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Mandated HIV Testing

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The first case of HIV/AIDS in the United States was identified in 1981; however a blood sample taken in 1959 confirms the existence of the disease at that time (History of AIDS, 2005; Gorman, 1998; Coughlin & Beauchamp, 1996). Initially, significant negative stigma hindered the public health processes that may have helped to identify and slow the progression of the disease within the society. HIV was viewed as a gay man’s disease, and diagnosis with the virus could have resulted in residential eviction, professional termination, social isolation, and other discriminatory practices (Beauchamp & Steinbock, 1999). The development of testing for HIV had additional negative connotations as some intended the results to identify homosexuals in order to fire them (Beauchamp & Steinbock, 1999). Due to the severe public reaction, public health information was gathered at a cost of extreme confidentiality; identifying the disease but not the individual carrying it. In this manner, the containment of the disease was slowed and transmission of the disease was not adequately countered.

In the after effects of the civil rights protections, public health means have been significantly hampered. As of 1999, testing was voluntary under most situations, and routine testing was prohibited (Beauchamp & Steinbock, 1999). Since people may be asymptomatic for extended periods of time while carrying HIV/AIDS, they are likely to continue engaging in risky behavior that may expose others within the population. “The incubation period between infection with HIV and a diagnosis of AIDS is often longer than ten years” (Beauchamp & Steinbock, 1999, pg. 215). One would conclude that HIV testing at earlier stages would allow patients to receive beneficial treatments earlier, as well as to practice safer behaviors that would reduce the risk of exposing others to the virus. With an asymptomatic incubation period of approximately ten years, adequate testing could potentially affect entire generations, reducing actions that could have otherwise been prevented by HIV-status awareness. Within the realm of public health, many diseases may be tested for without explicit patient permissions; however, due to the limitations and exceptions placed on HIV/AIDS because of the early stigma, the current population suffers without proper disease prevention and detection.

According to the CIA (2009), 1.2 million Americans are living with HIV/AIDS, with an estimated 33 million infected individuals worldwide. Approximately 40,000 new cases of HIV/AIDS are identified each year (Branson, Handsfield, Lampe, Janssen, Taylor, Lyss, Clark, 2006). As of 2002, 24,844 healthcare personnel were reported to have AIDS (CDC, 2003).

Given that over one million Americans have HIV/AIDS and an approximate 25,000 healthcare workers have been infected with the virus (CDC, 2003), one would naturally consider routine screening of the population, especially those at higher risk for exposure and transmission of the virus. Early detection may lead to a reduction of risk-exposure behavior, and early treatment may improve the outcomes and quality of life of a HIV/AIDS positive patient (CDC, 2003; Branson, et. al., 2006).

In 2006, the CDC updated their guidelines for HIV/AIDS detection: the current recommendations include routine testing for HIV/AIDS as part of the general medical examination for all individuals aged 13 to 64; as well as discontinuing written consent for testing while allowing for an informed opt-out of testing (Branson, et. al., 2006, Gostin, 2008). As the public has gained knowledge into the disease and the populations at risk, there is more understanding of lifestyle and exposure risks; and a person is less likely to be discriminated against due to their HIV/AIDS status.

Considering the obvious benefits of HIV screening (CDC, 2003; Branson, et. al., 2006), it is important to consider the routine testing of the general population yearly or relative to their risk level. “Screening is the systematic application of a medical test to a defined population with the objective of identifying persons with infectious diseases” (Gostin, 2002, pg. 394). Screening that is based on minority or sexual orientation may be considered discriminatory; however screening based on risk-exposure within the professional context of healthcare is an avenue of protecting the patient and within the burden of obligation secondary to the healthcare workers’ right to practice.

There are valid arguments against mandatory screening of healthcare providers, including the provider’s own privacy and right to freedom against discrimination (Fremgen, 2009).  However, one would argue that the benefits of protecting patients from risky procedures performed by HIV positive physicians, as well as protecting immunocompromised providers from secondary infections and diseases would outweigh the right to privacy for a healthcare provider. In the event that the patient was infected, having not been informed of the provider’s viral status, the provider may be found liable of misconduct or even malpractice. The Federation of State Medical Boards states that a healthcare provider not knowing their HIV-status would be professional misconduct (Fremgen, 2009). In lieu of this statement, one would logically conclude that healthcare workers, particularly those working in high-risk areas and may expose patients to HIV-positive bodily fluids, should be required to be tested for HIV/AIDS.

Any healthcare organization has vicarious liability for the actions of their employees (Rodriguez, 2009); by routinely testing employees for infectious diseases such as TB and HIV/AIDS, a hospital may be able to reduce the liability carried by providers performing risky procedures without knowing their viral status. The providers’ right to personal privacy only extends as far as their professional obligation to protect their patients: their ethical and moral obligation to respect the autonomy of the patient and to non-malfeasance supersedes their personal privacy.

In the same vein as TB testing for healthcare workers, HIV/AIDS testing should be required for all healthcare workers relative to the risk of patient exposure. For example, those providers who are at high risk of exchanging or exposing others to bodily fluids should be tested at a higher frequency than ancillary staff with limited or no direct-contact with patients. Because of the vulnerable and delicate nature of the provider-patient relationship, it is important that healthcare workers, the healthcare organizations employing them, and the applicable patients, are made aware of the potential risk involved with a provider’s HIV/AIDS status.

Providers that test positive should not be discriminated against; however, they must also maintain the legal, moral, and ethical standards of their profession. Providers who are known to have HIV/AIDS should behave in a manner that limits others’ exposures. This includes regular protection against the exchange of bodily fluids, including gloves and masks as indicated by the CDC and standards of the profession. Additional precautions may be necessary if the context of the job design lends to using sharp objects, such as phlebotomy, surgery, emergency departments or obstetrics/gynecology (Fremgen, 2009).

While healthcare workers may have a low probability of infecting their patients (Fremgen, 2009; CDC, 2003), one would still conclude that a healthcare professional has a moral and ethical obligation to do no harm and to protect the patient’s autonomy by disclosing all necessary information to make an informed decision. In addressing the medical code of ethics, a physician is obligated to address the principles of respect for persons, beneficence, non-malfeasance and justice (Rodriguez, 2009; Fremgen, 2009).

Particularly within the principle of respect for persons, it is important for physicians to be truthful so that a patient may make his or her own decision. The healthcare provider has a duty to disclose information that a reasonable person would need to make an informed decision. If an invasive or risky procedure is being discussed, than the provider’s HIV/AIDS status would be necessary information in order for the patient to make an appropriate healthcare decision. Healthcare workers that are HIV/AIDS positive should not perform invasive procedures that could place their patient at risk (Fremgen, 2009, CDC, 2003).  In either case, if the provider is positive, than they have an ethical obligation to disclose this information to the patient prior to the procedure, or should decline to do the procedure so as not to break fidelity with the patient.

A second principle of the medical code of ethics is non-malfeasance (Rodriguez, 2009; Fremgen, 2009).  Following this principle, a physician may not do harm to a patient. By inadvertently exposing a patient to the risk of HIV/AIDS contraction, even if the probability is low, is unacceptable because it generates unnecessary risk and potential harm.

After careful consideration of the aforementioned data, one would conclude that the public good of provider screening for HIV/AIDS is a greater need than the individual provider’s privacy. “Unless the medical profession is occasionally willing to put public interests before individual patient (and physician) interests, the social trust will falter” (Wynia, Kurlander & Green, 2006). As this quotation demonstrates, without some sacrifice on the side of the healthcare workers’ privacy, the trust in the healthcare system will fail. Without appropriate trust in the healthcare professionals and system in general, both public and individual health will suffer. In order to maintain the dignity of the profession, healthcare providers should be required to be screened and precautions should be taken to protect the interests of positive healthcare workers and their patients.

References

Beauchamp, D. & Steinbock, B. (Eds.). (1999). New ethics for the public’s health. New York, NY: Oxford University Press.

Branson, B., Handsfield, H., Lampe, M., Janssen, R., Taylor, A., Lyss, S., Clark, J. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Retrieved 6 December 2009 from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm.

C.I.A. (2009). The world factbook. Retrieved 6 December 2009 from https://www.cia.gov/library/publications/the-world-factbook/fields/2156.html?countryName=&countryCode=&regionCode=T

Centers for Disease Control and Prevention (CDC). (2003). Surveillance of healthcare personnel with HIV/AIDS, as of December 2002. Retrieved 6 December 2009 from http://www.cdc.gov/ncidod/dhqp/bp_hiv_hp_with.html.

Coughlin, S. & Beauchamp, T. (Eds). (1996). Ethics and epidemiology. New York, NY: Oxford Press.

Fremgen, B. (2009). Medical law and ethics (3rd ed.). Upper Saddle River, NJ: Prentice Hall Health.

Gorman, C. (1998). When did AIDS begin? Retrieved 6 December 2009 from http://www.time.com/time/magazine/article/0,9171,987824,00.html.

Gostin, L. (Ed). (2002.) Public health law and ethics: a reader. Berkley, CA: University of California Press, Ltd.

Gostin, L. (2008). Public health law: power, duty, restraint (2nd Ed.). Berkley, CA: University of California Press, Ltd.

History of AIDS. (2005). The history of AIDS. Retrieved 6 December 2009 from http://fohn.net/history-of-aids/.

Rodriguez, R., Ph.D. (2009, November 19). Chat posting. Retrieved from AIU Online Virtual Campus. Chat 1 week 2. The ethical and legal aspects of healthcare: HCM410-0904B-02 website.

Wynia, M., Kurlander, J., Green, S. (2006). Physician professionalism and preparing for epidemics: challenges and opportunities. In Balint, J., Philpott, S., Baker, R., & Strosberg, M., (Eds.), Advances in bioethics (Vol. 9). Oxford, UK: Elsevier.

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