The relationship between law and ethics is complicated. It would seem that all laws should be ethical and that ethical actions should always follow the rule of law. However, this is not always the case. Sometimes what is legal contradicts what is ethical. Laureate Education (2012) contends that ethics are moral principles that guide human conduct, whereas laws are rules established and enforced by the government. Ethics comes before the law because laws are made by people who follow ethical principles (Laureate Education, 2012). Laws dictate what people are required or prevented from doing within a society. Laws are the minimum standards for conduct. For example, the law allows anyone over the age of 21to drink alcohol. However, some people believe that it is ethically wrong to drink alcohol at any age and therefore abstain from consuming it all. For healthcare workers navigating the complexities between legal and ethical rules is like walking a tightrope; the slightest error could have catastrophic consequences.
Lena has privileged healthcare information that her sister’s boyfriend has tested positive for the Human Immunodeficiency Virus (HIV). She obtained this information in her professional capacity as community health nurse. Lena has both a legal and professional ethical obligation to protect patient confidentiality. However, she also has an ethical obligation to protect her sister, from being exposed to the HIV virus. Lena is facing an ethical dilemma; should she violate her patient’s confidentiality to protect her sister? Before deciding, Lena must evaluate her ethical obligation. Evaluating action and the motives that justifying that action is key in making an ethical decision (Laureate Education, 2012).
There are four primary principles that guide ethical decisions in the healthcare setting Autonomy, or protecting the individual decision of the patient; beneficence, the obligation to do the right thing; non-maleficence, the obligation not to do harm; and justice, or acting fairly and equitably (Laureate Education, 2012). According to Schröder-Bäck, Duncan, Sherlaw, Brall, and Czabanowska (2014), there are three other ethical principles that should be considered. Health maximization is the idea that intervention that does the most good for the most people is the best choice. Efficiency refers to the moral costs and benefits associated with public health decisions. And, proportionality is the notion that individual freedom must be considered in the context of the greater social good (Schröder-Bäck, Duncan, Sherlaw, Brall, & Czabanowska 2014).
It is important to recognize that laws regarding patient confidentiality and partner notification vary from state to state. Due to this fragmentation, it is imperative for healthcare providers to be up to date on current regulations affecting their practice. The Iowa Legislative Services Agency (2018) maintains that first healthcare providers should strongly encourage persons who test positive for HIV to refer their sexual partners for HIV testing and counseling. This can be done directly by the infected party or through the voluntary partner notification program. Under two circumstances, the healthcare provider is legally allowed to notify partners of the infected person without their consent, first if the infected party refuses to notify their sexual partners after the healthcare provider has strongly encouraged them to do so. Second, if the provider has reason believe the infected person plans to continue to have sexual relations with their partners without disclosing their HIV status. Additionally, the Center for HIV Law and Policy (2016) contends that the law in Iowa allows for criminal prosecution of persons who knowingly expose another to a communicable disease such as HIV. If convicted, penalties range from 1-25 years in prison and $1875 -$7500 in fines depending on the circumstances or the case (Center for HIV Law & Policy, 2016).
After carefully weighing the ethical and legal principles applicable to patient confidentiality and partner notification in Iowa, I believe that Lena’s sister has the right to know about her boyfriend’s HIV status. According to Iowa law, the healthcare provider should encourage the patient to notify all their sexual partners. Since Lena has a personal relationship with the infected patient, she should request that another healthcare provider contact the patient. If the patient is not prepared to contact his partners himself, or through the voluntary partner communication program, the process should be fully explained. The patient should be informed of his ethical and legal obligation to notify his sexual partners. Further, the healthcare worker should also educate the infected patient about the potential legal consequences for engaging in sexual intercourse without disclosing his HIV status. If the infected patient still refuses to notify his sexual partners, the healthcare worker should proceed with direct notification per Iowa law. Again, Lena should not contact her sister directly, because it would be difficult for her to be objective and impartial in this situation.
I believe that this solution is ethical. Offering the infected patient his options maintains his autonomy and is benevolent. If the client is unwilling to act within the parameters of state laws, alternative options, such as direct notification must be explored. The ethical principle of proportionality is applicable in this case because while the healthcare worker is obligated to the patient, they are also obligated to the public. Notifying the infected patient’s sexual partners will ultimately stop the spread of infection and foster the greater social good.
Moreover, partner notification also maximizes the health benefit and is ethically efficient. While partner notification may cost the infected partner, the associated benefit is far greater. Finally, partner notification adheres to the ethical principle of non-maleficence. Placing a higher value on patient confidentiality as opposed to partner notification harms the infected patient. The patient is physically ill, and mentally and emotionally vulnerable. Helping him to keep his HIV status a secret will only lead to further isolation. While this situation is complicated, careful consideration of the ethical and legal principles provide clear guidance.
Iowa Legislative Services Agency. (2018). Human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS). Retrieved January 20, 2019, from https://www.legis.iowa.gov/publications/search/document?fq=id:522637&pdid=701299&q=hiv
Khan, N. (2016). Between a rock and a hard place: When patient confidentiality conflicts with a physician’s duty to warn. Journal of Clinical Research & Bioethics,07(01). doi:10.4172/2155-9627.1000255
Laureate Education (Producer). (2012f.) Legal and ethical aspects of healthcare delivery. Baltimore, MD: Author.
Schröder-Bäck, P., Duncan, P., Sherlaw, W., Brall, C., & Czabanowska, K. (2014). Teaching seven principles for public health ethics: Towards a curriculum for a short course on ethics in public health programmes. BMC Medical Ethics,15(1). doi:10.1186/1472-6939-15-73
The Center for HIV Law and Policy. (2016). Iowa. Retrieved January 20, 2019, from https://www.hivlawandpolicy.org/states/iow