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Bioethics II Confidentiality
Prepared and presented by Marc Imhotep Cray, M.D.
Basic Medical Sciences and Clinical Knowledge (CK) Teacher
Steve is clearly uncomfortable with this reporting requirement. He states that he must have contracted the disease on a business trip in Miami, where he had a brief affair. He tells his doctor that he has not had any sexual contact with his wife since that out-of-town interlude and he would appreciate it if his doctor would not mention this to anyone, especially his wife.
The doctor has trouble making that sort of commitment, and wonders what his obligations are in this case.
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Risk that Steves wife has been exposed Risk that other contacts have been exposed Confirmatory antibody testing If the vesicle represent herpes, that indicates primary infection much earlier Wife herself may be source of infection Wife should be notified so she can be tested fetal risk, neurosyphilis in late stage HIV testing may be indicated
Role-related duties Consequences for md-pt relationship In some states, state licensing law, case law, state health codes or other state or federal regulations require confidentiality
In many states, legal obligation to report STDs to state health depts. for contact notificationnot to the intimate contact Disclosure to managed care organization or other insurer (unless he pays out of pocket)
MD may encourage Steve to disclose MD notification of wife that she has been exposed incompatible with traditional view
Hippocratic Oath
I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:...
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I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men who are engaged in this work.
Marc Imhotep Cray, M.D.
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At Selmas next visit to her physician, she is asked about her driving. Of course Im still driving, she says. How can you survive without a car out here? She is eager to point out that she has never been in an accident, she only drives to the store now and then, drives at a snails pace, and would certainly be able to see a cow or an elephant. She assures the doctor that there are no small children around and that she will be careful. Besides, she asserts, her peripheral vision is as good as ever.
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Functional ability, not diagnosis, is the issue Risk taking behavior may be more important than visual limitations Alzheimers disease, seizure disorders, alcoholism, may impair functions relevant to driving Correctible underlying disease states should be identified visual, auditory
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Some states require retesting for older drivers Some states require MDs to report persons with certain medical conditions (esp. epilepsy), but may cause patients to under-report symptoms Limited or restricted licenses available in some states
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The MD must at least encourage her to restrict her driving and refer her to community transportation sources If local law requires reporting loss of visual acuity, then MD must comply If not, assurance of confidentiality allows patients to feel they can confide in MDs And, as a practical matter, to whom would the MD report?
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Vulnerable persons (e.g., child abuse) Innocent third parties (e.g., risk of communicable disease) Persons in imminent or foreseeable danger
Ms. Selmas case does not fall neatly into any of these categories
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Is the MD a societal agent? So justified, where do such breaches of confidentiality end? Should private MDs become agents of the state? Whose job is it to ensure safety on the road?
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Public health
Tension between individual confidentiality and public welfare may be compromised in favor of latter
Serious threat Effective intervention available Least restrictive means possible Least compromise of confidentiality possible
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Genetic testing
Tests are hard to interpret, easy to over interpret, generally of limited predictive value, but very tempting Results of genetic tests for disease susceptibility may be of great interest to insurers, employers, academic institutions
Life/AD&D insurance Workplace hazards (Santa Fe case RE carpal tunnel) Admission to medical school?
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The US Dept. of Defense has millions of blood samples Huge private DNA databases being established
Biological materials
Consent of donor required for tissue samples to be used in research Samples unlinked to individually identifiable information preferable, but often impractical If linked samples are to be used consent must be obtained and link or key must be carefully guarded
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Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things to help or at least do no harm. The art has three factors, the disease, the patient, the physician. The physician is the servant of the art. The patient must cooperate with the physician in combating the disease. Hippocrates, Epidemics I
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The dignity of the physician requires that he should look healthy, and as plump as nature intended him to be; for the common crowd consider those who are not of this excellent bodily condition to be unable to take care of others. Then he must be clean in person, well dressed, and anointed with sweet smelling unguents that are not in any way suspicious. This, in fact, is pleasing to patients.
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In appearance, let him be of a serious but not harsh countenance; for harshness is taken to mean arrogance and unkindliness, while a man of uncontrolled laughter and excessive gaiety is considered vulgar, and vulgarity especially must be avoided.
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I urge you not be too unkind, but to consider carefully your patients superabundance or means. Some times give your services for nothing, calling to mind a previous benefaction or present satisfaction. And if there be an opportunity of serving one who is a stranger in financial straits, give full assistance to all such. For where there is love of men, there is also love of the art.
Hippocrates, Precepts
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E-Textbook Medical Ethics Today: The BMAs handbook of ethics and law Books; 3 edition (January 30, 2012) Updates http://bma.org.uk/practical-support-at-work/ethics/medical-ethics-today Best Price $148.33 or Buy New $181.49