Healthcare professionals, particularly nurses, face moral and ethical dilemmas about balancing honoring patient confidentiality and ensuring their family members have all the information they need to provide informed care. In this case, Carlos R., a Hispanic patient diagnosed with HIV, finds himself facing potential discrimination and stigma from his father and community due to both his status and sexual orientation. However, since a lack of Medicare funding for his nursing visit necessitates home care that will be provided by his twenty-two-year-old sister, Consuela, there is a need to ensure that she can take protective measures to avoid infection from wound treatment.
Consuela has a right to information, enabling her to make an informed decision about her capacity and willingness to care for her brother. Furthermore, the healthcare system must warn of potential health risks to a person or a population (Fleck & Angell, 2014). Essentially, most people in this situation would expect to be informed about the nature of the patient’s illness to manage their interactions positively (Mulligan, 2021). For example, a private nurse would expect that she would be given this information, as it would have a material impact on how they handle their wounds.
Although no one would be able to accurately measure the level of risk that she faces, the fact that there is an even remote chance that transmission could occur is reason enough to inform her. In particular, this is important because she does not have experience with universal precautions and would be likely to engage in activities that would expose her to transmission from the pus or blood in the wound. Moreover, she would need to be more diligent because this is his brother. She may fail to comply with universal precautions because she loves him. Additionally, it is possible that she would want to reconsider her eagerness to provide home care to her brother once she knows his status.
Furthermore, the fact that she has accepted the burden of providing care to her HIV-positive brother is due to an inability on the part of the health system to meet the needs of his brother. As such, it has an additional responsibility to ensure that the person taking on this duty is protected and has all the material facts that would allow her to provide appropriate care. For example, if she does not know about his HIV status, she could unknowingly engage in behavior or make statements in his presence that could make him feel stigmatized, even if that is not her intent.
Whereas the threat of transmission may not be imminent, it represents severe and irreversible harm. It is wrong to state that a general education about universal precautions without providing the context would be sufficient to meet the standard of duty to warn. Similarly, advising Carlos R. about the measures that he needs to take to protect his sister from potential infection would be insufficient because it does not account for the need for trances when he may be asleep or unconscious as she attends to his wound. Moreover, the suggestion that the risk of seroconverting is low because statistically, few caregivers who attend to wounds get infected from nicking themselves fails to account for the potential unexpected deterioration of the wound and other injuries. Even providing gloves and other protective gear without the context for why they must always be used would be inadequate due to her love for her brother and her willingness to go above and beyond to meet his needs and improve his life.
The fact that Consuela has been acting as a ‘mother’ to her brother suggests that knowing his status would not change her willingness to care for him and love him. Like many girls, she has been forced to take on a caregiving role because of the expectation that she should be a responsible and caring person. Besides taking on this responsibility graciously, she is now being asked to take on the nurse role. At twenty-two years, this represents a unique challenge that many girls face as they are forced to mature earlier than their male counterparts. Nonetheless, to assign her this role without allowing her to make an informed decision would infringe on her autonomy.
The concerns expressed by Carlos. R about potential stigma and discrimination by his father and community reflect stereotypes about the Hispanic culture. If it is proven accurate, then his sister is not responsible for placing herself at risk of infection. At the same time, his father may be surprised by the information and even struggle to accept it, but he could prove his fears wrong. Nonetheless, the only way to find out would be to inform him and navigate the implications of sharing this information based on how he responds.
Fundamentally, it would be both immoral and unethical to allow this young girl to unknowingly put herself at risk of HIV infection without ensuring that she has all the information she needs to protect herself. Honouring confidentiality is essential but must be limited to instances when it is only personal (Fleck & Angell, 2014). In contrast, doing so in this case could result in knowingly contributing to placing another person at risk. The high number of medication administration errors in a clinical environment demonstrates the fallibility of human beings and the fact that mistakes can occur even when someone knows the precautions and protocols to follow. Consequently, it would be cruel to expect a non-medical person to be able to protect herself without knowing about his HIV status.
The patient can waive the right to confidentiality to allow for an open and frank discussion between all the stakeholders in this case. This is because meeting the needs of an HIV-positive patient is a team effort, and the effectiveness of collaborative care in this case would be undermined if Consuela did not have all the information. Besides being selfish, Carlos R. expects the doctor to act unprofessionally to accommodate his preferences. The observation may be a reason for providing him with more counseling so that he can accept his current situation and thus be empowered to manage it and how he communicates about it with his loved ones. Accommodating his request would not only enable him to develop the right attitude necessary to address HIV in the long term. However, it could result in behaviors and activities that put more people at risk of this infection.
In conclusion, the optimal ethical resolution of this dilemma is for the caregiver to encourage Carlos R. to inform his sister about his status. In case he is unaIf he cannot, I can offer to do this for him. She could be requested to keep this information private from his father until Carlos is prepared to do so himself. However, if he insists that Consuela should not be told, the doctor must identify an alternative way to meet his care needs. In essence, this boils down to the fact that the generosity of care extended by Consuela must be rewarded with sharing his HIV status, or it should not be accepted.
References
Fleck, L & Angell, M. (2014). Case Studies: Please Do not Tell. The Hastings Center Report, 21(6), 39-40.
Mulligan, A. (2021). Patient Confidentiality and Disclosure of HIV Status: Disentangling the Entitlement to Disclose from the Duty to Warn, Medical Law Review, 29(4), 688–698.
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