AIDS policy: confidentiality and disclosure

Divergent ethical perspectives on the duty-to-warn principle with HIV patients

This article presents the case of an HIV-positive client who reported having sexual relations with an unknowing partner. The issue raised is whether the therapist was required to warn the unknowing partner, similar to the Tarasoff mandate that is imposed on therapists. The case is analyzed from an ethical framework similar to that presented by Beauchamp and Childress (1994). Two opinions are presented, each leading to different conclusions about whether the therapist should inform the unknowing partner. It is concluded that although such analysis is valuable in aiding the therapist in his or her decision-making process, no clear professional standard for the management of the problem is evident.

A history of psychiatric ethics

In the not-far-distant past, ethics for all doctors was, at best, an ill-attended lecture or two on how to keep out of trouble; it was assumed the rest was absorbed by a form of social and professional osmosis. Although ethics has entered the undergraduate curriculum, continuing medical education programs, journals, and books, it still is in a state of flux. Although immense progress has been made in the last 30 to 40 years, much remains to be done. Trainees are often naïve, and the older generation is on a steep learning curve. An encouraging feature is the current lively debate on matters ethical and how they can best be incorporated into everyday clinical practice. The long-held notion of ethics resting complacently in the paternal arms of Hippocrates has, with almost brutal haste, been projected into a rapidly evolving modern world of technologic, moral, and societal change. Yet, at its core, ethics has to retain its humanism and guard against influences from every quarter that tries to make it a set of rules, thereby negating the diversity and uniqueness of our patients. Even as you read, there will be new influences and pressures on clinical practice that have an ethical dimension. For instance, we are adjusting to new privacy laws in Australia that allow patients, whether public or private, access to their psychiatric records. Globalization is not restricted to world trade; it also operates in the framework of societal change and the wider dissemination and implementation of libertarian views. If such "freedoms" are not currently available to patients, they soon will be. This brief historical foray in identifying some of these forces can assist in their early recognition so that as a profession, we are forewarned and forearmed and, in that respect, be ahead of both Henry Ford ("History is more or less bunk...") [42] and the Bourbons ("They learn nothing and they forget nothing") [43].

Current analysis of the Tarasoff duty: an evolution towards the limitation of the duty to protect

In 1976, the Tarasoff case established a new legal duty to protect third parties from a psychiatric patient's foreseeable violence. After the Tarasoff case, courts expanded the scope and role of a clinician's duty to protect, sometimes in novel ways. Later interpretations of Tarasoff began to limit significantly the situations in which a duty to protect would attach. Recent Tarasoff-type cases in which courts have rejected the clinician's duty to warn suggest that Tarasoff is declining in significance. The advent of state statutes that codify the establishment and discharge of Tarasoff duty have contributed to a further limitation of the duty to protect. Lastly, when faced with the management of dangerous patients, we advocate for a thorough, well documented assessment of risk of violence as the best means for addressing concern about potential legal liability.

Patient confidentiality and the surrogate's right to know

Physicians treating newly incapacitated patients often must navigate surrogate decision-makers through a difficult course of treatment decisions. Such a process can be complex. Physicians must not only explain the medical facts and prognosis to the surrogate, but also attempt to ensure that the surrogate arrives at decisions that are consistent with the patient's own values and wishes. Where these values and wishes are unknown, physicians must help surrogates make decisions that reflect the patient's best interests.

The ethical limits of confidentiality in the therapeutic relationship

The author explores the moral underpinnings of psychiatric confidentiality in an attempt to define its ethical limits. Knowledge of this standard assumes growing importance as third party incursions into the patient-therapist dyad become increasingly common in day-to-day practice. The APA's AIDS policy on confidentiality and disclosure is offered as an illustrative example of the profession's ability to successfully translate moral deliberation into clinical policy.

HIV public policy and psychiatry. An examination of ethical issues and professional guidelines

The authors examine the interfaces among public policy, legal issues, ethical issues, and physician responsibility for the human immunodeficiency virus (HIV)-infected psychiatric patient within the realms of civil liberties and public health. Current professional guidelines on caring for HIV-infected psychiatric patients are discussed, including discussion of psychotherapy and the potential for behavioral change. The impact of the Tarasoff decision on confidentiality is reviewed, including discussion of whether a precedent was set mandating that a psychiatrist warn identifiable third persons at risk of becoming infected by his or her patient. The management of HIV-infected psychiatric inpatients who continue to put other patients at risk and the impact of HIV carriers on ward milieu are also addressed, as are difficulties encountered with the chronically mentally ill.

The HIV-positive psychiatric patient and the duty to protect: ethical and legal issues

A small, yet significant, percentage of HIV-positive patients have a concomitant psychiatric or neurological disorder associated with impaired judgment. Clinical problems such as psychoses, certain personality disorders, and dementias are associated with disinhibition of impulses and diminished capacity for self-monitoring. These deficits in reasoning and judgment may prevent the patient from comprehending the significance of their HIV status and the consequences of sexual behavior or needle sharing. There are indications that the Tarasoff duty-to-protect may apply to this situation.

METHOD

Available data about the prevalence of HIV risk behavior and HIV infection among psychiatric patients are reviewed. The applicability to these situations is described.

RESULTS

When an HIV patient engages in high risk sexual behavior with identifiable partners and refuses to notify them of their HIV status, physicians and mental health professionals may have a legal and ethical duty to warn.

CONCLUSION

A decision model for this clinical dilemma is presented. Clinical strategies for these patients may include ongoing supervision and monitoring as well as possible quarantine.

Psychiatric care for patients with HIV infection. The varying perspectives

This article reviews the literature on the classification and treatment of psychiatric morbidity associated with infection from the human immunodeficiency virus (HIV). The psychiatric disorders seen in HIV-infected patients are formulated by using one of the following four perspectives as treatment guides: 1) the syndromal or disease perspective, 2) the dispositional or personality perspective, 3) the behavioral or addictive perspective, and 4) the life story perspective.

HIV transmission: ethical and legal considerations in psychotherapy

Psychiatrists, particularly psychotherapists, have access to the most intimate details of patients' lives. As a result, psychiatrists may face a number of ethical dilemmas, particularly when the issue of potential human immunovirus (HIV) transmission is involved. This paper examines the principle and the limits of confidentiality, and outlines various ways to resolve situations in which there is a conflict between the risk of HIV being transmitted to the unsuspecting public and the principle of confidentiality. Psychiatrists should not assume that patients engaged in high risk behaviour that may be self-destructive fully understand the risks involved. An educational approach may be warranted with these patients, even though such an approach would not be consistent with non directive therapy.

AIDS: clinical and ethical issues on a psychiatric unit

Using a case illustration, this paper describes how AIDS has affected psychiatric practice on an inpatient unit. The clinical, ethical and administrative issues are discussed from a multi-disciplinary perspective. The issues are discussed as 1. clinical issues (diagnostic and management), 2. effects on ward milieu, 3. staff issues, 4. family counselling and discharge planning and 5. administrative issues. It is important for inpatient staff to discuss these issues and develop clinical guidelines and administrative procedures that will help staff provide the highest level of care possible. Because every patient is potentially an HIV carrier, many of the solutions developed around AIDS related concerns should apply to all patients on a psychiatric ward.

Community mental health's role in the AIDS crisis

Mental Health concomitants of the AIDS crisis are reviewed along with recommendations for a community mental health response. Proposed interventions range from traditional clinical services to support groups, case management, day treatment, training of caregivers, outreach, consultation, and community education. It is recommended that, at the very least, each community mental health center identify an AIDS specialist who will keep abreast of the rapidly changing information and become the in-house expert. The author predicts that AIDS is likely to become the major mental health problem of the next decade.