Situation of ethical dilemma that you have experienced in practice and how it was resolved. (Saunders, 2014)

Full Answer Section

This was a classic "duty to warn" vs. "duty to protect confidentiality" conflict. The potential harm to the fiancée (and potentially others) was substantial, yet breaching confidentiality carried its own significant ethical weight.

Resolution Process:

1. Initial Assessment and Dialogue with Mr. K:

   • My first step was to clearly explain to Mr. K the nature of the disease, its implications for his health, and the health of his partner. I emphasized the importance of partner notification, not just for his fiancée's safety, but also for his own successful treatment and prevention of re-infection.
   • I explored his reasons for wanting to keep it private, acknowledging his fears about the engagement. I empathized with his difficult situation but stressed my professional obligation to prevent harm.
   • I offered support and resources for him to inform his fiancée himself, explaining that this was the preferred and most empowering approach. I gave him a timeframe (e.g., 24-48 hours) to do so, offering to help him find the words or even be present during the conversation if he wished.

2. Consultation with Senior Colleague/Ethics Committee (if available):

   • While maintaining Mr. K's anonymity in the discussion, I consulted with a senior public health physician within the health center. I described the general situation (a patient with a notifiable STI refusing partner notification due to personal reasons) and sought guidance on the ethical and legal protocols.
   • The senior colleague reinforced the public health imperative but also stressed the importance of empowering the patient first. They confirmed that if the patient refused to notify, and all efforts to persuade them failed, the public health authority has a legal and ethical mandate to intervene (often through a public health nurse or designated contact tracer, and always with minimal disclosure).

3. Attempted Patient-Led Notification & Contingency:

   • Mr. K was given the resources and time. He was initially reluctant but eventually, after a follow-up call, he agreed to try to inform his fiancée.
   • I scheduled a follow-up appointment with him specifically to discuss this, emphasizing that our priority was her health and safety, and his long-term well-being. I explained that if he genuinely could not bring himself to do it, we would have to proceed with anonymous or direct notification through public health channels, as mandated by law for notifiable diseases, while still protecting his identity as much as possible.

4. Resolution:

   • In this specific case, after much internal struggle and my continued encouragement, Mr. K did inform his fiancée. He returned to the clinic, distressed but relieved, stating he had told her everything. His fiancée then came in for testing and counseling.
   • This outcome allowed both principles to be upheld: Mr. K's autonomy was respected by giving him the opportunity to disclose, and public health safety was ensured through the notification and subsequent testing of his partner.
   • Had Mr. K refused, the resolution would have involved a carefully managed breach of confidentiality, guided by public health regulations, to ensure partner notification, with the least amount of identifiable information being shared as legally permissible. The aim would have been to shift from a voluntary patient disclosure to a mandated public health intervention, always prioritizing the minimization of harm.

This situation highlighted the tension between individual rights and community protection, a common theme in public health ethics. It underscored the importance of strong communication skills, empathy, adherence to professional guidelines, and the availability of ethical consultation when navigating complex dilemmas in practice.

Sample Answer

Ethical Dilemma in Practice: Patient Confidentiality vs. Public Safety

Context: I was working as a public health officer in a local community health center. My role involved a mix of direct patient care, health education, and community disease surveillance. The community was relatively small and close-knit, which sometimes meant that individuals knew each other well, increasing the complexity of maintaining strict confidentiality.

The Dilemma: A new patient, Mr. K, presented at the clinic with symptoms highly suggestive of a notifiable infectious disease (specifically, a sexually transmitted infection with significant public health implications if left untreated and allowed to spread). During the consultation, Mr. K disclosed that he was engaged to be married in a few weeks and expressed extreme anxiety about his fiancée finding out, fearing it would break off the engagement. He explicitly stated, "Please don't tell anyone, especially my fiancée. I'll get treatment, but I need to deal with this privately."

My ethical dilemma arose from the conflict between two core principles:

1. Patient Confidentiality/Autonomy: I had a clear professional and ethical obligation to maintain Mr. K's confidentiality, respect his privacy, and uphold his autonomy regarding his health information. Breaching confidentiality could erode trust in healthcare professionals and deter others from seeking necessary care.
2. Beneficence/Non-Maleficence (Public Safety): I also had a duty to protect public health and prevent the spread of infectious diseases. Notifiable diseases require contact tracing to ensure partners are informed and tested, thus preventing further transmission. If Mr. K's fiancée was not informed, she would be at risk of infection and could unknowingly transmit the disease to others, posing a significant public health risk, particularly given the impending marriage.