One of my patients, a well-respected citizen in our small community, came to see me with a complaint of hematuria. My partner had recently treated him on an urgent basis for prostatitis, but the patient's symptoms had persisted in spite of antibiotic treatment. Now fearful and with blood in his urine, he returned to my office.
I asked him if he'd had any new sexual partners recently, and he admitted that he had. I explained to him that his urine specimen had been positive for Chlamydia. He seemed reluctant to discuss his condition with his wife, who is also my patient. If he refuses to confide in her, what should I do? Should I tell her that she could be infected?
Confidentiality between physician and patient has long been regarded as a sacred trust. It is embodied in the Hippocratic oath and in the ethical codes of virtually all health-related professions. Yet it is widely recognized that the physician's duty to respect confidentiality is not without limit1; for example, when an identifiable third party might somehow be harmed by the agency of the patient or if there is concern for the public health. A physician's dilemma in these situations is one of choosing between the good of the patient and the good of others whom the physician is in a position to protect.
The present case scenario illustrates this dilemma well. The patient is a well-known citizen in the community and a married man who has been diagnosed with a chlamydial infection. He has admitted to having a recent new sexual contact and is understandably reluctant to notify his wife of his diagnosis. The fact that the patient's wife is also this physician's patient is an additional complication. Information that the physician has gained while treating one of her patients reveals that another patient is at high risk of contracting (or perhaps has already contracted) a sexually transmitted disease.
The physician who incidentally uncovers information about another patient in this way is in a difficult ethical position. Our physician must decide whether the duty of beneficence she has to one of her patients (the wife) justifies breaching her duty to respect the confidentiality of this patient. And this is not the only ethical issue raised in this scenario. As we shall see, this case further challenges the physician to consider whether she has a broader duty to promote fair public policy practices regarding the reporting of sexually transmitted diseases.
BENEFICENCE AND CONFIDENTIALITY
Physicians confronted with dilemmas involving patient confidentiality frequently seek guidance from statutory regulations or legal precedent. In this case, however, neither avenue is likely to prove especially helpful.
Some states have laws requiring partner notification of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome, and contact tracing for syphilis and gonorrhea has been in place in many jurisdictions for many years. However, despite ample evidence that Chlamydia is the most common cause of serious sexually transmitted disease in the United States today, public policy has failed to address the need for contact tracing for this disease in a uniform manner. Indeed, contact tracing and partner notification by public health officials vary widely by disease, from 92 percent for syphilis (which affects men and women equally), to 53 percent for Chlamydia (the burdens of which fall disproportionately on women).2
Although this problem has been recognized at the national level, a well-coordinated solution has not been forthcoming, and sexually transmitted diseases remain a tremendous health and economic burden in our nation.3(pp28–68) Although some countries, such as Sweden, have initiated contact tracing with success,4 sexual contacts of patients diagnosed with chlamydial infection in the United States are usually left unsuspecting.
Case law is also unlikely to provide the physician with much assistance. One of the most well-known cases addressing the physician's duty to warn third parties of imminent harm is Tarasoff v. Regents of the University of California.5 This case involved a psychotherapist who was held liable for failing to effectively disclose that a patient under his care had expressed the intent to kill an identified third party. Although the therapist did inform appropriate authorities, he did not personally warn the intended victim, whom the patient later killed. In assigning liability, the court held that “the protective privilege [of confidentiality] ends where the public peril begins.”5
However, in other cases more directly relevant to this one, the courts have ruled inconsistently. For example, in one case a physician was held liable for breaching patient confidentiality after disclosing information to the patient's sex partners, while in another case, health care providers were found liable for not warning a man's fiancée of the fact that he had received transfusions of HIV-infected blood.6 The lack of consistency on the part of the courts in dealing with matters of sexually transmitted diseases suggests that any choice this doctor makes may subject her to civil action.
Because of the absence of public policy and the ambiguity in case law, the physician will want to search for what should be foremost in guiding thought and action—a set of ethical guidelines. We have proposed a list of factors that we believe bear on these difficult decisions.7 They provide concrete, helpful direction to a physician who must decide when the duty to warn might override the duty to maintain confidentiality. We believe that the following seven criteria are relevant in this circumstance: (1) the gravity of the harm; (2) the probability of the harm; (3) the identifiability of potential victims of the harm; (4) the imminence of the harm; (5) the probability that an intervention can mitigate the harm; (6) the degree to which means other than breach of confidentiality have been exhausted; and (7) whether the patient himself is the agent of the harm.
We suggest that the greater the degree to which these criteria are satisfied by the circumstances of the case under scrutiny, the greater the force of the argument to breach confidentiality and warn the parties at risk. Let us reconsider our case in light of these criteria.
First to be considered is the gravity of the harm. Although chlamydial infection is asymptomatic in the majority of women, it is the leading cause of pelvic inflammatory disease (PID) in the United States. Thus it threatens, often silently, the reproductive health of women by contributing to infertility, ectopic pregnancy, and pelvic pain.3(pp20–2) These considerations suggest that, while not life-threatening, the potential harm is genuinely grave.
The next three criteria are met with equal ease. In our present case, the victim (the wife) is clearly identifiable, and there is no doubt that the patient (the husband) is the agent of the harm. Finally, recent literature suggests that there is a high probability that appropriate intervention can mitigate the harm.8 Based solely on these criteria, then, the argument in favor of warning the wife carries considerable weight.
However, the next two criteria are less well met in our case and counter the arguments that favor the breaching of confidentiality. Consider first the likelihood of harm: it is impossible to predict whether a given case of chlamydial infection of the lower genital tract will result in PID. What do we know about the risk? Based on data from one study,8 an estimated 5 percent of women who are screened for Chlamydia will be found to have the infection. This same study also demonstrated that treatment of women whose Chlamydia screens were positive reduced the risk of PID by 56 percent over the control group. Another study9 found that a history of two chlamydial infections doubles the risk of ectopic pregnancy and quadruples the risk of PID; three or more such infections increases the risk of ectopic pregnancy 4.5-fold and the risk of PID 6.3-fold. Nevertheless, because Chlamydia is overwhelmingly asymptomatic in women and its complications are insidious, reliable data for absolute incidence and prevalence are lacking (although the bias is overwhelmingly toward underestimation).
These uncertainties are compounded by the fact that there may be a lag time of months to years before the more serious complications present. Thus, it is impossible to predict the likelihood of harm in any individual case. Because of these considerations, then, although the warrant to warn on the ground of likelihood of harm is appealing, it is not compelling.
Matters are similar when the imminence of the harm is considered. This criterion also fails to be satisfied because chlamydial infection of the lower genital tract may not develop into PID (and its attendant complications) for months, if ever.
The final criterion concerns the degree to which all means alternative to breaching confidentiality have been exhausted. To satisfy this criterion, the physician must have a fully informative discussion with the patient about the risk to his wife, the risk of reinfection to himself should his wife be infected and go untreated, all risks attendant to fertility and pregnancy, and potential risks to any future offspring. If there is mandatory contact tracing in the jurisdiction in which she practices, she should inform him that the case must be reported and, therefore it would be beter for him to inform his wife himself.
The physician must offer to assist the patient in making the disclosure and provide him with a reasonable period of time for self-reflection and deliberation before doing so. Having done this, she will have exhausted all reasonable alternatives to breach of confidentiality. With due consideration to all the foregoing (provided that the patient's wife is not currently pregnant, which would introduce other considerations), we conclude that the criteria are not yet sufficiently satisfied to justify the physician's breaching of confidentiality. Accordingly, the physician should not inform the patient's wife over his objection.
Situations that threaten the confidentiality of the physician-patient relationship are always difficult to resolve. We have argued that there are limits to the physician's duty to maintain the confidentiality of the physician-patient relationship, but these limits are difficult to define. Legal and judicial precedents are not sufficient to provide concrete direction. Helpful ethical guidelines exist, but they are not extensive enough. Public health policy is desperately needed to address the issues of contact tracing and partner notification for chlamydial infection. Issues of justice and fairness may underlie this imperative because the burdens of sexually transmitted disease fall disproportionately on women.