Mr. and Mrs. Johnson were in many ways your typical suburban couple. They were in their mid-30s. Married for eight years, with two small kids.
Both worked full-time, it doesn't matter what they did for a living. But Mr. Johnson had a secret. On the weekends, about twice a month, he went down a local bar and picked up gay men. Both were patients of mine. I didn't know about his weekend escapades until it became a rather important ethical dilemma.
I didn't see either of them very often in my practice, mostly because they were both young and healthy. Then Mr. Johnson came in with some non-specific, flu-like problems. Those resolved, but over the course of the next few months, he was coming down with a host of medical issues. At first, I was able to deal with these problems individually, but soon a scary pattern was starting to form in my mind - why was this otherwise healthy middle-aged man so sick all the time?
I asked a host of question regarding his medical history. He denied just about everything. He claimed to be monogamous, and I had little reason to not believe him. Regardless, one of his blood tests came back with a surprising result - there was evidence that his immune system wasn't fully functioning, despite a recent infection. I asked if I could run an HIV test. He wasn't particularly keen on this idea.
I finally convinced Mr. Johnson that the HIV test would be a really good idea. He always came to see me alone - his wife was never with him. This is actually quite common and I thought nothing of it at the time.
Sure enough, the test came back positive. He had HIV. A follow-up confirmatory test was also positive. I had a tough conversation with Mr. Johnson ahead of me. I called him in for a visit so we could talk about the results of his tests.
After a long conversation, he revealed to me his weekend activities. He simply enjoyed the thrill of going out to pick up men. He didn't consider himself to be homosexual at all. He did admit that he was not careful with the use of condoms. There were multiple partners over the course of the last two years - at least a dozen different men by his best estimation.
Then I asked him how we were going to approach his wife with the information. After all, she had a right to know. But he absolutely refused to tell her. Moreover, he didn't want me to tell her - claiming that I had no right to violate his doctor-patient confidentiality. But she was also a patient of mine, and I have a responsibility to take care of her as well, especially in the face of a known and very dangerous condition.
I was stuck in a real dilemma. If I called the wife and told her without his permission, I was violating his privacy. If I remained silent, I was potentially risking her life. I sent Mr. Johnson home from that visit, after virtually begging him to reconsider his position. I offered to arrange any situation he wanted for him to be comfortable telling her - with my help, without it, or with the help of a counselor. He refused, saying that it would destroy his marriage and he didn't want that. Nothing I could say would change his mind.
I week later I got a call from Mr. Johnson. My ethical dilemma was solved. He had thought it over and decided to tell his wife. He wanted me there when he did it. Needless to say, that was not one of my happier days at work. She was ultimately tested and was free of the HIV virus. Sadly, their marriage did not survive.
Medical ethics can be a tricky issue. It's not always completely clear how a doctor should go forward or what steps are appropriate and which ones aren't. In this case, I "got lucky" in that Mr. Johnson changed him mind and made the right decision. But if he hadn't, I honestly don't know what I would have done. Mostly, I'm grateful that he did do the right thing in the end, if only for his wife and kids.
Written by Mark Riegel, MD
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