Ethical And Legal Issues on HIV Testing Essay

Discuss the potential controversy when considering a patient’s right to know whether a caregiver has AIDS, and the caregiver’s right to privacy and confidentiality.

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Consider the following: A physician cut his hand with a scalpel while he was assisting another physician. Because of the uncertainty that blood had been transferred from the physician’s hand wound to the patient through an open surgical incision, he agreed to have a blood test for HIV. His blood tested positive for HIV and he withdrew himself from participation in further surgical procedures.
Discuss the ethical and legal issues.Ethical And Legal Issues on HIV Testing Essay

This paper is structured around the following: autonomy and consent, confidentiality, disclosure, knowledge of patient and provider HIV status, the right to choose whom to treat, testing for HIV and the importance of HIV policies in the workplace to guard against discrimination. The emergence of the HIV/AIDS pandemic has challenged traditional ethical values of the health care profession. These include the infectious nature of HIV, the social stigma of the disease and its ethical and legal dilemmas. This paper addresses some of the pertinent questions related to HIV infection and AIDS. The three broad principles of ethics, namely, autonomy, beneficence and justice, provide the basic framework on which this paper is based. Advances in the biotechnology of rapid oral fluid testing particularly in the detection of HIV antibodies from patients in the dental setting have raised additional ethical and legal considerations in the subsequent management of HIV infected patients to include disclosure of test results to the patient and proper referral to physicians or nurse practitioners. The oral health care worker must thus have a solid foundation in the application of bioethical principles. Ethical And Legal Issues on HIV Testing Essay A clinical case scenario related to HIV testing in the dental setting is presented to illustrate how a lack of understanding and the wrongful application of ethical principles may lead to patient harm and legal liability. Given the increasing infection rate of HIV worldwide, polices must be upheld and revised as needed to protect healthcare providers, patients, and society generally against discrimination.

Informed Consent for HIV Testing
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Special Procedures for HIV Testing
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Because the physical risks are minimal, blood tests in the U.S. typically do not require extensive informed consent discussions, and consent often is implied rather than explicit. However, early in the AIDS epidemic, HIV testing was recognized as different from other blood tests because it presented serious psychosocial risks, such as rejection by family; discrimination in employment; and/or restricted or no access to health care, insurance, and housing.(16) Moreover, because there was no proven treatment at that time, the benefits of early diagnosis to individual patients were uncertain. In recognition of these circumstances and to encourage testing, special procedures were adopted for obtaining consent for an HIV test, such as pretest counseling and specific informed consent.(17) Special protections for confidentiality of HIV test results also were enacted.(18-21)Ethical And Legal Issues on HIV Testing Essay

For the most part, these special requirements remain in effect. Nearly one-fifth of states require pretest counseling, and many of these specify the information that must be covered, including the nature of the test, the risks and benefits of testing, how to prevent transmission, and the confidentiality of HIV test results. The pretest counseling requirement typically is in addition to any requirements for informed consent. The majority of states require specific informed consent to HIV testing, and many of these require that consent be written. In addition, a number of these states specify the information that must be conveyed during the informed consent process, including information about the nature of the test, the nature of the illness caused by HIV, risk behaviors and prevention measures, the confidentiality of test results, reporting requirements and other circumstances under which test results may be disclosed, the voluntary nature of the test, the ability to withdraw consent, and the availability of anonymous testing. Some of these states require that written information also be provided during the consent process.Ethical And Legal Issues on HIV Testing Essay

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Exceptions to Informed Consent
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Some states permit HIV testing without informed consent under specified circumstances. For example, many states permit testing of patients without permission after a significant exposure to emergency response workers or health care workers occurs, although permission generally must be sought. In addition, some states permit the testing of prisoners and persons accused of sex crimes. Connecticut and New York also require mandatory HIV testing of newborns,(22,23) which indirectly reveals maternal HIV status.

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Prenatal HIV Testing
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Mother-to-child transmission of HIV has been a priority area for earlier detection because transmission is significantly reduced if pregnant women identified as seropositive take antiretroviral therapy.(24-28) In 1999, an Institute of Medicine panel on reducing perinatal HIV transmission concluded that pretest counseling and written informed consent requirements for HIV testing were barriers to prenatal HIV testing. To take advantage of the proven effectiveness of antiretroviral therapy for preventing perinatal HIV transmission, the panel proposed significant changes in HIV testing policies for pregnant women in the United States. It recommended that all pregnant women be tested for HIV as a routine part of prenatal care. Under its recommendations, women would be informed that an HIV test would be conducted, along with other prenatal blood tests, but would not be required to consent specifically to the HIV test.(29) The American College of Obstetrics and Gynecology and the American Academy of Pediatrics have supported routine universal prenatal HIV testing.(30)Ethical And Legal Issues on HIV Testing Essay

Whether the IOM recommendations are adopted remains to be seen. In October 2000, the U.S. Public Health Service (USPHS) issued draft revised guidelines for prenatal HIV testing that stop short of the IOM recommendations.(31) The USPHS recommended that health care providers recommend HIV testing to all of their pregnant patients, but embraced the requirements for specific written informed consent required by many states. It did note that verbal consent may be used, where permitted by state law, if written consent is deemed a barrier to testing.(31)Ethical And Legal Issues on HIV Testing Essay

The proposals to make HIV testing a routine part of prenatal care raise several concerns.(32) First, it is unknown whether such testing would be acceptable to pregnant women. Second, there is a danger that, if HIV testing becomes routine, it will become so habitual or mechanical that pregnant women may not realize that they have the option to decline testing. Thus, the decision to be tested may not really be an autonomous one. Third, caregivers and patients may forget that HIV testing entails much greater psychosocial risks than other blood tests and that prenatal HIV testing differs from HIV testing in other settings. Additional procedures or protections may be necessary to safeguard pregnant women’s autonomous choices. Fourth, by foregoing opportunities for education and counseling, routine testing may undermine prevention efforts. Finally, routine HIV testing in the prenatal context may affect adherence to the norms of pretest counseling and informed consent for HIV testing in other contexts.Ethical And Legal Issues on HIV Testing Essay

The ethical concerns surrounding prenatal HIV testing are different in developing countries. To date, the cost of antiretroviral prophylaxis has been prohibitive and therefore, for the most part, pregnant women do not receive it.(33,34) Although knowing their HIV status may be helpful in guiding decisions concerning breastfeeding, in many circumstances, bottle-feeding is not a feasible option because of cost and lack of access to clean water(35). Accordingly, determining HIV status may be of limited benefit. Moreover, such determination could subject women to risk of physical harm or loss of housing and support.(36,37) The benefits of testing will increase as prenatal antiretroviral prophylaxis, along with support services, becomes increasingly available.(38)

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End-of-Life Issues
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Early in the U.S. epidemic, before antiretroviral therapy was developed and shown to be effective, HIV infection often quickly progressed to a terminal illness. However, because the availability of highly active antiretroviral therapy has prolonged survival, end-of-life care in HIV infection has become a less prominent issue in the U.S. However, in the developing world, where antiretroviral therapy is generally not available, palliative care, which focuses on relief from suffering, is the only tenable goal. Severe resource constraints may render it difficult to provide palliative measures such as opioids for pain control. Under those circumstances, care may be limited to psychosocial support and helping patients make plans for such practical issues as burial and child custody and support. This focus will need to change as highly active antiretroviral therapy becomes increasingly available in developing countries. There have been many efforts to make HIV medications more available to the developing world by pressuring pharmaceutical manufacturers to reduce prices,(33,39,40) permitting production of generic versions of effective therapies,(41) and providing funds for drug purchases(40,42,43).Ethical And Legal Issues on HIV Testing Essay

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Research Ethics
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Research with human participants raises ethical concerns because people accept risks and inconvenience primarily to advance scientific knowledge and to benefit others. Although some research offers the prospect of direct benefit to research participants, most research does not Ethical And Legal Issues on HIV Testing Essay