Ethical Dilemmas in Primary Care: Applying Objective Standards to Individual Patients

MAY 18, 2007
Ray B. Bennett, MD, Shari Leidig Holland, MA, LPC, and Carolyn A. Conti, PhD, Mercy Hospital, Pittsburgh, Pa
Ray B. Bennett, MD
Chief Resident
Family Practice Residency Program

Shari Leidig Holland, MA, LPC
Behavioral Science Coordinator
Family Practice Residency Program

Carolyn A. Conti, PhD
PhD candidate
Duquesne University
Ethicist-in-Residence
Family Practice Residency Program

Mercy Hospital
Pittsburgh, Pa

Ethical dilemmas in primary care are as real as any that have made judicial history or have been featured on the evening news. This article provides a framework for approaching such dilemmas in the clinical context and reviews some legal considerations. Two case-study scenarios are used to demonstrate the accepted principles of biomedical ethics and how to apply them to specific clinical situations. The physician-patient relationship is at the heart of each case, but these ethical dilemmas can also affect the institution and the community.

We rarely think of bioethics in conjunction with primary care. Yet, there are as many ethical dilemmas in this field as in any high-tech, leading-edge intensive care situation. The ethical dilemmas that primary care physicians face every day are less likely to be reported on the evening news or to become the subject of a Supreme Court decision. They are not the ones that are written up in textbooks and casebooks. Nevertheless, they are as real as any case that has ever made headlines or judicial history.

The drug seeker who is actually in pain is one example of an ethical dilemma in an outpatient setting. An individual who is being abused but refuses to admit the abuse is another. Adolescents who are sexually active and are seeking birth control, abortion, or tests for sexually transmitted diseases (STDs) without parental notification or permission are still other examples.

PRACTICE POINTS
? Some of the ethical dilemmas primary care physicians encounter are directly linked to their institution and/or the community, in addition to the< individual patient.

? If the patient cannot afford treatment for HIV, does the hospital incur the costs?

? Does the physician have a moral obligation to disclose a patient's HIV status to the spouse or other partners?

? Does the patient have the right not to inform his/her partners?

When physicians must resolve ethical dilemmas, they do not have the luxury of referring to comparable paradigm cases. They must recognize and resolve ethical dilemmas based on the accepted principles of biomedical ethics, the policies and standards of their institutions, and the law of the land.

Reaching an ethical decision is not merely a matter of opinion. Rather, it is a matter of understanding the objective standards of ethical decision making and applying these standards to the case at hand. The principles of ethical decision making include1:

? Autonomy?the patient?s right to make decisions concerning healthcare
? Nonmaleficence?the physician?s obligation to do no harm to the patient
? Beneficence?the physician?s obligation to promote the patient?s well-being and balance risks and benefits
? Justice?the obligation to distribute risks and benefits fairly.

In this article we apply these objective standards in conjunction with the laws of the Commonwealth of Pennsylvania (where we practice) as an example, as well as the policies and standards of the Pittsburgh Mercy Health System and the Ethical and Religious Directives for Catholic Health Care Services.2

Because their patient mix is so diverse, and because they frequently practice in institution-sponsored community-based clinics, primary care physicians, perhaps more than other physicians, face ethical dilemmas that may have ramifications for their institution and for the community and society as a whole, in addition to the individual patient. These concerns can be viewed as 3 concentric circles (Figure).3

Like most physicians, primary care physicians have direct contact with the institutions with which they are affiliated. In addition, they frequently have direct contact with the community through a variety of clinics and outreach programs. Some of the ethical dilemmas physicians encounter are directly linked to the individual, the institution, and the community at large.

Case 1
A 16-year-old white girl presents to a primary care facility because she ?missed a period? last month. She also complains of nausea, abdominal cramps, and loss of energy. Maybe she is pregnant; maybe it is the flu. She hopes she is not pregnant. However, if she is pregnant, she does not want to have an abortion. She inquires about contraceptives and requests a pregnancy test. The pregnancy test is negative, but the results of the urinalysis are suspicious for a urinary tract infection. The gynecologic examination yields a positive wet mount preparation for trichomoniasis.

Ethical considerations
The individual patient
What is the responsibility of the physician to this patient? What does the good of this patient require from the physician? Should the physician inquire about her emotional health or refer her for other support services? Does the physician?s responsibility end with this patient? In this case, at least one other person is involved. The patient thought that she might be pregnant, although she is not, but she does have an STD.4,5 Therefore, her partner is involved, and the physician must consider treatment for both the partner and the patient (Table 1).

The institution
What is the responsibility of the physician to the institution? Who will assume the financial responsibility for this patient?s care? That she came alone, without a parent or a guardian, implies that the parent or guardian has not been informed of her situation and perhaps would not approve of her using contraceptives. Because the girl is 16 years old, she is still a minor. A physician may not prescribe any treatment for a minor without parental approval, with a few exceptions.

A second consideration is the institution?s policy about contraceptives. In our institution, contraceptives may not be prescribed for birth control but may be permissible for other conditions, such as dysmenorrhea or menorrhagia, as well as some skin conditions.2 This, obviously, is not the case in every medical institution.

A third consideration is the treatment of the patient and her partner. Does the institution have a policy that will guide the physician?s decisions in this respect? If no policy exists, should one be developed? Are there guidelines in place to aid the physician; treat the patient and partner; and also protect the patient, partner, physician, and institution?

The community and society
A third level of the ethical dilemma involves the community and society. First is the question of treating an adolescent without parental consent.6,7 In 25 states and in the District of Columbia, minors (those under age 18) have the sole authority to consent to contraceptive services; in 32 states and in the District of Columbia, pregnant minors may receive prenatal care and delivery services; other states allow a minor to consent to prenatal care if she is deemed to be ?mature?; and in all 50 states and in the District of Columbia, minors may consent to treatment for STDs, including HIV.8 In each of these cases, the law not only gives minors the authority to consent to medical care but allows them to do so without their parents? knowledge or permission, although in some cases physicians may inform the minor?s parents if this is considered to be in the minor?s best interests.8

In the Commonwealth of Pennsylvania, minors may consent to treatment, and thus physicians can provide treatment related to birth control, pregnancy, and prenatal care without involving the parents. This is not the case for abortion, however. Minors may also consent to testing and treatment for certain reportable diseases, including STDs.4,8,9

Furthermore, the physician is required to report STDs to the appropriate authorities and to inform the patient. Does this resolve the ethical dilemma with regard to the community and the society? Is complying with the law the same as doing what is right?

Since this patient has an STD, at least 1 other person is also infected. If she has more than 1 partner, and these partners also have several partners, the circle of infection is widening. Generally speaking, it is a violation of patient confidentiality and privacy for a physician or institution to inform partners. How much responsibility does the physician have to contain the spread of the infection?

Case 2
A 25-year-old married black man presents to the clinic complaining of groin pain. Questioning reveals his symptoms are consistent with urethritis and dysuria. He denies any penile discharge or skin lesions. Suspecting an infectious etiology, a sexual history is obtained. The patient admits to having an unprotected sexual encounter with a female colleague at his workplace during the past week. Concerned about the implications of infidelity and the tension it could cause, he is reluctant to provide additional information. You educate him on safe sexual practices, and he consents to STD screening that includes tests for gonorrhea, chlamydia, and HIV infection. You treat him empirically for chlamydia and gonorrhea, and inform him that his colleague may have a sexually contracted infection and would also need to be evaluated and possibly treated by her doctor. The patient refuses to notify his colleague that she may be infected or to tell his wife about the encounter. He leaves after scheduling a follow-up visit in 10 days.

When the patient returns, he reports that his initial presenting symptoms have resolved. In a private setting you inform him of his laboratory test results. The gonorrhea test is negative, but the chlamydia probe and HIV test are positive. Treatment was completed for the chlamydia infection during his first office visit, and his HIV infection is now the focus of concern. The patient states that this is his first extramarital affair but is not very forthcoming with information about any other high-risk behaviors either before or during his marriage.

Ethical considerations
The individual patient
The physician?s first duty is to the individual patient?to treat the STD, the condition that prompted him to seek medical aid. However, an STD always implicates at least 1 other individual, the person who transmitted the infection. In addition, since the patient is married, another individual (his wife) is also at risk. With these considerations, the physician?s duty to treat this patient comes into conflict with his concomitant duty to maintain confidentiality (Table 2).1

What duty, if any, does the physician have to treat?or even inform?a patient?s sexual partners? Do the patient?s right to privacy and the physician?s concomitant duty to maintain patient confidentiality outweigh any duty to warn others of their potential risk? The law varies from state to state with regard to these questions.

Since the physician has the duty to treat the patient, does that mean his duty ends when only this patient is treated? What is the physician?s responsibility in preventing a vicious cycle of recurring infection?

The positive HIV infection test adds another dimension of complexity, because HIV infection virtually always produces a spectrum of disease that, without prompt and consistent treatment, almost certainly will progress from a clinically latent or asymptomatic state to AIDS. Proper treatment of HIV infection involves a complex array of medical, behavioral, and psychosocial services.

The physician must also make the patient understand the necessity of telling his wife that she may have been exposed to HIV. Since this patient was unwilling to tell his wife that he had contracted an STD, it is possible that he will not want to tell her about his HIV infection. Does the physician have a duty to warn the patient?s wife about her risk? If the duty to warn does not apply in regard to the patient?s wife, does the fact that the wife is of childbearing age and could transmit HIV infection to an unborn child alter the physician?s responsibility?

Beyond any duty to respect confidentiality or any duty to warn, does the physician have the right to disclose confidential information to someone who may be harmed if the information is withheld?10

The institution
In addition to the individual patient, the physician has obligations to the institution. Does the institution have a policy about treating both patients and their partners for STDs, even if the partner is not a patient? In the absence of a policy, what should guide the physician in making the decision to treat both parties?

Does the institution have a policy about notifying partners of the results of HIV tests? What is the risk to the institution if a patient refuses to disclose pertinent information, and the physician decides to inform the partner? Which is more compelling: the physician?s duty to the patient or the physician?s duty to the institution?

Furthermore, the physician has responsibilities, both legal and ethical, not only to the individual patient but also to the common good of society. There is, for example, a duty to warn; in some cases, physicians have an obligation to warn spouses and other partners of HIV-infected patients.1 Does this duty to warn apply to this specific patient?

The community and society
The common good is that which constitutes the well-being of the community, including its safety. Members of the community strive to achieve a good life; maintaining health is one of the communal goals.

In this scenario, the communicability of the infections touches at least 2 communities, with the patient at the point of intersection. The first community is the sex partner or partners who transmitted the infections to this patient. The second community begins with the patient?s wife and any other possible sex partners. How much responsibility does the physician have to preserve the well-being of either or both of these communities?

Reporting STDs is mandatory.5 In Pennsylvania, the positive HIV test result must also be reported.11 This varies from state to state. Some states require that patient names be reported, while others require only patient-coded identifications. Is such reporting sufficient warning to the affected communities? What should the physician do to meet the moral obligations to the affected communities?

Identification of HIV infection in patients of any age imposes obligations to provide counseling and referral to appropriate treatment services.5 The patient?s partner(s) should also be informed of the HIV infection diagnosis to prevent further transmission. But this patient does not want to tell his wife about his infections. Therefore, she is at risk, and, if she becomes pregnant, so possibly would her unborn child. How far does the physician?s responsibility extend?

Legally, under certain defined circumstances the physician may notify a patient?s partner(s) even without the patient?s consent. If, for example, the physician is reasonably certain that the patient will not notify his partner(s) or that a significant risk to the partner(s) exists, the physician may provide the notification as part of a general duty to warn. If the patient?s refusal to notify his partner(s) endangers public health, the physician has the duty to warn.

But what if this particular case does not match the defined circumstances and guidelines, and the physician still believes that the patient?s wife must be notified? Should the physician follow conscience and the spirit of the law or adhere to the letter of the law? Does the need to protect society outweigh the need to respect patient confidentiality? How does the physician determine the right course of action?

The Role of the Physician
Perhaps there is a fourth dimension to resolving these ethical dilemmas: the physician?s responsibility to self. Rather than another concentric circle, this responsibility is analogous to a chord that intersects all 3 concentric circles and coexists with the physician?s responsibilities to patient, institution, and society. Furthermore, these competing and frequently conflicting responsibilities must be weighed and balanced under serious time constraints.

The primary care physician sees a wide variety of patients with an even wider variety of conditions but has a very limited amount of time with each patient. Physicians do not have the luxury of examining each case in detail to determine whether it presents an ethical dilemma, and then to weigh all the alternatives to arrive at the right solution. Physicians must recognize the subtle ethical dilemmas encountered in primary care and construct a framework for evaluating them when they occur. The 4 principles of ethical decision making provide objective standards for constructing this framework.

In the case of the HIV-infected patient (Case 2), the physician would be violating the patient?s autonomy as well as confidentiality by informing his spouse and colleague of the HIV-positive test result (autonomy and nonmaleficence). However, the physician may have an obligation to warn the spouse and other colleagues if the patient refuses to disclose his HIV-positive status and refuses to engage in safe-sex practices (beneficence). Furthermore, even respect for autonomy has only prima facie status. A prima facie obligation must be fulfilled unless it conflicts with an equal or stronger obligation.1 Thus, respect for autonomy can be overridden by more compelling, competing moral obligations.

For example, if the patient?s autonomous choices endanger public health or harm others, the physician can override the patient?s choices, namely, if the disclosure is medically appropriate; the patient has been counseled, and the physician reasonably believes the patient will not inform those at risk; and the physician has informed the patient of the intent to make the disclosure.

States may have individual guidelines, but all state health departments that receive federal HIV prevention funding have established partner notification programs. At least 37 states have enacted HIV/AIDS-specific partner notification laws that either allow or require physicians or public health personnel to notify sexual or needle-sharing partners that they have been exposed to the virus.12 Many of the remaining states permit partner notification under general communicable disease control efforts. In 2005, 38 states reported HIV data by the patient?s name, and 12 states and the District of Columbia used a code-based method to report HIV data.13

In the case of the minor patient (Case 1), the same considerations apply, plus the additional complication of parental notification. The girl must be treated for the STD. Her partner should be notified and treated. Birth control may be prescribed, without parental consent or notification if the law permits; otherwise the parents will have to be informed. There is no such thing as an easily resolved ethical dilemma.

Conclusion
Each physician must not only keep abreast of medical developments but also be aware of the laws of the land, the policies of the institution, and the principles of ethical decision making. Laws and guidelines are evolving constantly. The physician must apply the principles of ethical decision making, in conjunction with the emerging laws and guidelines, to the current ethical dilemma.

Self-assessment test
1. All these concepts are objective standards of ethical decision making, except:
A. Equality
B. Nonmaleficence
C. Beneficence
D. Justice

2. Which of these statements about minors? consent to healthcare is true?
A. A 14-year-old adolescent is considered a minor
B. In most states, minors need the consent of a parent or guardian to receive treatment for HIV infection
C. In some states that allow minors to consent to healthcare, physicians can still inform the parents if they think it is in the best interest of the minor
D. In all 50 states, minors have the sole authority to consent to contraceptive services

3. All the following principles should be considered when evaluating an ethical dilemma, except:
A. Promoting the well-being of the patient
B. Promoting the well-being of patients? partners
C. Letting patients make decisions about their healthcare
D. Distributing benefits and risks fairly

4. Which of these statements about the principle of autonomy is NOT true?
A. It should always be followed
B. It is a prima facie obligation
C. It can be overridden by more compelling, competing moral obligations
D. It can be disregarded if it conflicts with an equally compelling, competing moral obligation

5. Which of the following statements about HIV infection is true?
A. All 50 states have established partner-notification programs
B. All 50 states report HIV infection data using a code-based system
C. All 50 states report HIV infection data by patient name
D. All states that receive federal funding for HIV prevention have partner-notification programs

(Answers at end of reference list)

References
1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th ed. New York, NY: Oxford University Press; 2001.

2. United States Conference of Catholic Bishops. Ethical and Religious Directives for Catholic Health Care Services, Fourth Edition. 2001. Available at www.usccb.org/bishops/directives.shtml.

3. Glaser JW. The Three Realms of Ethics. Kansas City, Mo: Sheed & Ward; 1994.

4. Juvenile Law Center. Teenage Pregnancy & Parenthood in Pennsylvania. Available at www.jlc.org/index.php/factsheets/teenpreg.

5. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR Recomm Rep. 2002;51(RR-6):1-78.

6. Center for Health Improvement: Health Policy Guide. Maintaining Confidentiality for Teens Obtaining Reproductive Health Services. 2004. Available at www.healthpolicyguide.org/doc.asp?id=6569.

7. Juvenile Law Center. Consent to Treatment and Confidentiality Provisions Affecting Minors in Pennsylvania. 2nd ed. 2006. Available at www.jlc.org/home/publications/consent2.php.

8. Guttmacher Institute. State Policies in Brief (As of June 1, 2006): An Overview of Minors? Consent Law. Available at www.guttmacher.orgstatecenter/spibs/spib_OMCL.pdf.

9. Pennsylvania Department of Health. ?Sexually Transmitted Diseases (STD): STD Program Components.? Available at www.health.state.pa.us/php/std/.

10. University of Pennsylvania Health System Office of Legal Affairs. A Guide to Legal Issues in Health Care. Available at www.uphs.upenn.edu/legal.

11. AIDS Law Project of Pennsylvania. Comparison of Pennsylvania Confidentiality of HIV-Related Information Act (Act 148) and Federal Health Insurance Portability and Accountability Act. Available at www.aidslawpa.org/comparativechart.pdf.

12. Centers for Disease Control and Prevention. Legislative Survey of State Confidentiality Laws, With Specific Emphasis on HIV and Immunization. Atlanta, Ga: Centers for Disease Control and Prevention; 1996.

13. AIDS Foundation of Chicago. ?Illinois to Report Cases of HIV by Name in 2006.? October 19, 2005. Available at www.aidschicago.org/advocacy/hiv_surveillance.php.

Answers: 1. A; 2. C; 3. B; 4. A; 5. D.



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