of said information were to reduce the risk, than it is permissible.
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