A question of ethics

What does a doctor do when confronted with an hiv -positive case

Published: Tuesday 15 August 2000

-- of late , there has been a great deal of activity connected with aids awareness and control. Yet, it seems that all sponsored, funded and media-hyped activities do not translate into specific guidelines or mandatory protocols when a seropositive hiv case is identified. Identification of such a case takes place in a hospital or, more specifically, in a testing laboratory. And there is no mechanism that the identifying doctor can put in motion to prevent the identified hiv -positive person from spreading it.A medical man confronted with an hiv -positive case finds all the hyped awareness and prevention campaign measures farcical, and ends up just counselling the carrier, hoping against hope that good sense will prevail. Here are the details of a recent case to substantiate the point.

A 21-year-old young man suffering from low grade fever, loss of body weight and generalised lymph node enlargement of the body was suspected to be a case of lymphoma. He had been referred to a reputed hospital laboratory for examination of his lymph node that had been removed elsewhere.

The pathologist did not find evidence of lymphoma in the lymph node. But, by the changes seen in the section of the node, he grew suspicious of the possibility of hiv infection.

The young man was taken into confidence and it was suggested that the pathologist would like to rule out the possibility of hiv , and for this he would need to do a blood test on him. The young man's blood was tested for hiv by the Elisa Method. It turned out to be positive. When the patient returned after a couple of days, he was informed about it.

When asked about his sex life, he flatly denied any exposure and said he was unmarried. He was asked if he had received any blood transfusion; but he denied it. He was asked about any injections that he might have taken, but he said he had taken none. To be certain that the test result in his case was correct, he was advised to get the test done by a more specific method i.e. the Western Blot Test.

The young man returned after a week and admitted that he along with four of his friends had visited "a place" and had sex with a girl. He further confided to the doctor that he had also lied about his marital status. He was married. However, his 'wife' had not yet come to stay with him.

He asked the doctor what his fate would be. To this, the doctor's reply was that it usually took 5 to 10 years for the disease to manifest itself in its fatal form. He was apprised of the likely course and progress of the disease. The possibility of his transmitting the disease to his sex partner was explained to him. He was told to disclose the fact of his hiv positivity to his 'wife-to-be' and take her informed consent. He was advised about safe sex and was warned not to donate his blood.

The identifying doctor had done all that he was required to do. The farce of the situation is that this is all that he was required to do. Consider the following points in this regards :

Did the doctor do all that he was required to do ethically, morally and legally?

Was the doctor ethically, morally, legally and socially responsible to ensure that his patient did not transmit the disease to innocent persons? If yes, how was the doctor to ensure it?

Considering the nature of the infection, the doctor should have found out about the patient's friends who had visited the source of infection and subjected them to the same test.

Did he have to power to do it? Could the boy be compelled to disclose the names of his friends?

The doctor should have found out the source of the infection and then conducted the test on that woman.Was he empowered to do it? Could the woman be compelled to submit to the test? Supposing the doctor did locate the source of the infection and confirm that the woman was hiv positive, how was he, then, to ensure that she did not transmit the disease any further?

Did the doctor have any duty towards the girl betrothed to the hiv positive patient? Knowing that the girl was at risk what should he do?

What about the implications of the recent Supreme Court Judgment ( (1998) 8 scc 296) declaring that transmission of the disease by a seropositive hiv person to another (in this case his wife-to-be), would amount to an offence under Sections 269 and 270 of the ipc ? Also to be considered is the relevance and import of Sec 39 of c r pc . in this context. Having come to know that a person is going to commit a cognisable offence, not informing the appropriate authority about it is a crime.

The writer is a senior scientist at the Indian Institute of Health and Management Research, Jaipur

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