Spreading a disease on purpose

tallaght01

An issue that crops up in medicine from time to time is the conflict between patient confidentiality and the public interest.

So, say you come across a commercial sex worker who has a sexually transmissible illness that he/she knows about, but is unwilling to give up working in the trade, and says that clients won't pay them if they insist on using condoms.

In the case of HIV, many countries can prosecute the people (though I'm not sure about Ireland).

But what about hepatits etc?

How should we deal with these people?

I've come across this issue a couple of times, and have managed to resolve it by referring people to STI clinics and following up. But I think we should have some kind of legal framework to help protect the public. But it can potentially set so many precedents, that it's a difficult one to call.

Anyone else dealt with this before? Any thoughts on what would make it easier to manage? Better sexual health services? Better laws? Clamping down harder on prostitution?

ZYX

Your obligation to patient confidentiality only goes so far. So for example, if you know someone is HIV/Hep B/C pos, then it is up to you to inform their partners. This is even if patient tells you not to. It is not enough for you to tell patient to inform partner. You must ensure it is actually done. This is according to MPS legal representatives.

tallaght01

Even for hep C???

But this was the reason I brought up the case of a sex worker.

How do you inform his/her partner?

metrovelvet

Do doctors have to inform patients if they themselves have hiv or hep?

Odysseus

The HIV topic comes up often enough at our clinical meeting, I only know of cases where the person was informed that confidentiality would be breeched if they did not inform.

I have never heard it metioned about Hep C. Lots of my clients would be Hep C and work in the sex area. Though all would state that condoms are used.

AFAIK in the case example you have given Tallaght there is little that can be done. If you push the person into a corner they will state that they no longer work. I have heard of cases aboard where people have been prosecuted but its difficult to prove. I know there is a precedent for HIV but know that I heard for Hep C. Though I don't carry too much of that info around, that's what my consultant psych get paid for.

tallaght01

Yea, I wouldn't be worried about HepC, and we have legal backing in Oz to detain and prosecute someone who we believe to be endangering others, in terms of HIV risk.

I'm more thinking of HepB, I guess.

mardybumbum

Good question.

I know the Irish Medical Council's code of ethics is merely a "guide" but it states clearly that the Fitness to Practise committee must be informed immediately.

Personally, I would feel the need to inform the appropriate parties.
But then again, I have never found myself in that position and If the colleague were a good friend of mine my judgement may be compromised.

Medicine is never easy I guess.

tallaght01

mardybumbum wrote: »

Good question.

I know the Irish Medical Council's code of ethics is merely a "guide" but it states clearly that the Fitness to Practise committee must be informed immediately.

Personally, I would feel the need to inform the appropriate parties.
But then again, I have never found myself in that position and If the colleague were a good friend of mine my judgement may be compromised.

Medicine is never easy I guess.

The question is about sex worker with an STD, as opposed to a doc with an STD. I know they can be hard to differentiate, though

What would you do as a student, who's not been through the cynicism mill yet, if a sex worker told you they had Hepb and were gonna continue having unprotected sex? rather, what do you, and the other students, think is the ethical and right thing to do, if you were making the rules. Confidentiality? Or public interest?

Bear in mind, if the world gets out that you rat up sex workers who get tested, others may never come to be tested. It's classic medical school ethics.

imported_guy

im sure there would be alot of sick minded people who if found out they had HIV/aids/hep(or even smaller diseases like herpes etc) would probably become enraged, and go around having unprotected sex anyone they can find to get revenge on the world... i think if they dont comply with the doctor and genuinely agree to have protected sex, they should be recomended psychotherapy or in extreem cases put into isolation (i know the latter breaches several human rights, but the person is severely endangering lives of others, and if someone tries to infect someone else with HIV or something, the concequences should be grave i.e. lay down some attempted manslaughter charges), in reality it would be hard to procecute though.

mardybumbum

Sorry tallaght, didnt read your post clearly.
I thought you were referring to a doctor/nurse who worked in a STD clinic.
I have never heard the term "sex worker" before. :pac:


That is an extremely hard question.
Even if I made the decision to publicise the fact that a "sex worker" had HepB how does one let the public know?
Put up posters?
Ask the local radio DJ to announce it?
Put a bell around their neck?
I joke.

I guess the most appropriate thing to do is inform the police that the person is a "sex worker", If that in itself did not break any laws.
But Im going to assume that in the areas where this is a problem, the police force dont give a damn anyway.
I may get flamed for this but I believe that public safety comes before confidentiality.

What did you make of the proposition a few years back where people tested positive for HIV would be required to wear a tattoo that stated so on a normally hidden part of their body?
I really haven't made up my mind on it.

Bottle_of_Smoke

imported_guy wrote: »

im sure there would be alot of sick minded people who if found out they had HIV/aids/hep(or even smaller diseases like herpes etc) would probably become enraged, and go around having unprotected sex anyone they can find to get revenge on the world... i think if they dont comply with the doctor and genuinely agree to have protected sex, they should be recomended psychotherapy or in extreem cases put into isolation (i know the latter breaches several human rights, but the person is severely endangering lives of others, and if someone tries to infect someone else with HIV or something, the concequences should be grave i.e. lay down some attempted manslaughter charges), in reality it would be hard to procecute though.

how would you differentiate between a genuine and non-genuine case though? also. "attempted manslaughter"? think about that one for a while.

I wouldn't report the prostitute. I think it would lead to CSWs avoiding getting tested. If a man is insisting on unprotected sex with a prostitute I can't help but have limited sympathy.

mardybumbum

Bottle_of_Smoke wrote: »

If a man is insisting on unprotected sex with a prostitute I can't help but have limited sympathy.

This too

imported_guy

Bottle_of_Smoke wrote: »

how would you differentiate between a genuine and non-genuine case though? also. "attempted manslaughter"? think about that one for a while.

I wouldn't report the prostitute. I think it would lead to CSWs avoiding getting tested. If a man is insisting on unprotected sex with a prostitute I can't help but have limited sympathy.

yeah thats why i said it would be hard to do it in reality <edited by tallaght01>

and umm if you get infected with HIV/AIDS your lifespan becomes SIGNIFICANTLY smaller and it will be an unnatural death (AKA they call it homicide in america, death at the hands of another individual)

edit http://www.wrongdiagnosis.com/h/hiv_aids/deaths.htm i think i need to reference everything from now on cuz some people assume im trolling, by the way i present my facts

suspectpackage

imported_guy wrote: »

yeah thats why i said it would be hard to do it in reality :< read the whole thing its in english..

and umm if you get infected with HIV/AIDS your lifespan becomes SIGNIFICANTLY smaller and it will be an unnatural death (AKA they call it homicide in america, death at the hands of another individual)

edit http://www.wrongdiagnosis.com/h/hiv_aids/deaths.htm i think i need to reference everything from now on cuz some people assume im trolling, by the way i present my facts

Can you see a link here?

tallaght01

Rubbish edited out of imported_guy's post. Dude, we'll only take so much of that.

Next time and I'll be taking proper action.

tallaght01

Bottle_of_Smoke wrote: »

#

I wouldn't report the prostitute. I think it would lead to CSWs avoiding getting tested. If a man is insisting on unprotected sex with a prostitute I can't help but have limited sympathy.

The problem is that, depending on where you live, a person with HIV might give it to 2 or 3 other people, who may well be perfectly innocent too.

So, the implications are more far-reaching than the person who uses the prostitute's services.

drkpower

ZYX wrote: »

Your obligation to patient confidentiality only goes so far. So for example, if you know someone is HIV/Hep B/C pos, then it is up to you to inform their partners. This is even if patient tells you not to. It is not enough for you to tell patient to inform partner. You must ensure it is actually done. This is according to MPS legal representatives.

That is true to an extent. Both data protection law and guide to ethical conduct and behaviour allows confidentiality to be breached if it is required urgently to prevent injury or other damage to the health of a person so, where they were at imminnent risk of a communicable disease, disclosure could be warranted. But, and this is a big but, a doc would first need to try and obtain consent from the patient to disclose the info and urge the patient to tell their partner themselves (ie. in a consultation with the doctor). And this process of convincing the patient would need to be more than a cursory "do you mind if I tell her" process!

But ultimately, this is one of the exemptions to confidentiality. However, while a doc could breach confidentiality, he is not necessarily legally obligated to do so. However, ethically (acc. to the Guide to Ethical Conduct...), the doc is obligated to do so.

On the detention question, there is provisions to detain those who suffer from communicable diseases (1947 Health Act, i think) in the public interest in certain circumstances. Rarely used but permissable in theory; there was a recent High Court case involving a woman detained on this basis for >6/12 as she had TB.

ZYX

drkpower wrote: »

That is true to an extent. Both data protection law and guide to ethical conduct and behaviour allows confidentiality to be breached if it is required urgently to prevent injury or other damage to the health of a person so, where they were at imminnent risk of a communicable disease, disclosure could be warranted. But, and this is a big but, a doc would first need to try and obtain consent from the patient to disclose the info and urge the patient to tell their partner themselves (ie. in a consultation with the doctor). And this process of convincing the patient would need to be more than a cursory "do you mind if I tell her" process!

.

Not according to a meeting I was at with MPS a few years ago. Things may have changed since then but I doubt it. They had 4 or 5 legal representatives at this meeting and all agreed that convincing patient to tell partner was not enough. If in the end the patient did not tell partner and partner got HIV/Hep B/HepC (yes Hep C was included) then the doctor could be held liable. Their stance caused a lot of discussion and disagreement from the doctors present but in the end all MPS representatives agreed this was true (ie doctor could be held responsible). I should add they did say they had no case law to back up their position but it was the position of MPS.

drkpower

ZYX wrote: »

Not according to a meeting I was at with MPS a few years ago. Things may have changed since then but I doubt it. They had 4 or 5 legal representatives at this meeting and all agreed that convincing patient to tell partner was not enough. If in the end the patient did not tell partner and partner got HIV/Hep B/HepC (yes Hep C was included) then the doctor could be held liable. Their stance caused a lot of discussion and disagreement from the doctors present but in the end all MPS representatives agreed this was true (ie doctor could be held responsible). I should add they did say they had no case law to back up their position but it was the position of MPS.

I should clarify.

There is no strict legal obligation to discose in this scenario, AFAIK.
However, as the MPS guys said, there is an arguable case that if someone suffered injury (partially) as a consequence of a docs failure to inform them, they could take a personal injry action against the doc. AFAIK, this issue has not been litigated in Ireland.

Its a tough one to call, there is a strong practical and public policy argument for not imposing such an onerous positive legal duty to report on a doctor. And there are difficulties of determining what class of people the doc would have to inform. But, no doubt, there is a possibility of an action being taken against a doc.

drzhivago

ZYX wrote: »

Not according to a meeting I was at with MPS a few years ago. Things may have changed since then but I doubt it. They had 4 or 5 legal representatives at this meeting and all agreed that convincing patient to tell partner was not enough. If in the end the patient did not tell partner and partner got HIV/Hep B/HepC (yes Hep C was included) then the doctor could be held liable. Their stance caused a lot of discussion and disagreement from the doctors present but in the end all MPS representatives agreed this was true (ie doctor could be held responsible). I should add they did say they had no case law to back up their position but it was the position of MPS.

In the end of the day its a balance
Confidentiality versus protecting partner or public

If you breech confidentiality person can report you to medical council they will investigate and likely no sanction as it was greater good

If the person takes civil action (ie they have to fund it themselves) it will be a jury court where you both (or your representatives tell the story)
The jury will have to put themselves in both positions and I would think come down in favour of the doctor again in that they are never going to be in doctors position but could be in the other position and would want to be able to protect themselves from harm

drzhivago

Sorry to be pedantic but the title is a little misleading

Example
Person has disease, doesnt know but infects many others (Typhoid Mary)

Person has disease, knows they have it, dont understand how disease passed on

Person has disease, knows they have disease, have poor reaction to the knowledge gets angry with world and deliberately wants to infect people

Sex worker has disease (presume this is street walker not high class brothel/agency as they screen and refuse work), now finds out they have disease, has no other possibility of employment and works hoping they dont pass on disease


Maybe we should get into more details of the situation as there are different solutions

• Public health directives regarding communicable disease
• occupational health legislation
• criminal sanction
• moral action on doctors behalf

tallaght01

Well,ok, let's say the aim of the game isn't to purposely spread disease. But with something like HepB, we all know the chances are high. And for something like HIV the consequences are enormous. Not really convinced about HepC.

BUt let's say the sex worker is refusing to wear condom, and works on the street.

drzhivago

tallaght01 wrote: »

Well,ok, let's say the aim of the game isn't to purposely spread disease. But with something like HepB, we all know the chances are high. And for something like HIV the consequences are enormous. Not really convinced about HepC.

BUt let's say the sex worker is refusing to wear condom, and works on the street.

One chance in clinic

still refuses you have to get on to authorities
the consequences are too high

tallaght01

drzhivago wrote: »

One chance in clinic

still refuses you have to get on to authorities
the consequences are too high

I agree. It's difficult to do here in Oz, unless it's HIV.

drzhivago

tallaght01 wrote: »

I agree. It's difficult to do here in Oz, unless it's HIV.

Suggest you look at old health regulations related to TB

Many countries brought in draconian enforcement policies which i presume are still on statute
Have to see if could be slanted that way for your current case

I doubt the regs were removed

Reloc8

In the UK there have been a number of successful prosecutions of persons who were considered to have deliberately infected a sexual partner with HIV - I don't think any other STD transmissions have been been taken. Deliberate infection has been considered to involve unprotected sex following the notification to you of a positive test result for HIV, and I recall one case where a seven year sentence was given. The prosecutions were under the UK Offences Against the Person Act - which is pretty much identical to our OAPA 1997 (in fact I believe we copied theirs).

In relation to disclosure by a doctor of a patient's HIV status, I can recall a civil case taken in relation to breach of privacy by a prisoner who's psychiatrist sent his Opinion on the guy to a parole board where the parole board psych was reccomending release but the guys own psych was convinced he remained highly dangerous. The parole board refused release and the prisoner sued for breach of confidence & privacy on the basis that he had not authorised the transmission of the report compiled by his own doctor. He lost on the basis of the public interest in the parole board being in possession of the Opinion outweighed his individual right to privacy. The Court of Appeal commented that in a hypothetical case of a doctor informing a person's partner of their HIV status where they believed there was a risk that person would not do so, this would also be lawful as a justifiable breach of privacy. They fell short however of finding that there would be a positive duty on the doctor in that instance to inform the partner and it is probably the case that he or she would not have such a duty.

The position is probably the same in Ireland although a similar case has not arisen. HIV is still not a 'mandatory reporting' situation to the authorities in Ireland or UK...I believe it is in France and in most US states.

In relation to e.g. a commercial sex worker who tests positive, the Doctor's difficulty in say Ireland is really who to tell presuming he or she does not know the sex worker's partner. You can't make people wear a sign, thank god, and there is no offence without a victim, so the cops will not be interested. The reason why the hypothetical doctor discussed was considered correct to inform the partner was because of the clear and immediate risk to that specific person which isn't really present in the case of a prostitute and their prospective johns. The Doctor in that case has no permissible disclosure to make to any person without breaching confidence & privacy short of following the infected person around and shouting a warning.

There ya go - have some law lol

nb bottom line - you have unprotected sex, you take the consequences.

Jessibelle

Surely though, ethically and morally there is the obligation to not "stand idly by" and allow people to become intentionally harmed. Like the obligation a councilor has to inform the authorities if they believe a client will harm themselves or others?
Historically when something/someone has posed a significant health risk, patients who did not voluntarily seek out treatment were forcibly institutionalized to receive treatment or to disclose. The justification is that the untreated patient poses an improper risk to others which justifies limiting the patients freedom. Similarly, if maintaining confidentiality will threaten public or an innocents health, then I feel, that must take precedence and information must be appropriately revealed. If I have to weigh private rights versus societal obligations, I personally feel society has a right to limit the autonomy of individuals if such limitations are reasonable and necessary for public health. I’ll be the first to admit though; it’s the definitions of ‘reasonable’ and ‘necessary’ though where my logic tends to waiver a bit…

Bottle_of_Smoke

tallaght01 wrote: »

The problem is that, depending on where you live, a person with HIV might give it to 2 or 3 other people, who may well be perfectly innocent too.

So, the implications are more far-reaching than the person who uses the prostitute's services.

That's a very good point and I'd overlooked it.

Really is an awful situation. Gonna have to think for a while.

Lassiecomehome

Funny, when I first read the title of this thread I thought you were referring to the 'Swine Flu parties' people have been organising, similar to the Chicken Pox party you might have been brought to as a child. I.e. someone has a child, or is themselves sick, with H1N1 & they invite others around to propagate the virus. If one of the invitees becomes lethally ill from transmitted H1N1 would there be legal ramifications for the organiser of the party? I have heard of numerous such parties being organised by patients.