by Jacob Dahlke, Bioethics Program Alum (MSBioethics 2012)
Nebraska’s highest court ruled last week that an Omaha-area woman can pursue her lawsuit against a local clinic that she alleges disclosed her HIV-positive diagnosis. The case began in 2010, with the plaintiff, known only as C.E., visiting a diagnostic lab in Omaha as a part of a health insurance application. After sending the results to another lab, C.E.’s lab results arrived to her local physician’s clinic, Prairie Fields in Fremont, 30 miles NW of Omaha. C.E. was told at her consultation in the fall of 2010 of her positive diagnosis for HIV. She had initially asked for her results from an employee and former high school classmate Kristy Stout-Kreikemeyer, who appeared to see the results but deferred the actual disclosure to C.E. to a staff physician assistant. C.E. was told the test was inconclusive, and she agreed to take another test. Barely more than 24 hours later C.E. was contacted by an ex-boyfriend, Jonathan Karr, to ask about how she was, having heard from another mutual acquaintance, Jamie Goertz, that she had “full blown AIDS”. It is alleged by C.E. that Kristy Stout-Kreikemeyer told Jamie Goertz about the diagnosis, and that Prairie Fields is also responsible for this violation of her privacy.
While the details of the case may seem to read like a sort of tabloid story, the ethical issues remain real. What are the public health implications of disclosing vs. keeping private STI diagnoses, including HIV? What are medical facilities’ obligations regarding such disclosures? Does the public have a right to know such private details about individuals? How does the size or intimacy of the community change the issue, or should that be irrelevant?
Let’s begin with some lingering unknown factors. First, it remains unknown C.E.’s actual HIV status, and I would anticipate it will remain unknown to the general public, even through the course of her future trial. While her initial screen was positive, it was recommended by the clinic that she have another, more definitive test performed in order to rule out false-positive screen. According to the CDC, “(f)urther testing is always required to confirm a reactive (preliminary positive) screening test result.” While the court paper refers to only an initial ‘blood test’, it would remain possible that the test would provide a false-positive result, meaning that the test indicated the presence of HIV antibodies when there were none. This would have been why the PA at Prairie Fields wanted C.E. to return for a follow up, more definitive test.
What does this have to do with privacy and public safety? The first is that C.E. was not diagnosed with having HIV; she only screened positive for it. Not until C.E. undergoes (underwent) the second test and is positive there, would she be considered HIV-positive. This may matter for C.E. from a legal standpoint because her lawsuit may include some claims to libel, in which the defendants publicly slandered her, saying she has a disease that she doesn’t. From a public perspective, the only reporting that is to be done is to the appropriate health departments. This was appropriately not yet done by the clinic, since a confirmed positive diagnosis was not present. The purpose in reporting to health departments is tri-fold: 1) it can aid the patients who may need treatment by connecting them to local resources and by providing local context to their disease; 2) it helps to identify and support sex partners who may not yet be infected, or partners who are at risk of infection, or partners who may be infected but who do not yet know; and 3) it can help to track disease patterns and trends, thus ensuring that appropriate resources are being devoted. It is done confidentially to ensure that a patient maintains control (autonomy) over their own healthcare decisions, including the circumstances (who, what, when, where, why, how) of telling others.
It is perhaps obvious to say that a case like this can lead to a loss of trust between patient and physician in a community. Confidentiality is a benchmark of quality healthcare. Patients are ill, concerned, and otherwise vulnerable; healthcare providers are there to have intimate and personal conversations with patients that are often not discussed with even the most privileged of the patients’ inner circle of friends and family. In the event that C.E. had a negative confirmatory test for HIV, it should have been up to her to share her ‘close call’ with whomever, including no one. Likewise, were she to test positive, the ability to at least control the context of her telling her sexual partners ought to have been hers. But that did not happen, due to someone’s (alleged) violation of her privacy.
Instead, what transpired highlights why confidentiality in healthcare is so important. C.E. was instead left to defend herself against her community, which appears to quite closely knit and connected to each other for long periods of time. What should have been a conversation between C.E. and her physician was instead being talked about at a local bar, which led eventually to her ex-boyfriend (and father to one of C.E.’s children) asking her about it. Breach of confidentiality is obviously not a problem that exists only in rural or small communities, but in this case it sure seems like it was exacerbated by it.
[This blog entry was originally posted on Mr. Dahlke’s blog on March 18, 2014. Its contents are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]