|
Ethics
questions
The general principles of medical ethics should apply
when dealing with HIV and other sexually transmitted
infections, although sometimes professionals dealing
with these issues can find they face particular dilemmas.
We base most of our information on guidance provided
for doctors and available online from the General
Medical Council and the British
Medical Association. The book Medical ethics today:
its practice and philosophy (British Medical Association,
1993) also provides a useful overview of ethical issues
for doctors.
Disclaimer
The following questions and answers are based on
UK law, guidance and practice. They are purely illustrative
and are not intended to be a definitive statement
of advice. The circumstances of individual cases
may give rise to exceptions or legitimate differences
of opinion. If in doubt, please seek more personalised
advice from your professional, regulatory or indemnifying
body. |
| Should
I record it in the notes if a patient is HIV
positive? |
In
general practice, ordinarily, yes. It is clinically
relevant information and you could be liable
if you failed to record it and as a result,
say, did not recommend appropriate investigations
when the patient became ill. But it's wise
to tell the patient that this information
will be recorded and to be prepared to answer
any questions s/he may have about who has
access to the records and how you keep them
confidential.
In hospitals the situation may be more complicated
as you may be less able to control who has
access to the notes, and there are unresolved
issues about the inclusion of patient-identifiable
clinical information in contract minimum data
sets. You should certainly keep some form
of record of the fact that a patient has HIV
infection, but where feasible it may be preferable
for you to hold this yourself, apart from
the main hospital records. Again, it makes
sense to discuss with the patient how records
will be kept and which members of the health
care team will need to be informed of the
diagnosis.
|
|
| Can
I warn the sexual partner or spouse of an
HIV positive patient if the patient is not
willing to do so? |
In
the final analysis, yes, if you believe this
is necessary to protect the partner from a
significant risk of acquiring HIV infection.
But you must be prepared to justify this action.
Before considering telling the partner without
the patient's consent make sure that you have
fully discussed the matter with the patient
and explored his/her reasons for not wanting
the partner to know. It can be helpful to
refer the patient to a health advisor or counsellor
who is experienced in helping people with
sexually transmitted infections to find acceptable
ways to warn their partners. If you do decide
to warn the partner without the patient's
agreement, then tell the patient what you
are going to do. Don't act in secret behind
the patient's back.
|
|
|
I'm writing a discharge letter for a patient
who was found to be HIV positive while under
my care. Should I disclose this diagnosis
to the patient's GP? |
You
should seek the patient's agreement before
disclosing this to the GP. It's important
for the patient to understand that the GP
will not be able to provide optimum care unless
s/he knows about the HIV diagnosis. But if
the patient does not want you to reveal this
then you should not, unless there are exceptional
circumstances which give you reason to believe
that such disclosure is essential to prevent
a serious infection risk to the GP or his/her
staff/colleagues. (We can't imagine any such
circumstances, since all health workers should
be careful to minimise blood exposure risks
at all times, but we like to cover all possibilities.
If you think that such circumstances apply,
it might be wise to get a second opinion from
a professional colleague or your professional,
regulatory or indemnifying body).
|
|
| I'm
referring an HIV positive patient to a specialist
(doctor or dentist). Should I mention in the
referral letter that the patient has HIV? |
You
should seek the patient's agreement first,
by explaining that the specialist is unlikely
to be able to provide proper assessment and
care without knowing about the HIV infection.
If you are reasonably confident that the condition
for which the patient is being referred is
unrelated to the HIV infection, and the patient
does not want you to reveal this, then it
need not be revealed unless there are exceptional
circumstances which give you reason to believe
that such disclosure is essential to prevent
a serious infection risk to another person.
|
|
| Can
I test a young person under the age of 16
for HIV infection without his/her parents'
knowledge? |
Yes,
if you have provided thorough pre-test discussion
and the following conditions apply:
- you have assessed
the young person's mental capacity and
you judge that s/he is mature enough to
understand the implications of being tested
(or not being tested) and to give valid
consent.
- you are satisfied
that performing the test will be in the
young person's best interest.
- You have discussed
the benefits of involving the parent(s)
in the decision, encouraged the young
person to agree to this, and explored
the reasons why s/he is unwilling to do
so.
If, after discussion,
you do not perform the test, then you should
still maintain confidentiality and not disclose
to the parent(s) that testing has been discussed.
If you judge, however, that the test would
provide significant benefits to a young
person who refuses to be tested, or who
is not competent to give valid consent,
you should seek further advice from your
professional, regulatory or indemnifying
body.
|
|
| Can
I test a patient for HIV infection if s/he
is unconscious and unable to give consent? |
Not
ordinarily. This is permissible if the HIV
test is necessary in the patient's own interest,
in other words, if you need to know the HIV
status in order to diagnose and treat the
immediate problem while the patient remains
unable to give consent. In most cases this
is not necessary and testing can wait until
the patient is able to discuss it and give
(or refuse) consent. If you do decide to test
the patient without his/her consent, then
you must be prepared to justify this decision
to the Courts and/or the General Medical Council.
If a health care worker has suffered a needlestick
or other significant exposure to the blood
of an unconscious patient, then you should
normally wait for the patient to regain consciousness
before seeking his/her consent for HIV testing.
In high risk situations, the exposed person
may want to start taking post- exposure prophylaxis
before the source patient's consent to testing
can be obtained. The General Medical Council
acknowledges that in exceptional circumstances
it may be acceptable to test an existing blood
sample from the source patient without his/her
consent, eg where you have good reason to
suspect HIV infection and where the patient
has not regained full consciousness within
48 hours of the exposure incident, but you
should consult an experienced colleague first.
You must not take blood for this purpose -
drawing blood without consent may leave you
open to criminal charges.
|
|
| Does
a person need to see a counsellor before being
tested for HIV infection? |
No.
It's rarely necessary for a person to see
a fully trained counsellor. However, the person
should be given appropriate information about
the test and its implications, and time to
consider and discuss it, before s/he decides
whether to consent to the test. The amount
of discussion necessary will depend on the
circumstances of the test - eg routine antenatal
testing, immediate diagnosis for symptomatic
patients, or testing requested by asymptomatic
patients who have been at risk. In more complex
cases it is appropriate for pretest discussion
to be provided by someone with specialised
expertise, eg a GU clinic counsellor. However,
unnecessary barriers to testing should be
avoided.
If you're a GP and are referring a patient
to a GU clinic for HIV testing, it's a good
idea to explain to the patient that the reason
for the referral is so that s/he can see someone
with more experience of HIV, and that as the
GP you would wish to share in any follow-up
care. Otherwise,there's a risk that the patient
may misinterpret a well-intended referral
as a signal that the GP is unwilling to get
involved in the care of people with HIV.
|
|
| I'm
a health professional and I am worried that
I may be infected with HIV. What should I
do? |
There
is detailed ethical guidance relating to HIV
infected health care workers - contact us
directly. The first thing you must do is seek
advice from a suitable expert, eg a consultant
specialising in HIV medicine or a consultant
occupational physician with experience of
HIV/AIDS. If s/he advises that it is necessary
for you to be tested for HIV, then you must
comply. If you are HIV positive, you must
then seek advice about whether you need to
change your practice in any way to prevent
a risk to patients. Most health professionals
are able to go on working normally, since
there is no risk in most medical procedures
(even some invasive procedures like venepuncture
where there is a chance that the worker can
be exposed to the patient's blood but not
vice versa). But if you perform some surgical
and other procedures which present a (very
small) risk of the patient being exposed to
your blood then further action may be needed.
Detailed guidance is available in the UK
Health Department's AIDS/HIV infected health
care workers guidance on the management of
infected health care workers and patient notification.
|
|
| I'm
writing an insurance medical report for a
patient who is gay. How should I answer questions
about his risk of getting HIV? |
|
You should refuse
to answer any questions which invite you
to speculate about a patient's lifestyle
and risk of acquiring HIV (or another disease)
in future. Write "Refer to proposer"
to tell the insurance company to direct
any lifestyle questions to the patient him/herself.
Do this routinely, for all patients, regardless
of whether you know about their sexual orientation
or other lifestyle factors.
You should also refuse to answer questions
which ask if the patient has ever had a
negative HIV test. Write "In accordance
with ABI guidance that insurers should not
ask about previous negative HIV tests, I
will not answer this question".
But if the question is a factual one, seeking
clinical information about the patient's
medical history - eg has this patient, to
your knowledge, ever had hepatitis B infection?
Or is this patient, to your knowledge, HIV
positive? - then answer accurately according
to the information in the records. If doing
so means disclosing information which may
be to your patient's detriment, then it
is wise to contact the patient and advise
him/her to see the report before it is sent
to the insurance company (even if s/he has
previously indicated that s/he does not
want to see the report).
Joint guidance from the Association of
British Insurers and the British Medical
Association states that practitioners should
not reveal information about STIs (unless
they have long-term health implications).
See the British
Medical Association and Association of British
Insurers joint guidelines on Medical Information
and Insurance (December 2002) and their
GP
insurance package (October 2003).
|
|
| Does
being tested for HIV affect one's future insurance
prospects? |
It
shouldn't, unless the result is positive,
in which case new life insurance will be costly
and difficult to obtain. The Association of
British Insurers has advised companies not
to ask about prior negative HIV tests when
people apply for life insurance.
Even if the test is positive, it should not
affect existing life insurance policies unless
the insurance company suspects that the person
did not provide full information when the
policy was first taken out. At the Medical
Foundation for AIDS & Sexual Health we're
worried that people with HIV sometimes get
bad advice which encourages them to hide their
diagnosis from insurers when taking out new
policies. This is unwise, as if the insurance
company suspects this has happened there can
be problems later on if the person dies. If
the claim is rejected at that stage, then
all the premiums will have been wasted and
the person's dependents may be left with unexpected
debts.
Because people applying for insurance are
required to answer the insurer's questions
fully and honestly, there is no insurance
advantage in concealing an HIV diagnosis from
one's GP. Whether or not the doctor discloses
such information to the insurer, the applicant
him/herself must do so.
|
|
|
 |
