Case Scenario

I was taking care of a 19-year-old woman who was pregnant with her second child. The results of an initial routine prenatal test for chlamydia were negative; however, later in the pregnancy, she had five positive test results despite adequate treatment. The patient’s boyfriend also was treated each time, and the patient was confident that their relationship was monogamous. I prescribed several different antibiotics to make sure the chlamydia was not drug resistant, and the patient assured me she and her boyfriend were complying with the medication regimen.

Several months later I was working in the hospital and evaluated an inpatient presenting with abdominal pain for possible pelvic inflammatory disease (PID). She had previously told a nurse that she had been with her boyfriend for six years and that they had a two-year-old child together. As I entered the room, I was surprised to see the same man who had been with my previous patient who had chlamydia during her pregnancy. I spoke to the boyfriend privately about the situation. He said he had been sexually active with both women during the first patient’s pregnancy.

If I tell the first patient about what I have discovered and under what circumstances, it could be a privacy violation for the second patient. However, I do not want her to continue to have unprotected sex with this man while thinking that he is faithful to her. The current inpatient being treated for PID probably assumes that the man is faithful to her as well, although he may be the source of her PID. How should I handle this dilemma? What is my responsibility to these patients and to the boyfriend?

Commentary

This scenario raises complex ethical questions. The physician-patient relationship is characterized by a network of obligations and expectations that becomes more complex when patients with close ties are treated by the same physician. Medical ethics principles stress respect, beneficence, and justice; however, cases like this stretch our concept of these principles. The underlying premises of the physician-patient relationship, such as the expectation of confidentiality and the locus of the physician’s primary obligation, clearly are called into question in this scenario.

Although confidentiality is an essential part of the physician-patient relationship, there are three situations that may justify breaching confidentiality: (1) there is abuse of a vulnerable person, such as a child or older person; (2) there is public health risk, such as with communicable disease; and (3) the patient is a substantial danger to himself/herself or to others.¹

When determining how to balance confidentiality obligations with the need to protect others, the likelihood, the seriousness, and the preventability of harm should be considered. In this scenario, the risk of reinfection in the women is high unless all three persons are adequately treated. The seriousness of harm also is high, especially because women infected with chlamydia are five times more likely to acquire human immunodeficiency virus (HIV) if exposed,² and chlamydia has potentially serious long-term sequelae for the women and infants. The harm may be preventable if all three persons are treated and subsequently practice safe sex. In addition, prompt testing, diagnosis, and treatment of HIV, if one of them is infected, could help prevent the spread of the virus. The patients have the right to know about this risk of harm and to take steps to prevent or mitigate the harm.

Preventing sexually transmitted disease (STD) reinfection requires notification, education, and treatment of all three persons. In general, partner notification can be accomplished through patient referral (i.e., the patient advises the partner to seek medical treatment) or through provider referral (i.e., the physician contacts the patient’s partner and suggests treatment).

Unfortunately, public health notification is not a viable option. A study showed that only 12 percent of patients with chlamydia were provided with partner notification services,³ and states generally are unable to provide the appropriate level of notification, education, testing, and treatment. Although all states require physicians or laboratory workers to report chlamydia cases to the public health department, many do not have adequate mechanisms for partner notification. Because of the boyfriend’s behavior and the lack of viable alternatives, the best option in this scenario is provider referral. If the boyfriend insists on telling the women himself, the physician should be present to ensure that the women are fully informed.

The physician’s ambitious goal is to ensure that all three patients know how chlamydia spreads, how to prevent it, and that they may be infected. The physician also should attempt to make sure the patients obtain and adhere to treatment, and that they know that each partner is receiving treatment. It is not up to the physician to inform each person about the likely source of his or her infection. Unless the patient truly is in a monogamous relationship, the source cannot definitively be determined; therefore, physicians should be careful to avoid attributing responsibility unfairly. The physician should limit the confidentiality breach to include only the information each person needs to know. The physician should not reveal the women’s names to each other.

The boyfriend is not one of the physician’s patients, but the physician should be respectful of what the boyfriend has confided. First, the physician should inform the boyfriend that he plans to advise each woman separately that she may be exposed to chlamydia. The physician also should make it clear that the women will not be told that the boyfriend is the likely source. This gives the boyfriend a chance to tell the women himself. Although the boyfriend currently is not a patient, the physician should offer full education, testing, and treatment or refer him to another physician or clinic. The physician also should urge him to get HIV counseling and testing.

The women should be advised to notify all current sexual partners and those from the past 60 days. Both women should receive extensive counseling about safe sex and proper condom use and should be offered HIV counseling and testing.

Although challenging, this notification process can be accomplished without revealing the names of the persons involved, thereby protecting privacy, avoiding unwarranted assumptions, and facilitating appropriate medical treatment. Preserving confidentiality is important to foster trusting physician-patient relationships, but the duty to protect others sometimes outweighs confidentiality considerations. In this scenario the harm is probable, serious, and preventable; therefore, the physician should act promptly to stop the spread of disease.