Carlos R. For many who are HIV positive, their anguish only One commentator on this case...

Transcribed Image Text:

Carlos R. For many who are HIV positive, their anguish only One commentator on this case argues against deepens if others know about their condition. They violating confidentiality. He contends that for a phy- sician to have a duty to warn, there must be (I) "an imminent threat of serious and irreversible harm," demand medical confidentiality, and physicians are obliged to comply-but the "duty to warn" others of the risk of infection haunts both physicians and pa- (2) no other way to avert that threat except by tients. Typically those thought to need warning are breeching confidentiality, and (3) a situation in which the harm done by the breech is on a par with the harm avoided by the breech. In his view, none of these conditions are fully met in this case. He does not believe that the risk of Consuela becoming in- fected with HIV is very great-and certainly not sexual partners and spouses, but sometimes caregiv- ers-whether professionals or family members-are the ones of concern. This case is of the latter kind. It recounts the events that lead up to the question at issue-whether the physician's weightier duty is confidentiality or warning-then provides the op- posing views of two commentators. Twenty-one-year-old Carlos R. entered the hos- pital for treatment of gunshot wounds received in gang violence. During his stay, he confided to the attending physician that he was HIV positive, and testing proved him correct. Eventually he recovered well enough to leave the hospital to have his wounds "imminent." He also thinks that there are alterna- tives to breeching confidentiality-the main one being instructing Consuela in safe wound care. Moreover, he insists that the risks to Consuela from not telling her about Carlos' HIV status are far out- weighed by the awful disruption of family relations that breeching confidentiality would cause. The second commentator argues for violating cared for at home. The attending physician advised confidentiality to warn Consuela. She maintains that Consuela has a right to information whether or not there is an appreciable risk to her. One reason is that if Consuela is not being told the truth, she is being deceived. Most people in Consuela's situation would want to know the facts and would probably assume that Carlos was not HIV positive because no one said so. Furthermore, in getting Consuela to provide nursing care, "the health care system is using her to avoid providing a service it would otherwise be responsible for." If so, then the system has an ob- ligation to give her the information she needs to Carlos to have daily visits from a nurse to tend to his wounds. But Carlos was uninsured, and Medicaid would not pay for the home nursing visits because his 22-year-old sister Consuela was willing and able to care for him. For 10 years since their mother died, Consuela had assumed the role of mother for both Carlos and their younger sister. ' Caflos was willing to let Consuela be his nurse, but he was adamant that she not be told about his HIV status. She was unaware of his homosexual ac- tivity, and so too was his father. More than anything else he feared that his father would learn the truth. There was also the cultural factor. Among many Hispanics, homosexuality is a social stigma. The choice for Carlos' physician, then, was be- tween preserving confidentiality and breeching it to warn Consuela of the risks involved in caring for an decide whether to accept the responsibility. In the end, the physician should require the pa- tient to choose: "Carlos can decide to accept Con- suela's generosity-in return for which he must tell her he is HIV-infected (or ask the doctor to tell her)-or he can decide not to tell her and do with- strict adherence to the principle of confidential- ity. But a rule-utilitarian could also reason that APPLYING MAJOR THEORIES In Kantian ethics, the morality of truth-telling the best rules are those that require less than full and confidentiality seems unambiguous. Physi- disclosure to patients and less than absolute com cians who adopt the means-end formulation of 6dentiality-that is, rules with some exceptions the categorical imperative, for example, seem committed to an absolute duty of preserving both. In the Kantian view, treating people merely privacy-except when maintaining confhdential- as a means to an end is impermissible, a violation of the principle of autonomy. Lying to patients ity could put someone's life in danger. and breeching confidentiality (by breaking a promise to respect privacy) are clear instances of this moral outlook might contend that if a phy- such violations. For a strict Kantian, these prohi- sician cultivates the virtues of honesty and hder- bitions would have no exceptions; there would be ity be will be more likely to communicate no allowances made for extraordinary circum- stances. Arguments that truth-telling could be injurious to patients and must therefore be done with an eye to medical consequences would carry no weight. Likewise, there would be no place for the notion that confidentiality may be truth-telling accordingly. He will also be able to set aside if there is a conflicting "duty to warn." For an act-utilitarian, the morality of truth- telling and confidentiality must be judged case by case, the right action being the one that maxi- mizes the good for all concerned. In each in- stance, physicians must decide carefully what to disclose to a patient, calculating the impact that right to privacy any disclosure would have on the patient, her family, and everyone else involved. For each de- cision about confidentiality, physicians must weigh the effect of the choice on the patient, the physician-patient relationship, third parties who claiming that truth-telling can evoke in patients may be harmed by maintaining confidentiality, feelings of panic, hopelessness, and degression and themselves (who may have to contend with legal consequences). Rule-utilitarianism tries to regulate actions by rules that, if generally followed, would result argument, saying that it exaggerates the harm in the best consequences, everyone considered. done to patients by full disclosure and does not A rule-utilitarian might argue that the greatest recognize that misleading or lying to patients can amount of good is produced by a rule stating that a physician should, with care and sensitivity, tell patients are better patients and that deception patients the truth about their condition. This breeds distrust. In these debates we often hear rule would presumably not only be beneficial to that patients do not want to know the truth, but patients, but also help foster trust in patients for scientific surveys suggest that most patients do built in. For example, the best confidentiality rule might demand full respect for a patient's Virtue ethics also has something to say about veracity and confidentiality. Many who favor truthfully with patients, to keep his promises to them, and to maintain their confidences. More- over, if he possesses the virtue of compassion, he will be sensitive to the effect that blunt truthful- ness could have on patients and will adapt his empathize with patients and understand why confidentiality matters so much to them. KEY TERMS confidentiality SUMMARY Some medical writers contend that there are good reasons for misleading or lying to patients, that can worsen the patient's condition or state of mind. Honest disclosure must be modulated to promote the patient's welfare. Others reject this also do damage. They maintain that informed principle of autonomy, the idea that people should be allowed to exercise freely their rational capac- ity for self-determination. Confidentiality concerns patients imparting information to health professionals who promise, implicitly or explicitly, not to disclose that infor- mation to others. Consequentialist arguments for confidentiality say that without it, physicians would be hard pressed to obtain information from patients that could help in treatment, and trust between physician and patient would break down. Moreover, disclosure of confidential medi- cal information could expose patients to discrim- ination, disrupt their personal relationships, and subject them to shame or public ridicule. Non- consequentialist arguments appeal to the princi- ple of autonomy, contending that autonomous persons have a right to determine what may or may not be done to their bodies as well as to their private lives. They have a right to privacy, the au- thority of persons to control who may possess and use information about themselves. A major issue is whether the obligation to re- spect confidentiality is absolute or prima facie. Some argue for absolute confidentiality, insisting that any breech of it undermines trust between physicians and patients and amounts to impermis- sible deception. But many believe that exceptions are sometimes justified when confidentiality must be weighed against other duties, such as the duty to prevent serious harm to the patient and others. of breast results came back, her oncologist brought up the option of a prophylactic mastectomy and advised her to inform her living relatives of the results of the test. Mrs. Durham's primary care physician, Dr. Bartlett, expected she would do so, too. At her first appointment after the diagnosis, Dr. Bartlett asked Mrs. Durham how she was holding up and how her sister, Mrs. Weir-her only living family member and also one of Dr. Bartlett's patients-had taken the news. "Oh. Well, I haven't told her." "Are you going to?" asked Dr. Bartlett. Mrs. Durham responded, "You know we haven't spoken in quite some time, and I can't imagine making this the topic of our first conversation." "Yes, I know...but I think this is important in- formation that may affect her health." Mrs. Durham sighed. "We're estranged, for one thing, and for another, I want to keep my cancer private. I don't want people knowing I'm sick and pitying me." Dr. Bartlett felt pulled in two directions-his obligation to respect Mrs. Durham's wishes and protect her privacy conflicted with his obligation to promote Mrs. Weir's health. BRCA1 mutations are not "reportable" illnesses like HIV and tuberculo- sis, so he was not compelled by law to break Mrs. Durham's confidentiality. Dr. Bartlett consid- ered how he might be able to encourage Mrs. Dur- ham's sister to be tested for the BRCA mutations while preserving Mrs. Durham's confidentiality." Cases for Evaluation Does Mrs. Durham have a moral obligation to inform her sister of the results of the test? Why or why not? For Dr. Bartlett, what moral principles are in con- flict? If Mrs. Durham refuses to inform her sister, should Dr. Bartlett tell her? What should Dr. Bartlett do if he can't subtly ask Mrs. Weir to be tested (that is, if he can't ask her without revealing the real reason CASE I Disclosing Information about the Risk of Inherited Disease Mrs. Durham was diagnosed with an invasive epi- thelial ovarian cancer and, in conjunction with conversations about her treatment, was offered ge- for his request)? netic testing for the BRCA1 and BRCA2 mutations. It was revealed that she carried a harmful BRCA1 "AMA Journal of Ethics, vol. 17, no. g9 (September 2015), DP. 819-825. 00 tho lifatime risk Carlos R. For many who are HIV positive, their anguish only One commentator on this case argues against deepens if others know about their condition. They violating confidentiality. He contends that for a phy- sician to have a duty to warn, there must be (I) "an imminent threat of serious and irreversible harm," demand medical confidentiality, and physicians are obliged to comply-but the "duty to warn" others of the risk of infection haunts both physicians and pa- (2) no other way to avert that threat except by tients. Typically those thought to need warning are breeching confidentiality, and (3) a situation in which the harm done by the breech is on a par with the harm avoided by the breech. In his view, none of these conditions are fully met in this case. He does not believe that the risk of Consuela becoming in- fected with HIV is very great-and certainly not sexual partners and spouses, but sometimes caregiv- ers-whether professionals or family members-are the ones of concern. This case is of the latter kind. It recounts the events that lead up to the question at issue-whether the physician's weightier duty is confidentiality or warning-then provides the op- posing views of two commentators. Twenty-one-year-old Carlos R. entered the hos- pital for treatment of gunshot wounds received in gang violence. During his stay, he confided to the attending physician that he was HIV positive, and testing proved him correct. Eventually he recovered well enough to leave the hospital to have his wounds "imminent." He also thinks that there are alterna- tives to breeching confidentiality-the main one being instructing Consuela in safe wound care. Moreover, he insists that the risks to Consuela from not telling her about Carlos' HIV status are far out- weighed by the awful disruption of family relations that breeching confidentiality would cause. The second commentator argues for violating cared for at home. The attending physician advised confidentiality to warn Consuela. She maintains that Consuela has a right to information whether or not there is an appreciable risk to her. One reason is that if Consuela is not being told the truth, she is being deceived. Most people in Consuela's situation would want to know the facts and would probably assume that Carlos was not HIV positive because no one said so. Furthermore, in getting Consuela to provide nursing care, "the health care system is using her to avoid providing a service it would otherwise be responsible for." If so, then the system has an ob- ligation to give her the information she needs to Carlos to have daily visits from a nurse to tend to his wounds. But Carlos was uninsured, and Medicaid would not pay for the home nursing visits because his 22-year-old sister Consuela was willing and able to care for him. For 10 years since their mother died, Consuela had assumed the role of mother for both Carlos and their younger sister. ' Caflos was willing to let Consuela be his nurse, but he was adamant that she not be told about his HIV status. She was unaware of his homosexual ac- tivity, and so too was his father. More than anything else he feared that his father would learn the truth. There was also the cultural factor. Among many Hispanics, homosexuality is a social stigma. The choice for Carlos' physician, then, was be- tween preserving confidentiality and breeching it to warn Consuela of the risks involved in caring for an decide whether to accept the responsibility. In the end, the physician should require the pa- tient to choose: "Carlos can decide to accept Con- suela's generosity-in return for which he must tell her he is HIV-infected (or ask the doctor to tell her)-or he can decide not to tell her and do with- strict adherence to the principle of confidential- ity. But a rule-utilitarian could also reason that APPLYING MAJOR THEORIES In Kantian ethics, the morality of truth-telling the best rules are those that require less than full and confidentiality seems unambiguous. Physi- disclosure to patients and less than absolute com cians who adopt the means-end formulation of 6dentiality-that is, rules with some exceptions the categorical imperative, for example, seem committed to an absolute duty of preserving both. In the Kantian view, treating people merely privacy-except when maintaining confhdential- as a means to an end is impermissible, a violation of the principle of autonomy. Lying to patients ity could put someone's life in danger. and breeching confidentiality (by breaking a promise to respect privacy) are clear instances of this moral outlook might contend that if a phy- such violations. For a strict Kantian, these prohi- sician cultivates the virtues of honesty and hder- bitions would have no exceptions; there would be ity be will be more likely to communicate no allowances made for extraordinary circum- stances. Arguments that truth-telling could be injurious to patients and must therefore be done with an eye to medical consequences would carry no weight. Likewise, there would be no place for the notion that confidentiality may be truth-telling accordingly. He will also be able to set aside if there is a conflicting "duty to warn." For an act-utilitarian, the morality of truth- telling and confidentiality must be judged case by case, the right action being the one that maxi- mizes the good for all concerned. In each in- stance, physicians must decide carefully what to disclose to a patient, calculating the impact that right to privacy any disclosure would have on the patient, her family, and everyone else involved. For each de- cision about confidentiality, physicians must weigh the effect of the choice on the patient, the physician-patient relationship, third parties who claiming that truth-telling can evoke in patients may be harmed by maintaining confidentiality, feelings of panic, hopelessness, and degression and themselves (who may have to contend with legal consequences). Rule-utilitarianism tries to regulate actions by rules that, if generally followed, would result argument, saying that it exaggerates the harm in the best consequences, everyone considered. done to patients by full disclosure and does not A rule-utilitarian might argue that the greatest recognize that misleading or lying to patients can amount of good is produced by a rule stating that a physician should, with care and sensitivity, tell patients are better patients and that deception patients the truth about their condition. This breeds distrust. In these debates we often hear rule would presumably not only be beneficial to that patients do not want to know the truth, but patients, but also help foster trust in patients for scientific surveys suggest that most patients do built in. For example, the best confidentiality rule might demand full respect for a patient's Virtue ethics also has something to say about veracity and confidentiality. Many who favor truthfully with patients, to keep his promises to them, and to maintain their confidences. More- over, if he possesses the virtue of compassion, he will be sensitive to the effect that blunt truthful- ness could have on patients and will adapt his empathize with patients and understand why confidentiality matters so much to them. KEY TERMS confidentiality SUMMARY Some medical writers contend that there are good reasons for misleading or lying to patients, that can worsen the patient's condition or state of mind. Honest disclosure must be modulated to promote the patient's welfare. Others reject this also do damage. They maintain that informed principle of autonomy, the idea that people should be allowed to exercise freely their rational capac- ity for self-determination. Confidentiality concerns patients imparting information to health professionals who promise, implicitly or explicitly, not to disclose that infor- mation to others. Consequentialist arguments for confidentiality say that without it, physicians would be hard pressed to obtain information from patients that could help in treatment, and trust between physician and patient would break down. Moreover, disclosure of confidential medi- cal information could expose patients to discrim- ination, disrupt their personal relationships, and subject them to shame or public ridicule. Non- consequentialist arguments appeal to the princi- ple of autonomy, contending that autonomous persons have a right to determine what may or may not be done to their bodies as well as to their private lives. They have a right to privacy, the au- thority of persons to control who may possess and use information about themselves. A major issue is whether the obligation to re- spect confidentiality is absolute or prima facie. Some argue for absolute confidentiality, insisting that any breech of it undermines trust between physicians and patients and amounts to impermis- sible deception. But many believe that exceptions are sometimes justified when confidentiality must be weighed against other duties, such as the duty to prevent serious harm to the patient and others. of breast results came back, her oncologist brought up the option of a prophylactic mastectomy and advised her to inform her living relatives of the results of the test. Mrs. Durham's primary care physician, Dr. Bartlett, expected she would do so, too. At her first appointment after the diagnosis, Dr. Bartlett asked Mrs. Durham how she was holding up and how her sister, Mrs. Weir-her only living family member and also one of Dr. Bartlett's patients-had taken the news. "Oh. Well, I haven't told her." "Are you going to?" asked Dr. Bartlett. Mrs. Durham responded, "You know we haven't spoken in quite some time, and I can't imagine making this the topic of our first conversation." "Yes, I know...but I think this is important in- formation that may affect her health." Mrs. Durham sighed. "We're estranged, for one thing, and for another, I want to keep my cancer private. I don't want people knowing I'm sick and pitying me." Dr. Bartlett felt pulled in two directions-his obligation to respect Mrs. Durham's wishes and protect her privacy conflicted with his obligation to promote Mrs. Weir's health. BRCA1 mutations are not "reportable" illnesses like HIV and tuberculo- sis, so he was not compelled by law to break Mrs. Durham's confidentiality. Dr. Bartlett consid- ered how he might be able to encourage Mrs. Dur- ham's sister to be tested for the BRCA mutations while preserving Mrs. Durham's confidentiality." Cases for Evaluation Does Mrs. Durham have a moral obligation to inform her sister of the results of the test? Why or why not? For Dr. Bartlett, what moral principles are in con- flict? If Mrs. Durham refuses to inform her sister, should Dr. Bartlett tell her? What should Dr. Bartlett do if he can't subtly ask Mrs. Weir to be tested (that is, if he can't ask her without revealing the real reason CASE I Disclosing Information about the Risk of Inherited Disease Mrs. Durham was diagnosed with an invasive epi- thelial ovarian cancer and, in conjunction with conversations about her treatment, was offered ge- for his request)? netic testing for the BRCA1 and BRCA2 mutations. It was revealed that she carried a harmful BRCA1 "AMA Journal of Ethics, vol. 17, no. g9 (September 2015), DP. 819-825. 00 tho lifatime risk

Answer rating: 100% (QA)

Carlos R was a 21yearold Hispanic man who sustained gunshot wounds to the abdomen as a result of gang fighting He lacked insurance His stay in hospital was little brief than predicted but nonetheless ... View the full answer