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CASE #1--"PLEASE DON'T TELL!"
A twenty year old Hispanic male was brought to a hospital emergency room, having suffered abdominal injuries due to gunshot wounds obtained in gang violence. He had no medical insurance, and his stay in the hospital was somewhat shorter than expected due to his good recovery. Physicians attending to him felt that he could complete his recovery at home just as easily as in the hospital and he was released after only a few days in the hospital.

During his stay in the hospital, the patient admitted to his primary physician that he was HIV positive, having contracted the virus that causes AIDS. This was confirmed by a blood test administered while he was hospitalized.

When he was discharged from the hospital, the physician recommended that a professional nurse visit him regularly at home in order to change the bandages on his still substantial wounds and to insure that an infection did not develop. Since he had no health insurance he was dependent on Medicaid, a government program that pays for necessary medical care for those who cannot afford it. However, Medicaid refused to pay for home nursing care since there was someone already in the home who was capable of providing the necessary care. That person was the patient's twenty-two year old sister, who was willing to take care of her brother until he was fully recovered. Their mother had died years ago and the sister was accustomed to providing care for her younger siblings.

The patient had no objection to his sister providing this care, but he insisted that she not be told that he had tested HIV positive. Though he had always had a good relationship with his sister, she did not know that he was an active homosexual. His even greater fear was that his father would hear of his homosexual orientation and lifestyle Homosexuality is generally looked upon with extreme disfavor among Hispanics.

The patient's physician is bound by his code of ethics that places a very high priority on keeping confidentiality. That is, information about someone's medical condition that he or she does not want known cannot be divulged by the physician. Some would argue that the responsibility of confidentiality is even greater with HIV/AIDS since disclosure of someone's homosexuality normally carries devastating personal consequences for the individual who is forced "out of the closet."

On the other hand, the patient's sister is putting herself at risk by providing nursing care for him. Doesn't she have a right to know the risks to which she is subjecting herself, especially since she willingly volunteered to take care of her brother?

If you were the physician, what would you do in this case? Would you breach the norm of confidentiality to protect the patient's sister, or would you keep confidentiality in order to protect he patient from harm that would come to him from his other family members, especially his father?

Perhaps as good a question as "what would you do" in this situation is the question, "how would you decide what to do" in this situation? The process of making a moral decision can be as important as the decision itself, and many ethical decisions that people encounter are so complex that it is easy to exhaust oneself talking around the problem without actually making any progress toward resolving it. The response to many moral dilemmas is "where do I start?' and the person who is faced with these decisions often needs direction that will enable him or her to move constructively toward resolution and "see the forest for the trees."

In order to adequately address the ethical dilemmas that people encounter regularly, the following is a model that can be used to insure that all the necessary bases are covered. This is not a formula that will automatically generate the "right" answer to an ethical problem. Rather it is a guideline that is designed to make sure that all the right questions are being asked in the process of ethical deliberation.

Given the ethnic and religious diversity of our society, it is important that the model used for making ethical decisions have "room" in it to accommodate a whole host of different moral and ethical perspectives. This model is not tied to any one particular perspective, but can be used comfortably with a variety of cultural, ethnic and religious backgrounds. This is not a distinctively Christian model, though it is consistent with the Scripture and any Christian can use Biblical principles in utilizing this model. As was explored in chapter two, what makes many moral dilemmas so difficult is that the Scripture does not speak to the issue as clearly as one would prefer because Scripture has not directly addressed the issue. More general principles can be brought to bear on the issue at hand. However, in these instances, there is often disagreement about which Biblical principles are applicable to the specific issue under discussion. For example, in Case #1 (Please Don't Tell) the physician could invoke the Biblical principle of compassion toward his patient in refusing to disclose information that would harm him. But at the same time, he could invoke the same principle of compassion toward the sister in protecting her from the risk of medical harm. It is not clear that appeal to principles alone will conclusively resolve this case. Thus to insist that all ethical dilemmas are resolved simply by appeal to Biblical principles seems to oversimplify the case. Certainly many moral questions are resolved conclusively by appeal to Scripture. But there are other cases in which that does not happen. That is not to say that Scripture is not sufficient for the believer's spiritual life, but that the special revelation of Scripture is often supplemented by the general revelation of God outside Scripture. This model makes room for both general and special revelation, and gives each a place in helping to resolve the difficult moral dilemmas facing people today.

Here are the elements of a model for making moral decisions:

1. GATHER THE FACTS
Frequently ethical dilemmas can be resolved simply by clarifying the facts of the case in question. In those cases that prove to be more difficult, gathering the facts is the essential first step prior to any ethical analysis and reflection on the case. In analyzing a case, we want to know the available facts at hand as well as any facts currently not known but that need to be ascertained. Thus one is asking not only "what do we know?" but also "what do we need to know?" in order to make an intelligent ethical decision.

2. DETERMINE THE ETHICAL ISSUES
The ethical issue(s) are stated in terms of competing interests. It's these conflicting interests that actually make for an ethical dilemma. The issues should be presented in a __________ vs. __________ format in order to reflect the interests that are colliding in a particular ethical dilemma. For example, many ethical decisions, especially at the end of a patient's life can be stated in terms of patient autonomy (or the right of the individual to make his or her own decisions about medical care) vs. the sanctity of life (or the duty to preserve life). In Case #1 above, the interests of the patient in having the physician keep confidentiality conflict with the interests of his sister in being protected from the risk of contracting the HIV virus.

3. WHAT PRINCIPLES HAVE A BEARING ON THE CASE?
In any ethical dilemma, there are certain moral values or principles that are central to the competing positions being taken. It is critical to identify these principles, and in some cases, to determine whether some principles are to be weighted more heavily than others. Clearly Biblical principles will be weighted the most heavily. There may be other principles that speak to the case that may come from other sources. There may be Constitutional principles or principles drawn from natural law that supplement the Biblical principles that come into play here.

4. LIST THE ALTERNATIVES
Part of the creative thinking involved in resolving an ethical dilemma involves coming up with various alternative courses of action. Though there will be some alternatives which you will rule out without much thought, in general, the more alternatives that are listed, the better the chance that your list will include some high quality ones. In addition, you may come up with some very creative alternatives that you had not considered before.

5. COMPARE THE ALTERNATIVES WITH THE PRINCIPLES
At this point, the task is one of eliminating alternatives according to the moral principles that have a bearing on the case. In many instances, the case will be resolved at this point, since the principles will eliminate all alternatives except one. In fact, the purpose of this comparison is to see if there is a clear decision that can be made without further deliberation. If a clear decision is not forthcoming, then the next part in the model must be considered. At the least, some of the alternatives may be eliminated by this step of comparison.

6. WEIGH THE CONSEQUENCES
If the principles do not yield a clear decision, then a consideration of the consequences of the remaining available alternatives is in order. Both positive and negative consequences are to be considered. They should be informally weighted, since some positive consequences are more beneficial than others and some negative consequences are more detrimental than others.

7. MAKE A DECISION
Deliberation cannot go on forever. At some point, a decision must be made. Realize that one common element to ethical dilemmas is that there are no easy and painless solutions to them. Frequently, the decision that is made is one that involves the least number of problems or negative consequences, not one that is devoid of them.

BACK TO CASE #1--PLEASE DON'T TELL!
Using the model, let's return to the case that began the chapter. This will illustrate how the model is used and clarify exactly what is meant by each of the elements in the model. Two additional cases will be presented and analyzed in the framework of this model to insure that it can be used profitably.

1. GATHER THE FACTS
The relevant facts in this case are as follows:

• The patient is a young man, infected with HIV and an active homosexual.
• He suffered fairly severe abdominal wounds but is recovering well.
• Homosexuality is looked down upon in Hispanic communities.
• The patient has insisted that his physician maintain confidentiality about his HIV status.
• The patient is afraid of rejection by his father if his homosexuality is discovered, an understandable fear given the way homosexuality is viewed in the Hispanic community.
•  He was wounded by gunfire in gang violence. It is not clear but is a reasonable assumption that he is a gang member. As a result, he likely fears rejection and perhaps retribution from his fellow gang members, especially if they discover that he is HIV positive.
• He is uninsured and cannot afford home nursing care by a professional.
• Medicaid refuses to pay for professional home nursing care.
• The patient's sister is willing and able to provide the necessary nursing care for her brother. She is accustomed to providing maternal-like care for her brothers and sisters.
• The patient has specifically requested that his sister not be told of his HIV status. She does not know that he is an active homosexual.
• The patient's sister would be changing fairly sizable wound dressings for her brother and the chances are high that she would come into contact with his HIV infected blood. The probability of her becoming infected with the virus from this contact is difficult to predict.

2. DETERMINE THE ETHICAL ISSUE(S):
The competing interests in this case are those of the sister who will provide the care and the patient who will receive it. Both have interests in being protected from harm. The patient fears being harmed in a psycho-social way if his homosexuality and HIV status were discovered. Thus he has put the physician in a difficult situation by demanding that his right to confidentiality be kept. Though she does not know it, his sister fears medical harm due to the risk of contracting the HIV virus from contact with her brother's blood. This could be stated as a conflict between confidentiality for the patient vs. the right to know the patient's condition for his sister due to the risk she would be taking in giving him nursing care. The conflict could be summarized by the need for patient confidentiality vs. the duty to warn the sister of risk of harm.

3. WHAT PRINCIPLES HAVE A BEARING ON THE CASE?
Two moral principles that speak to this case come out of the way in which the ethical issue is stated. This case revolves around a conflict of rights, a conflict of duties that the physician has toward his patient and toward the sister. He is called to exercise compassion toward both, but what compassion (or the duty to "do no harm") demands depends on which individual in the case is in view. Thus two principles are paramount. First is the widely recognized principle that patients have a right to have their medical information kept confidential, particularly the information that could be used to harm them if it were disclosed. But a second principle that comes into play is the duty of the physician to warn interested parties other than the patient if they are at risk of imminent and substantial harm.

One of the difficult aspects of any ethical decision is knowing what weight to give the principles that are relevant to the case. Here, the principle of confidentiality is considered virtually sacred in the medical profession and most physicians will argue that it is necessary to keep confidentiality if patients are to trust their physicians and continue coming for treatment. But confidentiality is often considered subordinate to the duty to warn someone who will likely be harmed if that information is not disclosed. For example, if a psychologist believes that his patient will kill his wife, or beat her severely, he has a moral obligation to inform the wife that she is in danger from her husband. The duty to warn someone from imminent and severe harm is usually considered a more heavily weighted principle than confidentiality in cases like these.

The key question here in weighting the principles of confidentiality and the duty to warn (both fulfilling the Biblical notion of compassion toward those in need of it) is the degree of risk that the patient's sister is taking by providing nursing care for her brother. If the risk is not substantial, then that weights confidentiality a bit more heavily. But if the risk is significant, then the duty to warn is the more heavily weighted principle. This is particularly so given the fact that the sister has volunteered to perform a very self-sacrificing service for her brother. Some would argue that her altruism is an additional factor that weights the duty to warn principle more heavily. Others would suggest that his contracting HIV is an example of "reaping what one sows," and that minimizes consideration of the patient's desire for confidentiality. An additional factor that should be figured into the deliberation is that the risk to the patient, though it may have a higher probability of happening, is not as severe as the risk to the sister. After all, if the worst case scenario happened to the patient, his father would disown him and the gang would throw him out (though their action could be more severe than that). He would recover from all of that. But if his sister contracted HIV, she would not recover from that. Though the probability of the worst case scenario is higher for the patient, the results of the worst case are clearly higher for the sister.

4. LIST THE ALTERNATIVES:
In this case, there are a number of viable alternatives that involve compromise on either the patient's part or his sister's. However, there are two alternatives that do not involve compromise and they each reflect a weighting of the principles.

One alternative would be to tell the sister that her brother is HIV positive. This alternative comes out of taking the duty to warn principle as higher priority. On the other hand, a second alternative is to refuse to tell her that information, upholding the patient's request for confidentiality and taking the confidentiality principle as the one that carries the most weight.

However, there are other alternatives. For example, the physician could warn the patient's sister in general terms about taking appropriate precautions for caring for these types of wounds. She is to wear gloves and even a mask at all times when handling the bandages. Should she get any blood on her clothes or body, she is to wash immediately with a disinfectant soap. In other words, she is to take universal precautions that any medical professional routinely takes in caring for patients.

A further alternative is to request that the patient inform his sister of his condition. He could then request that she not tell any other family member or any or his friends. If he refused, then the next step might be to say to him in effect, "If you don't tell her, I will."

5. COMPARE ALTERNATIVES WITH PRINCIPLES:
In many cases, the principles resolve the case. Depending on how one assesses the relative weight of the principles, that may be the case here. In fact, it may be that the alternative of encouraging universal precautions for the sister but not telling her why, comes very close to satisfying all the relevant principles. But certainly there are questions about the adequacy of those precautions. Will she follow them, or treat them casually? However, assume for the moment that appeal to principles does not resolve the dilemma.

6. ASSESS THE CONSEQUENCES:
Here the task is to take the viable alternatives that attempt to predict what the likely consequences (both positive and negative) of each would be. In addition, one should try to estimate roughly how beneficial are the positive consequences and how severe the negative ones are, since some consequences are clearly more substantial than others.

In many cases, when two opposing alternatives are presented, the consequences of one are the mirror image of the other. This is the case here with the alternatives of telling that sister, or refusing to tell her of her brother's HIV status.

In the first alternative, that of telling the sister (or insisting that the patient tell his sister), the likely consequences include the following:

The sister would be properly warned about the risks of taking care of her brother, minimizing the risk of her contracting HIV, and saving her from the risk of developing a fatal illness.

The brother's HIV status would be out in the open, leaving family and gang friends to draw their own conclusions about his homosexuality. Should they draw the right conclusion, which is likely, he suffers significant psycho-social harm from his gang members, and possibly (though not certainly) from his family.

Trust with the physician and the patient suffers and he may refuse to see that physician, or any other one again until a dire medical emergency. This would be unfortunate since due to his HIV status, he will need ongoing medical care.

But if the physician refuses to disclose the information, the following may be expected as the likely consequences:

The sister would not know about the risks she is taking, making her vulnerable to contracting an infection for which there is no cure. The degree of risk that she is taking is open to debate, but some would argue that if the degree of risk is any more than minimal, that justifies warning her since the virus produces a fatal disease.

The patient's HIV status is a well-kept secret, as his homosexuality. But it is not likely that either his HIV status or his homosexuality can be kept a secret forever, since as HIV develops into full-blown AIDS, both are likely to come out at some point in the future.

Trust between the physician and patient is maintained.
If the alternative of telling the sister to take general precautions is taken, the following are the likely consequences:

She may exercise appropriate caution in taking care of her brother, but she may not. She may treat the precautions casually and unknowingly put herself at risk. If the physician tells her about the precautions in very strong terms to insure her compliance with them, that may start her asking questions about why the doctor was so insistent on her following his precautions. In fact, one of the motives of the physician might be to nudge her toward asking some of those questions, of her brother, to further minimize the risk of contracting HIV.

In general, the patient's HIV status and homosexual orientation are kept secret, and confidentiality is honored, but the question of how long it will remain a secret is unknown and it is likely that it will become known eventually.

Trust with the physician and patient is maintained. However, if the sister is nudged to ask her brother some pressing questions about why these precautions are so important, he may conclude that the physician has prompted his sister to ask these questions, leaving him feeling betrayed.

7. MAKE A DECISION
What would you decide in this case? Which principles are the most weighty? Are there others that you would include? Which alternatives are the most viable? Are there others that you would suggest? Which consequences seem to you the most severe? Are there others that you think will occur? It is important to realize that at some point you must stop deliberating and make a decision, as uncomfortable as that may be.

Taken from the Hastings Center Report 22 (January/February 1992): ???.
This model is adapted from the seven step model of Dr. William W. May, School of Religion, University of Southern California, from his course, "Normative Analysis of Issues."
 

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Copyright © Scott Rae. All rights reserved. International copyright secured. Used with author's permission.
The article originally appeared in the chapter one of Beyond Integrity, 1st edition, published in 1996.

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