We are Child and Youth Care students looking for some different perspectives and opinions on
an ethical topic we are writing a paper on. Our scenario is:
It comes to our attention that a youth in our residential facility has been diagnosed with AIDS. This particular youth has boundary issues and often participates in sexual activity with other youth in the facility. Our question is: Do we have an ethical responsibility to break confidentiality of one youth to save the other youth in the group home or are we ethically responsible to maintain the confidentiality of the one youth no matter the costs?
We are wondering if you have run into the same/similar situation during your experiences in the field, and if you would mind sharing? We're also wondering if you know of any legal policies regarding this situation or if you could point us in the right direction for finding it?
Thank you!! :)
Dear Nova Scotia Community College Students,
This is an ethical question that different professionals grapple with, and it is a very real dilemma. My position is that you have an obligation to inform the youth that his actions are irresponsible and can likely lead to the infection of others. If he is aware of this, and has the intellectual capacity to really understand the consequences of his actions, and still continues to engage in unprotected sex with others without informing them of his status, he could possibly even face criminal prosecution. However, his partners have an equal responsibility to protect themselves when engaging in sex, and HIV is not the only risk they take, so the responsibility is not all his. The difference is that he knows that he is infected, and he knows that he might infect them – that is a deliberate act. If you have done everything possibile to convince him to use protection and to be honest with his sexual partners, and he still continues to have unprotected sex, then you have an obligation to tell his partners – but you have to inform him that you will do so. It is still a risk for you however, because it is an ethical problem, and new ground is broken in this area all the time, and legal positions change all the time, so there is no risk-free action for you. You have to take into consideration your responsibility to have the youth's best interest at heart, without allowing him to harm others. So in the end, I would tell. (I'm not assuming it’s a "him", just being brief.)
Werner van der Westhuizen
SOS Children’s Villages, Port Elizabeth
I would think that it is your duty to tell the other youth because their life is at risk. That's just my opinion though, good luck with your final decision.
Why are you assuming that nobody else in the facility has AIDS? My opinion is yes you are absolutely bound to keep that information confidential. If there is an issue in relation to sexual activity between the youth, then that is a separate (though related) issue in itself that needs to be addressed and policies should be developed from the place of assuming that everyone could have AIDS!
John Byrne (Ireland)
Any health issues re: blood borne pathogens/ hygiene etc. should be talked about to/with the staff and then to the youth through the staff. Knowledge here is the key. There are many things you can do without breaking the HIPPA laws (that is where you get your law from). I teach universal precaution to the staff where I work and the knowledge you give to them passes to the residents. I also teach the school teachers and they in turn teach the students. www.cdc.gov will help you with information that is true and factual.
You can also offer free testing to individuals that are interested in finding out if they are safe. Not just our youth should keep up on the testing. I suggest the staff get tested if they work with our at-risk youth. Going to the nearest health department can help with the test and avoid the health insurance game of denial of coverage because you were tested. (Illegal but sometimes done)
Aids is not the only worry Hepatitis B and C are also a very big threat and a bigger one to our youth and staff for it doesn't die outside the body like HIV does.
As for the youth that wants to live his own life and ignore the aids or kill people before he goes or just doesn't realize what he is doing. Talk to him (if he told you he has it) and help him to see if you can convince him to use protection. See if he wants to know all about what he has and the breakthrough meds that are out there for him.
Along with testing comes free products to protect against unwanted anything.
I caution here by saying staff must be limited to what the job policies are. If you are tied by rules than outsource your information, give out numbers and info.
I have had exactly that experience when I ran a group foster group home, however the child had hepatitis that is shared via more ways than needles or unprotected sex. I could not breach confidentiality however, I did create a health and life skills program that all residents attended and we covered all sorts of communicable infections from STI's (as they are now called in Ontario instead of STD's), HIV, AIDS and the various hepatitis strains. I then covered ethics, responsibility and confidentiality with the kids and asked "what if" questions. If you were HIV positive would you want others to share this information, what if you were having sex with other residents ...
Then explaining our responsibility about not being able to breach confidentiality but being worried about everyone's health and safety while being the "keeper of information". This created lots of opportunity for dialogue and the child who was having risky sex discontinued with residents and to my knowledge began to take better care of his own health. Hope that helps.. thanks for asking the question.. I will be interested in seeing how others respond..
Ontario , Canada
My understanding is that when a person knowingly infects another person he is charged. It's like having shooting someone with a time delayed gun I suppose. I have heard of people being charged for this. I am sure the internet will have the actual details.
If you were the infected person's unsuspecting partner ... what you would you? If you do nothing then you are an accomplice for putting the other person's life at risk. I have a right to know and then I will decide whether or not to take the risk. No one has the right to play God with the future and life of another human being ... no one. I ask again ... if someone with HIV/AIDS wanted to have sex with you .... wouldn't you want to know? And what if you didn't know and found out from someone else besides the infected person ... how would you feel? Wear the other persons shoes and then decide what the right thing to do is.
Confidentiality is a hard one!
For me there is something around always respecting confidentiality, unless it puts the individual, or others at risk of harm. I would consider, given the diagnosis of AIDS, and the resulting behaviour, that this can be seen as potentially putting others at risk of harm.
My instinct would be to first of all approach the individual, explain the potential risks to others from his behaviour, and to state clearly the boundaries in terms of confidentiality. This allows for the individual to make concrete choices re their behaviour, whilst being clear of potential consequences of it?
It is of course both partners' equal responsibilty take precautions when having sex. So even if the partner who knows that he is HIV+ does not tell his partner, his partner should also know to take precautions.
Werner van der Westhuizen
SOS Children’s Villages, Port Elizabeth
I cannot find the original question raised by "Nova Scotia Community College Students" about a resident with HIV (whether or not the person has AIDS...) -- but I wanted to send them a long reply that I wrote when this same question was asked in January of 2004, on this discussion group.
The 2004 original was a very long reply, but I have the entire thing in my files and would be happy to send it to anyone (privately) if you want to e me to request this: firstname.lastname@example.org
I will paste parts of that reply below here, so feel free to contact me if you want the whole thing...
2004 original reply:
I have been counselling youth who have HIV, for over a dozen years now, and I have a few things to share on this topic:
Although a particular kid might be infected, you are just as likely to have many other kids (OR STAFF or FRIENDS!) who have HEP or HIV but just don't know it yet!!
Let me explain: you never know for sure WHO has a virus (HIV, HEP- C,etc) until people are tested and so many are walking around actually having both viruses, with no symptoms, and no-one knows, not even
them!. That's the precise reason for "universal precautions"!! You are right that we need to be careful around "blood accidents" with those who you already know have one of these viruses, but it's even MORE important to still also be EQUALLY careful with anyone we might think to share a needle, or sex, with, who we assume do NOT have them (maybe they don't "look like" the type, whatever that is -- or maybe they say "I was tested; I'm OK")!
Hep C's different, but with HIV, even when the nurse says "your results are negative", that doesn't mean you don't HAVE it; it only means that as of a few months ago, you didn't have it (!) -- but you could have got it recently but it's too soon for there to be enough "traces" of it to be seen in the test results (ain't THAT a shock,
eh!). So, for example, with HIV, if I got infected today, I would likely still test negative (as if I don't have it) for several weeks -- and likely a couple months -- before I would turn up as being "positive" (having it) on a blood test! So I could infect you without even knowing I could -- because I honestly did not know it was there even while not showing up on a test!!! yes!!
SO... what I'm trying to say here is that:
a) ALL of us (& youth especially) should be educated to understand that anyone could have either virus and truly not know (even if they WERE recently tested!) -- and therefore we/they ARE easily able to put others at risk through normal pleasant activities (or violence, though this is MUCH more rare) and
b) therefore we should all instead be living with the approach that it is possible that ANY of our youth (AND CO-WORKERS too) likely could have both viruses and just don't know it yet -- With that perspective in mind, "universal precautions" become understandable as just good "common sense"-- and then
c) just go on with life, keeping this in mind re: those you know, strangers you don't yet (someone who needs first aid that you meet suddenly, etc...).
I guess my point is that it's not just this one youth you have to be worried about -- it's all of us, everyone "out there" in the world (even doctors or nurses themselves, grandparents, kindergarteners, parents, clergy, and others you'd never ever suspect -- i.e., not just the "usual" kind you think might have it!)
1) treat everybody -- all your youth (and co-workers) -- friends & family too -- with the same degree of caring concern re: blood-borne viruses (that anybody could have it and just not know yet), and
2) make sure all your youth who are engaging in any kind of "risky behaviour" are at least told the info above, even if they choose not to listen -- at least you won't feel as bad then, when one of them turns up infected, because at least then you know you did your best yourself.
3) protect yourself as best you can re: ALL youth in your care (& ditto co-workers!), as you will NEVER know who has these things and who doesn't, regardless of their test results!, and
4) realize that Hep-C is "caught" only by blood exchange and so unless your kid is sharing needles or having unprotected sex with family members you are likely safe in this particular situation -- BUT...what do you know about Hep-A and B, re: similar concerns (i.e. they are easier for us to catch other ways than blood!)??
As they say in this field of work, "Knowledge is power... silence is death... and ignorance totally inexcusable..."
Judy Weiser (long-ago Child and Youth Care but still love the profession!)
I have been in the field for ten years I have not experienced that situation however I have heard situations in the news where an individual knew they had AIDS but still became intimate and infected their partners. They were charged, if this individual is of sound mind and is aware clearly of his disease which sounds like he is if he is being intimate with his peers, then I believe it our obligation as Child Youth Workers to also advocate and protect other clients who also live in the capacity in which we work. I will sacrifice my job so that the integrity I made a commitment to in serving all individuals within our vulnerable population and if that means breaking confidentiality in your particular scenerio I would.
In May 2007 I put this same question on this discussion board as in the past we have had youth in our program who have had communicable diseases such as sexually transmitted infections (STIs) and who have been HIV positive. Our confidentiality policy was not giving us the needed direction to be helpful in all areas of this dilemma with those who may be affected. We felt that the youth who were participating in these activities were at risk of being harmed, as STIs and HIV are life altering, if not fatal.
Our intake package includes a paragraph stating that any residential facility has the potential to have youth who have communicable diseases and Youth Care Workers are trained in taking universal precautions. We also have discussions and do programming with the youth about communicable diseases and the precautions to use.
Our question put on this discussion board was if we know that a youth has engaged in an activity with another resident that has put him/her at risk of being infected with a communicable disease, who's responsibility is it to inform the youth, and who's jurisdiction would this fall under (i.e., the facility's or the Department of Community Services)?
We received many helpful responses from people to our question and as a result of our enquiries, our province Nova Scotia, Canada established a committee that would further review and refine the provincial policy for residential care regarding the concerns surrounding communicable diseases, including HIV and sexually transmitted diseases that can cause life lasting harm.
We saw this as a positive action plan and we on the front line were invited to send on our thoughts in writing as well for the committee to consider when shaping the policy. This committee is facilitated by the Provincial Ombudsman's office and is comprised of representatives from various public and private sectors. Two days ago representatives from our organization met with our legal counsel. We were informed that while it is important to protect the privacy of our residents we are not under statutory obligation to do so. We are permitted to disclose information if we feel there is significant risk to someone's health. So, we are permitted to disclose if someone has a communicable disease if they are participating in behaviour that puts other people at risk of harm.
If we have reason to believe that one of our residents has a communicable disease we are permitted to disclose this information to the resident's suspected sexual partners and the resident's social worker. We would encourage the resident to make this disclosure to the appropriate people themselves but if they did not do this we are permitted to do so. It is important to note that any actions taken would have to be documented completely in the youth's logs.
At present we are reviewing our confidentiality policy
and it will be rewritten to include the guidance we have recently received
from our legal counsel. I hope this information helps with the paper you are
HomeBridge Youth Society
Thank you for stressing this Werner -- and I completely agree.
I have often heard it said: "these days it is your own fault if you get HIV". Now I know there are many exceptions to this statement (being raped, getting a tainted blood transfusion, etc...) -- however there is a part of me that totally agrees with that statement because these days people should be protecting themselves, rather than putting this responsibility onto someone else instead.
There was a case here in Canada last year where a man was sentenced to prison for knowingly lying about his positive status and infecting many "innocent" women". I found this fascinating in where the blame was put, because if the woman were protecting herself, regardless (i.e., there ARE "female condoms" and one CAN refuse to have sex if no protection is used by the other person) -- then whose "fault" is this really?
I do not mean to "blame the victim" but, as I said before, "ignorance is no excuse". Yes there are "accidents" (condoms break; oral sex CAN infect, though very rarely; etc) but unless one was forced into a sexual encounter there is no real excuse for letting oneself become infected.
Even if the person says they don't have it (or "just got back test results and they are negative"), this means little because: a) they could be lying and/or b) the test results show one's zero-status up to a few months ago but since the virus needs to grow a bit before it's detectable in a blood test, the person COULD be infected, not know it yet, and their test results NOT show this yet!
So it's good to see what you wrote!
In response to your question regarding the legalities of disclosing information/breaching confidentiality.
To knowingly infect a person with HIV/AIDS is a criminal offense. If you are privileged with the knowledge in your question, then technically you are aware that a potentially life threatening crime is being committed against another resident.
Would the nature of the crime play a role in you making an ethical decision?
Would your relationship to the perpetrator play a role in you making an ethical decision?
From a legal standpoint, if you are aware that a person who is infected with HIV/AIDS is having unprotected sex with another resident in care, you are within your legal rights to disclose that information to the other resident.
Further comments on the Aids/ethics query ...
Wow – lots of interesting thoughts on this matter. Just wondering...I happen to agree with Patsy regarding sharing this information if the client with HIV is knowingly putting others at risk. I wonder what the legal ramifications will be if we don't share this information and (even if it is due to ignorance, state of mind, suicidal ideation, immaturity, etc.) clients are being put at serious risk. Our youth have enough to deal with without adding (particularly "knowingly") to their troubles.
Re: Keisha's comment that people DO infect their partners, my point is that the best way of "protecting your clients" is not to focus on the person who might knowingly have unprotected sex with them, but rather to educate your clients that the reason for unprotected sex does not lie solely in only one person of the two!
Unless the sexual encounter is forced (a completely different situation!), then the person who is not yet infected is at least equally responsible for the act of unprotected sex to have happened... THAT is the point I'm trying to make.
It seems the focus here is on people who KNOW they have HIV (whether or not it has advanced yet to AIDS)...
I suggest that your focus of "protecting your clients" would have better results if you focused on educating them that the best way to protect themselves is to assume that EVERYONE they have sex with could well have HIV but not know it yet. THOSE people are much more dangerous at infecting others, than the ones who KNOW they have it. THAT is where protecting clients (and co-workers, and OURSELVES also, I might add!!), begins...
Teaching them that THEY are responsible for what happens to their body and that there IS choice about who you let "in there"... would seem to me to be the best protection! There will always be people out there with HIV, who lie, or don't care, and won't use protection themselves. Your clients need to know that condoms can do a lot for keeping infections (of MANY kinds) from entering their bodies -- and that the responsibility for this is their own, not someone else's...