Tuesday, August 30, 2011

Disapproval dog is not amused by your ethical dilemma

Our ethics lecture was really interesting yesterday. As a disclaimer, I have made a lot of this information up. But the concept we discussed is still viable.

The case we were given was...controversial. A HIV-positive woman tells her doctor that she doesn’t want to tell her husband about her HIV-positive status. 

....

I disapprove.

However, this woman is pregnant. And her child will need to take anti-viral medication for 6 weeks after birth. And, of course, she wants to hide the reason that their child is taking medication for 6 weeks. So, she asks the doctors to prescribe the baby medication without telling the father.

When I first heard this, I was appalled. And a bit angry. What is she doing hiding her HIV+ status from her husband? And as our class got going, I realized there were things I hadn’t even thought of.

What are the father’s legal rights? Does he have a right to know what medication his child is taking? Is it ethical to give medication to a child without telling both parents (especially when both parents are in his life)?

While it is legal for the woman to have sex with her husband without disclosing her HIV+ status – what do you do as her doctor? It rubs me the wrong way to just let him go about his merry way. After all, one of our “callings” as a doctor is to “prevent” right? Not doing a great job of that if we don’t tell him. But is it even legal for us to tell him? Should we be compelled to tell him?

The case becomes more complicated when you consider that the woman feared for her life. Her husband had been violent in the past with her. She was convinced that if her husband found out, he would kill her. Undoubtedly bad for the baby’s health. Even if he didn’t kill her, she was certain she would be disowned from her multi-generational home. Her family was extremely Catholic, located in a Southern state and associated HIV+ with promiscuity. Also, bad for the baby.

My brain is about to explode now. Who is my loyalty to? The baby, the mother, or the father? What if all three of them are my patients? Should we just side with the baby since it’s, well, a baby, and they are different than adults? They need more protection than mom and dad. But if we don’t take care of dad, he might get complications from untreated HIV. If we take care of dad, then we no longer take care of mom because she is either dead or excommunicated (supposedly). And if either parent is incapacitated, the baby is unlikely to get the care it deserves. Well, crapbox.


The decision that was made left me feeling uncomfortable, but convinced I had no better answer. The decision was to not tell the dad. The rationale was that he probably already had HIV. The wife had no other risk factors for HIV, so it was probable that she originally contracted it from her husband.

And the questions didn’t even stop once the decision is made!

What if the dad asks a doctor directly: “What is this medication I am giving my child?” Should the physician lie? And if the physician doesn’t lie and tells the dad the truth – can you imagine the dad’s reaction? He’d probably go get a lawyer and sue the pants off any doctor/hospital he could find involved in withholding this information from him. What would your reaction be to information like that?

Intellectually, I knew that everything was grey, but not this grey. Making decisions that leave me feeling crappy does not sound fun. But I’m actually really excited for ethics. I can’t believe I’m going to be allowed to make decisions like this. Really scary and really awesome all at the same time.

4 comments:

  1. Ooh, good ethical dilemma. By the way - I have nothing to do with the medical profession but am visiting anyway.
    Love disapproval dog, can I borrow him?
    Can you choose not to treat the patient? Make her just go away and find another doctor?
    Scarey decisions.
    Stella

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  2. The rationale was that the husband already had HIV? Really? That's seems sketchy. Man, what a dilemma. Hopefully the husband will question and research the drugs that are given to the baby and find out the HIV status himself. But omg wouldn't you be upset if you found out that your sexual partner has HIV? What a sad situation all around. Good luck with this!

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  3. @bloggingmyproclivities: Welcome! Ha, disapproval dog is an internet meme. I didn't make him up, he's been floating around on the internet for quite some time. You can find lots of disapproval animals. =) You could not treat her, but imagine if you've built a repoir with her over the years. It might be difficult to part with that.

    @Anon: I agree, I would be sad as well. But the woman painted the picture of her husband as a pretty scary dude. I have less sympathy with him considering he'd been violent with his wife in the past.

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  4. (as an aside, I also just put up an ethics case that you might find interesting ... https://drinkingfromthefirehose.wordpress.com/2011/09/02/ethics-case-part-i/ )

    You'll encounter a lot of ethics cases in the first two years, and it's helpful to have a framework from which to start. Often when you start breaking it down, even difficult cases become simple (but not easy ...).

    In this case, as a physician you are legally bound (read: you will lose your license and may face criminal charges) to report this woman's HIV status to the state health department in most (every?) state. In fact, the lab will most likely has already reported the positive test (whether ELISA or viral load) automatically. There are few (if any) exceptions to this, although there is variance from state to state.

    If you have never tested her, and she reports being HIV+ by history, or from an anonymous (as opposed to confidential) HIV test, the issue is a bit murkier, but you would might still be legally required to report her once she tells you she is HIV+.

    If she is at high risk of domestic violence, then the state public health office should WEIGH the risks vs. benefits, but that is NOT YOUR JOB as a physician. Your job is to document everything (especially the history of abuse) and then give the information to the state health authorities and follow the procedures.

    What if the woman has multiple partners? What if she uses IVDU and infects her drug-using contacts? What if she goes into the ED tomorrow night and someone gets a needlestick while drawing an ABG? What about her past partners (when did she get HIV)?

    And as for the wife having "no other risk factors" ... everybody lies ... especially those who are least suspected ...

    Furthermore, your patient's having unprotected sex while knowingly HIV+ without disclosing her HIV status to her partner(s) may be a crime!

    Honestly, the best advice to give this lady is to plug her in with domestic violence / social supports and get her out of the house, both for herself and for her child, since she is at such high risk for domestic violence. Safely treating the child would be almost impossible if the dad will fly into a murderous rage once he finds the AZT ... solve the domestic abuse problem and you solve all the others ...

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