By Robyn Alie, Manager, MMS Health Policy and Public Health
If a health care worker is exposed to a patient’s body fluids in the workplace, should the patient be required to undergo HIV testing? This issue, the subject of discussion at the 2018 MMS Annual Meeting, exemplifies the ethical dilemmas that come up in policy and advocacy within the MMS and in public health broadly.
Laws, institutional policies, and professional ethical guidelines often provide clear guidance on how physicians must practice medicine. When considering new laws or policies, or the repeal of existing ones, the rights or needs of one individual or group may be weighed against those of another. Should schools or pediatric practices require children to be immunized? Under what circumstances should an individual be quarantined? Should health care workers be allowed not to treat certain populations
based on their own moral or religious beliefs?
Mandatory HIV Testing
Steven A. Ringer, MD, PhD, chair of the MMS Committee on Public Health, testified on the HIV testing resolution. Photo by Doug Bradshaw
At last year’s annual meeting,
delegates considered a member-proposed resolution that the MMS advocate for the mandatory HIV testing of patients when a health care worker is exposed to potentially infected body fluids in the hospital. Testimony at the reference committee highlighted the complexity of the issue, prompting a vote to have the MMS further study it.
Thirty-five other states have laws allowing for some form of unconsented testing following health care worker exposure to body fluids. Massachusetts requires informed consent. Many Massachusetts hospitals require separate written consent beyond their legal obligation.
Impact on the Health Care Worker
The risk of an occupational exposure resulting in a health care worker contracting HIV is extremely low. No reported conversions have been reported in Massachusetts in 20 years, and
in the last case the source was unknown. In addition, HIV is now a treatable disease. Those facts, however, may not eliminate the anxiety of the health care worker facing post-exposure prophylaxis or a possible lifelong HIV
infection.
Impact on the Patient
Knowledge of one’s HIV status can benefit the source patient — for example, by linking a seropositive patient to early treatment and support. Almost all patients consent to HIV testing following possible worker exposure and there are procedures for obtaining consent for incapacitated patients.
Some argue that HIV is no longer stigmatized, and exceptional policies around HIV may themselves create stigma and inhibit care. But reports indicate that people with HIV continue to experience discrimination and stigma, and that may affect individuals’ health and health care.
Ethical and Other Issues
The proposal to test without patients’ consent raises a number of ethical and other issues for physicians: Is it ethical to perform a procedure on a patient without the patient’s informed consent — particularly when that test is explicitly for the
benefit of someone other than that patient?
Is it appropriate to advocate
for such an act to benefit health care workers who are exposed by patients but not patients who are exposed by health care workers? The MMS and the AMA oppose the mandatory release of health care worker disease status to patients. Patients or non–health care workers may be exposed to the bodily fluids of others — for example, if a newborn is erroneously given the breast milk of an HIV-infected mother.
If a patient refuses consent, will blood be forcibly drawn? What precedent would such a law create for exposures that occur outside the hospital, where privacy rules do not apply? What abuses might result? What are the legal implications of such a policy? What impact could it have on the patient-
physician relationship, and on patients’ trust in their health care providers?
The committees charged with making a recommendation on this resolution identified the opportunity to reduce the risk of occupational exposure and to improve support for affected patients and health care workers. Citing the ethical principles of patient autonomy, and the primacy of the physician’s responsibility to the patient, the committees recommended against the Society advocating for unconsented HIV testing.
