Ethical Issues with HIV Positive Clients

Introduction

HIV and infectious diseases is a sensitive issue that has prompted the introduction of additional laws to protect the psychological and emotional needs of the clients. Ethical values basically guide ethical behavior and conduct. Various moral concerns have been identified since the emergence of HIV.

Ethical Principles

Basic principles that guide medical behavior include respect for persons, justice and beneficence (Angel, 1998). Fundamentally, these are achieved through keeping promises, upholding respect and maintaining confidentiality (Wolf, 2001).Other ethical principles include utilitarian perspective and the ethic of caring (Wolf, 2001).

Ethical Issues

Confidentiality. Generally, all medical information and records are expected to be kept confidential. Gostin et al (1997) shows that the sensitive nature of information related to HIV and other infections have prompted creation of additional laws to protect the affected clients. There are exceptions however that allow the healthcare personnel to report cases to healthcare authorities (Gostin et al, 1997); the need to disclose the status to the persons at risk (Gostin & Webber, 1998); the case relating to infected healthcare personnel that rested in the formation of a panel of experts that restrict the activities of the infected workers or inform the patients of their status (Kass, et al, 1996; Lurie & Wolfe, 1999; Singer et al, 2006; Varmus & Satcher, 1999); prenatal testing that has introduced routine testing to all expectant mothers (Connor et al, 2004, Levine 1998 ; Sargent, 2000)

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End of life issues. Ferriman (2001) ascertains that this existed during the initial times of the emergence of HIV when it had the capacity to develop in to a terminal disease in a short period of time. Availability of effective ARVs has changed the situation (Lurie & Wolfe, 1999). However, it still affects populations with limited resources. Palliative care is essential.

Vaccine Research. Wolf and Berkey (2000) indicate that the minority are employed in trials. Wolf (2001) notes that the populations have false hopes about the possibility of being cured. Vaccines have adverse impacts on the immunity of the participants. Participants may be denied travel rights due to the health implications of the vaccine. There eligibility of taking up certain jobs is affected. Gostin and Webber (1998 show that at times the participants are labeled very vulnerable to infection. This has far reaching implications n their behavior. Confidentiality is often breeched by the researchers.

Research ethics. Feriman (2001) points out that the participants are not given vital information prior to research. In other instances, their consent is not sought. Healthcare providers contribute to the misconceptions (Gostin, 2000). Patients are not informed about the implications of the research. Loyalty by patients makes them to avoid informing themselves of the necessary procedures. Patients at times provide information in return for better services from the healthcare in future. Healthcare providers undertaking research place greater emphasis on financial benefits rather than the interests of the patients.

Summary

It is clear that the ethical principles of respect for people, justice and beneficence provide essential guidance in health care. In addition, the utilitarian perspective and the ethic of caring also provide vital guidance to medical behavior. Notably, these enable the clinicians to interact with HIV positive patients and those with infectious diseases in a sustainable manner. Ethical concerns such as confidentiality, end of life, informed consent, vaccine research, research design and conflict of interest characterize the interaction between patients with infectious illnesses such as HIV and clinicians.

Recommendations

Patients need to be informed of their legal rights prior to testing. Pretest procedures and counseling need to be upheld. With regard to HIV vaccine research, it is important that the trials be carried out on a population that is globally representative. Finally, it would be important for the researchers carrying out medical research about infectious diseases to be guided by fundamental clinical ethics

References

Introduction

The sensitivity that is associated with HIV positive clients, infectious diseases and relative information requires the clinicians to uphold a high degree of morality when interacting with the patients at different levels. Since the emergence of the epidemic, various ethical concerns have been identified in different instances. In order to ensure that the wellbeing of the patients and healthcare providers is protected, measures have been undertaken to address the concerns accordingly. Indeed, it is worth acknowledging that the psychological wellbeing of the HIV positive patients plays a critical role in their holistic wellbeing. Physical wellbeing can be achieved if the patients are handled with the greatest level of care.

It is against this background that this paper explores the ethical issues concerning HIV positive clients and other infectious diseases controlled by the health department guidelines. In order to enhance a harmonic consideration, the paper starts by underscoring the basic ethical principles underpinning healthcare and relative research. Then, it exhaustively reviews several ethical concerns and comes up with recommendations that would effectively address the ethical issues.

Ethical Principles

Clinical work and related research is governed by various ethical and moral principles that guide professional behavior and conduct. When dealing with persons that are HIV positive or those with other infectious diseases, it is imperative to observe these principles as they make the patients feel appreciated and cared for. Of great importance is the moral worth that these values enhance. In particular, Angell (1998) indicates that respect for people, justice and beneficence are fundamental values that govern any form of clinical interaction.

The value of respect for persons demands that the decisions and autonomy of other individuals be upheld. In addition, this principle postulates that persons that lack autonomy and those that are unable to make independent decisions be protected. Justice requires that all persons irrespective of their status be treated in a fair manner. The ideal state of justice is characterized by equal distribution of the burdens and benefits within the society. Finally, beneficence imposes upon the clinicians a responsibility to act in the interests of the patients. In order to achieve this Wolf (2000) asserts that the ability to keep promises, uphold respect and maintain a high degree of confidentiality is essential.

Other ethical principles that can be used to guide the conduct of clinicians in this field include the utilitarian perspective and the ethic of caring (Wolf, 2001). The former places emphasis on the consequences of the activities and postulates that clinical behavior can only be morally acceptable if its consequences are desirable and enhance the greatest good for the majority of the population. The latter on the other hand judges the activities based on the effect that they have on relationships. However, Wolf (2000) indicates that some of these principles conflict and therefore can not be applied jointly. In addition, it is notable that some principles can not be applied in some situations. The clinicians should therefore weigh the relevance of a principle to a situation before applying it. This is important to avoid conflicts that are likely to stem from application of multiple principles. Of great importance however is to ensure that the greatest degree of good for the greatest majority is always upheld.

Ethical Issues

Over time, various ethical concerns have arisen from the interaction between HIV positive patients and clinicians. Confidentiality is one such issue that has been considered to be very important in this regard. Generally, the law provides that all medical information be treated with a high degree of confidentiality. However, Gostin et al (1997) shows that the sensitive nature of information related to HIV and other infectious diseases has prompted various states to adopt relevant laws that offer additional protection to the same. These laws prevent disclosure of information related to HIV without prior authorization. However, as indicated earlier, there are different contexts that might require that such information be disclosed without the knowledge and/ or authorization of the patients. Basically, such steps are considered ethical as they seek to enhance the greatest good for the greatest percentage of a population.

To begin with, the law allows the healthcare personnel to report HIV infections to relevant public heath authorities. Gostin (2000) contends that the advantages of this reporting basically outweigh the risk discrimination of the infected individual. Usually, the name of the individual is not provided during reporting. However, epidemiological studies show that in order for intervention measures to yield optimal results, there is need to encourage provision of name based information during reporting. Nonetheless, it has been argued that this has the capacity to increase the risk of discrimination and therefore should be avoided. This position is also held by the Centers of Disease Control and Prevention that ensure that testing of HIV is made anonymous.

Another scenario that breeches confidentiality but is not punishable by law is when the healthcare providers disclose the status of a patient to persons that may be at risk of infection. In this regard, Gostin and Webber (1998) ascertain that the right of a patient to be accorded confidentiality is often in conflict with the right of the partner to be notified accordingly. Despite the fact that confidentiality is instrumental in avoiding discrimination, it needs to be appreciated that the implications of failing to inform a non suspecting partner can be far reaching. In order to avoid conflicts, the patients are usually advised during counseling to reveal their status to their sex partners.

Another exception with regard to confidentiality of information that is HIV related concerns the healthcare workers that are infected with the disease. This particularly affects the workers who perform exposure prone procedures. In this respect, Singer et al (2006) cites the US law that demands that the status of these workers be reviewed by the expert panel. This then makes a decision regarding whether to prevent the infected workers from performing such procedures or to inform the patients about their infection. The equivalency policy that demands that the healthcare workers disclose their status has been increasingly adopted by various states.

From an ethical perspective, disclosure of HIV status by the health workers and enforcement of some form of restrictions is in line with the best interests of the patients. However, various studies of whom Lurie and Wolfe (1999) are represented argue that this contravenes the privacy of health workers and enhances discrimination especially when the patients are informed. However, it should be appreciated that the benefit of the uninfected patient outweighs the risk of discrimination of a heath worker by the same. To address these concerns, a more viable approach would be for the council of experts to place restrictions but avoid informing the patient, unless under special conditions.

Another ethical issue regarding HIV positive patients and those with infectious diseases is informed consent before testing. Basically, various clinical tests that involve testing of the blood samples of the patients do not require consent. However, the realization that testing for HIV had various negative implications led to the need for informed consent. The specific psychosocial risks that are presented by HIV testing include restriction of lack of access to insurance, healthcare or housing, possibility of rejection by family, friends and/ or close relatives and discrimination during employment. Thus special procedures that seek the consent of the patient such as pretest counseling and need for specific informed consent from the patient are a prerequisite. These measures ensure that the patient is psychologically and emotionally prepared to deal with the implications of the results.

Essentially, the information that needs to be availed to the patient prior to testing include the benefits and risks of testing, risky behaviors, measures undertaken to prevent transmission, the nature of the test and confidentiality of the test. These are always coupled with an informed consent from the patient. In their review, Varmus and Satcher (1999) indicate that most states require that the patient provide a written consent. However this provision has various exceptions. In some instances, prisoners are persons that are accused of sexual crimes are often tested without consent. In addition, some states have made the testing mandatory for new born babies. In his study, Kass et al (1996) indicates that this also reveals the status of the mother.

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Notably, prenatal testing is also undertaken without consent from the mother. Fundamentally, early detection is instrumental in preventing mother to child transmission. Initially, prenatal testing was undertaken after a pretest counseling and informed consent. However, changes were proposed and currently, all pregnant mothers undergo a routine prenatal HIV testing. However, the revised edition of this law by the US Public Health Service presented a need for informed consent, although it is not clarify whether this needs to be verbal or written. Connor et al (2004) ascertains that the proposals that seek to make HIV testing mandatory for pregnant mothers are compounded by different complexities.

To begin with, the provision does not ascertain whether it would be accepted by all the mothers or not. In this regard, it should be appreciated that some mothers may not be willing to undergo the test. It was posited that once this provision is made a routine requirement, it would become difficult for the pregnant mothers to determine whether they have a right to decline the test or not. Notably, this undermines the principles of autonomy as this critical decision would be beyond the ability of the affected mothers. Further, Sargent (2000) indicates that the care provides are likely to forget that HIV testing has various psychological implications that are likely to compromise the wellbeing of the mothers. In this respect it is recommended that precautionary protective measures be undertaken prior to testing.

Further, foregoing the pretest procedures has the capacity to undermine preventive efforts. Connor et al (2004) indicates that in this regard, the mothers would not be informed about these important measures and they would fail to take necessary measures to prevent themselves from contracting new infections. Generally, it is agued that the proposed routine testing may compromise the adherence to vital pretest procedures. The possible spill over effects to the rest of the population can adversely affect the wellbeing of the general population.

Further, Levine (1998) points out that pregnant mothers who are HIV positive are usually expected to make various choices regarding their health and pregnancy. In this regard, these women should not be forced to either undergo sterilization or abortion. In addition, the pregnant mothers should be counseled accordingly in order to enable them make viable decisions to either continue carrying the pregnancy or terminate it.

Another ethical issue regarding HIV positive patients includes end of life issues. In this regard, Ferriman (2001) appreciates that before the development of antiretroviral therapy, HIV usually progressed very quickly to a terminal disease. However, this concern has in the recent past been less prominent due to the availability of antiretroviral therapy. However, it should be acknowledged that some segments of the global population lack vital resources to cater for these concerns. In such incidences, palliative care that seeks to reduce suffering is essential. In instances where resources are not available, care is fundamentally limited to psychological support that basically helps the patients plan for issues such as child custody and burial. Nevertheless, Lurie and Wolfe (1999) indicate that this scenario is probably changing as measures are being undertaken to increase the provision of anti retroviral drugs to the affected population. Practical measures in this respect include pressuring the relevant pharmaceutical companies to provide the drugs at affordable prices, providing resources for purchase of the drugs and allowing production of generic drugs.

Further, it is argued that the HIV vaccine research has also been fraught with numerous ethical complications. To begin with, Wolf and Berkeley (2000) indicate that the minority of the population has increasingly been employed in research. In this respect, it is posited that population samples for trials are often picked from developing countries. Furthermore, Wolf (2001) notes that the population involved in research often has positive hope because of the belief that it is actually a cure. As such, participants tend to involve themselves in risky behaviors. This implies that the nature and function of the trial is not often communicated to them in an effective manner. In addition, it shows that the researchers place more emphasis on the results of the research rather than the protection of the participants. In this regard, it would be imperative for the researchers to protect their participants too. This will not only enable them to get high quality research but also save the lives of the vulnerable population.

The HIV vaccine trials have also been identified to pose various risks to the participants. In this regard, it is indicated that the participants are often refrained from participating in future researches. In addition, the implications of the trials to the immunity of the participants are still unknown. Further, Levine (1998) asserts that the participants may be frustrated in the long run due to the fact that the vaccine may not be effective. Also, it is argued that the participants often react differently to specific antibody tests that characterize the trial. As a result, they may be prevented from traveling to other countries. In addition, these effects are likely to undermine their eligibility for some government jobs such as the military. This may happen irrespective of the fact that their seroconversion may not be a representation of an infection.

Furthermore, the participants are likely to face some form of stigmatization as a result of disclosure to friends and relatives. In their review, Gostin and Webber (1998) ascertain that certain phases of the trial often identify some of the participants to have a high risk of contracting the infection. This has various implications and may pose difficulties to the particular person. Finally, consistent research indicates that confidentiality of the status of the participants has increasingly been breached in the past. Recent surveys affirm that this often happens, irrespective of the fact that the researchers are charged with the responsibility of keeping the status of the participants confidential.

Further, ethical issues have increasingly been raised with regard to conducting research about infectious diseases and HIV. To begin with Ferriman (2001) indicates that the participants need to be informed prior to the research and their consent sought. Often, the expectations of the participants tend to undermine the quality of the research. In this regard it is worth acknowledging that most of the participants consent to participate in research, not because of the need to help the researcher to obtain vital results but of the expectations to attain personal benefits. The widespread misconceptions about the importance of the research often make some patients to misinterpret the information availed to them. In the long run, the quality of the research is greatly undermined.

Health care providers have been cited by Gostin (2000) to contribute significantly to these misconceptions. In this regard, it is noteworthy that the health personnel undertaking a certain research often have an upper hand with regard to the knowledge about the research. In some cases, they fail to inform the patients about the importance of the research. In other instances, they provide wrong advice to the participants and since they have the authority over the patients, the participating patients are inclined to follow their misguided advice.

Further, Kass (19996) argues that some patients participate in researches because of the need to please the healthcare staff. In such instances, the participants believe that they would get quality healthcare in return. Moreover, emergent research indicates that the trust that the patients have in the medical institutions often makes them participate in the researches without reviewing the relevant conditions. In such cases, the healthcare providers undertaking the research over estimate the benefits of the same and fail to inform the participants of relevant procedures.

Conflict of interests in the area of research and especially that pertaining to infectious diseases also raise various ethical considerations. In this respect, Angell (1998) indicates that these are attributable to the benefits that healthcare researchers get from positive results of their research. In particular, they usually get grants, prestige and promotions fro their research and other published work. As a result, they always aim at recruiting and retaining particular participants in their researches. In some instances, this interest conflicts with the basic interests of the participants. However, the conflicts that are financially oriented often influence the quality of the researches as the decisions made are not objective. In addition, financial conflicts some cases make the researchers to halt the research irrespective of the fact that it is likely to benefit very many individuals.

Summary

To sum up, it is clear that the ethical principles of respect for people, justice and beneficence provide essential guidance in health care. In addition, the utilitarian perspective and the ethic of caring also provide vital guidance to medical behavior. Notably, these enable the clinicians to interact with HIV positive patients and those with infectious diseases in a sustainable manner. Ethical concerns such as confidentiality, end of life, informed consent, vaccine research, research design and conflict of interest characterize the interaction between patients with infectious illnesses such as HIV and clinicians

Recommendations

From the analysis, it is certain that ethical issues pertaining to infectious diseases like HIV and Aids are wide and varied. In order to uphold the relevant ethical principles that govern the interaction of patients and clinicians in this regard, it is imperative to put in to consideration various factors. These would ensure that the overall wellbeing of the patients and the clinicians is achieved.

To begin with, it is important for the psychologists and other clinicians to inform the patients of their legal rights before assuming any form of treatment or tests. Knowledge about their rights would enable the patients to make objective decisions regarding their status. Particular areas of concern in his regard would be to inform the patients about various exceptions to confidentiality. This would ensure that the patients make informed decisions and in a timely manner. Wolf (2000) proposes that before informing the persons at risk about the status of the patient, psychologists need to inform the patients about their intentions. This would be instrumental in avoiding conflicts at a family level.

Furthermore, the importance of pretest procedures and especially counseling should not be understated. Basically, these seek to psychologically prepare the patients to deal with the implications of testing with ease. In particular, the importance of positive living needs to be emphasized. This procedures needs to be extended to prenatal testing. Pregnant mothers have a right to make their decisions and should be allowed to do so through counseling. Much as it is important to protect the life of the unborn, it is worth noting that routine testing that deprives the mother of relevant pretest counseling.

With regard to HIV vaccine research, it is important that the trials be carried out on a population that is globally representative. The participants should be well informed about the implications of the trials and their consent sought before the onset of the same. Relevant information should be all inclusive and should entail the emotional, psychological, social and legal implications of the trials. Most importantly, the researchers need to uphold a high level of confidentiality about the status of the patients.

Finally, it would be important for the researchers carrying out medical research about infectious diseases to be guided by fundamental clinical ethics. Of great reference in this respect would be their ability to put the interests of the patients before their own. In this regard, they need to inform the participants about the procedures of the research and ensure that they get their consent before beginning the research. In addition, they need to uphold a high level of objectivity when undertaking the research.