Traditional confidentiality for patients with AIDS

Reported here is the debate over AIDS and confidentiality that took place during the June 1987 conference of representatives of the British Medical Association's local medical committees (LMCs). At issue was a motion that general practitioners be told if a patient of theirs was diagnosed with AIDS or tested positive for antibody to the human immunodeficiency virus while under the care of a specialist, even if the patient opposed disclosure. Some conference participants maintained that disclosure would enable the general practitioner to better care for the patient with AIDS, while others argued that general practitioners had no right to know a diagnosis by another physician that a patient wanted to keep secret. After a lengthy debate, the LMC representatives voted to confirm the traditional policy on confidentiality, with the final decision on disclosure resting with the patient.     

AIDS and medical confidentiality

In summary, I have argued that the arguments offered or hinted at in favour of doctors' breaking medical confidentiality by passing on information about their patients' HIV state to others, including other doctors, when this is against the patient's considered wishes are generally unconvincing. Although in highly exceptional cases there may be justifications for overriding confidentiality, the requirement of medical confidentiality is a very strong, though not absolute, obligation. Patients, their contacts, doctors and their staff, and the common good are most likely to be best served if that tradition continues to be honoured.     

Legal limits of AIDS confidentiality

The author contends that reliance cannot be placed on the law to protect the confidentiality of medical data and identity of persons infected with the human immunodeficiency virus (HIV). He demonstrates how the law may be used to compel, justify, tolerate, and excuse disclosure of information. Dickens argues that, rather than enacting further legislation in an attempt to protect confidentiality, laws against discrimination in education, employment, housing, insurance, and access to medical care should be strengthened and enforced in cases involving persons infected with HIV.     

HIV infection and AIDS: the ethics of medical confidentiality.

An Institute of Medical Ethics working party argues that an ethically desirable relationship of mutual empowerment between patient and clinician is more likely to be achieved if patients understand the ground rules of medical confidentiality. It identifies and illustrates ambiguities in the General Medical Council's guidance on AIDS and confidentiality, and relates this to the practice of different doctors and specialties. Matters might be clarified, it suggests, by identifying moral factors which tend to recur in medical decisions about maintaining or breaching confidentiality. The working party argues that two such factors are particularly important: the patient's need to exercise informed choice and the doctor's primary responsibility to his or her own patients.     

对病人讲真话与保密的伦理思考

医生对病人讲真话是一种义务，也是尊重病人自主权的表现，但是，在中国的传统文化背景下，对某些病人保密而仅对家其家属讲真话，这与对病人讲真话发生了矛盾，也与病人的自主权发生了冲突。然而，这种矛盾和冲突，可以得到伦理的辩护，也可以得到中国现行法律的支持，尽管如此，也应该逐渐改变。     

Survival trends for patients with AIDS

To evaluate trends in the length of survival for patients with acquired immunodeficiency syndrome, we calculated survival following diagnosis of acquired immunodeficiency syndrome for 4323 cases reported in San Francisco, Calif, between July 1981 and December 31, 1987. Patients were followed up prospectively through December 31, 1988. The median survival for all patients was 12.5 months, with a 5-year survival rate of 3.4%. Significantly improved survival was observed for patients diagnosed with Pneumocystis carinii pneumonia in 1986 and 1987. Survival for patients diagnosed with Kaposi's sarcoma declined significantly between 1981 and 1987. Survival was unchanged among patients diagnosed with other opportunistic infections or malignancies. Proportional hazards analyses indicated that initial diagnosis, age, and year of diagnosis were significant predictors of survival. For a subset of patients (n = 644), therapy with zidovudine was an additional significant predictor of survival. This study suggests that survival following diagnosis of acquired immunodeficiency syndrome has improved in recent years, primarily among patients with carinii pneumonia. Therapy with zidovudine may be partially responsible for these recent improvements.     

国外艾滋病社区支持模式的比较分析及其对我国的启示

建立适宜的艾滋病社区支持模式,将有利于解决HIV感染者/AIDS患者难以获取有效的医疗卫生服务所产生的问题,有利于减轻一些流行严重地区医疗卫生部门不堪重负的情况,有利于改变人们对艾滋病感染者的歧视态度,从而减少艾滋病的传播。通过对国外艾滋病社区支持模式的比较分析,探索适合我国国情的艾滋病社区支持模式。     

艾滋病19例死亡原因分析

目的分析艾滋病的死亡原因,以改进防治措施,降低病死率。方法对我院收治的19例获得性免疫缺陷综合征（AIDS）的死亡患者进行回顾性分析。结果19例AIDS死亡患者CD4＋T细胞计数平均为（48.30±46.47）cells/mm3,可同时合并多种机会感染,63.16%的患者死于呼吸衰竭。结论呼吸衰竭是HIV死亡的常见原因。     

艾滋病患者的疾病不确定感与社会支持相关性分析

目的 探讨艾滋病患者的疾病不确定感与社会支持的相关性.方法 采用由Mishel设计的住院患者疾病不确定感量表(MUIS)和由肖水源设计的反映患者社会支持状况的社会支持评定量表(SSPS)对艾滋病患者的疾病不确定感和社会支持的相关性进行分析.结果 艾滋病患者的疾病不确定感普遍处于较高水平,与社会支持呈负相关.结论 临床护理中应注重患者疾病不确定感和社会支持之间的内在联系,更好地服务患者.     

Limits of confidentiality.

A patient is described, a woman of 60, who at that age was diagnosed as having Huntington's chorea, a genetic disease which is transmitted as an autosomal dominant. She had one daughter, who was married and lived abroad. The patient's mother and maternal aunt, it emerged during the consultations, had had the disease, and shortly after the diagnosis had been made the patient's sister was admitted to hospital with a repiratory condition, and in the course of treatment Huntington's chorea was diagnosed in her also. She had one daughter. Throughout, the problem was not only that of treating the patient herself, but the situation of all those of the family affected in any way. The patient's husband had not known of her medical history at the time of the marriage. At no time had the daughter been told. The discussion, in which seven doctors, a moral philosopher, and a social worker took part, centered on the basic issue of confidentiality in the case of a disease, from which would stem problems for the affected family through several generations. All were agreed that in these circumstances those affected must be told, but differed as to who should make some of the subsequent decisions. Some thought that having told of the diagnosis and its implications, the doctor should leave further decisions to those concerned; others that in a disease such as Huntington's chorea one is looking at part of a whole chain of genetic material, and, although the individual patient or potential patient is of course important, he or she must be seen in the genetic setting of the community. The participants also considered the psychological.     

Radiologic diagnosis for AIDS patients complicated with candidal esophagitis

Background  Candidal esophagitis is the primary infection among all digestive tract opportunistic ones in acquired immunodeficiency syndrome (AIDS) cases. X-ray manifestation reports of it are still rare. This study aimed to conduct a retrospective analysis on the X-ray data of 6 AIDS cases complicated with candidal esophagitis, and to study the X-ray characteristics of it combined with the findings from gastroscopy.

Methods  Among 6 cases in this series, all cases were confirmed by Shenzhen Center for Disease Control and Prevention (CDC) to be HIV positive and all of them had CD4 cell counts less than 150×10⁶/L. All cases underwent X-ray and gastroscopy, and mycelium were found in the mucous membrane of the esophagus.

Results  In this series, the findings of the X-ray were as follows: (1) Affected areas: Four cases in the whole esophagus, 2 cases in the middle and lower part of esophagus; (2) Abnormal motivity: Six cases had decreased tension, loose walls, weakened peristalsis, decreased number of peristalsis waves and delayed emptying of barium; (3) Abnormal contour: Six cases had the sign of “decorative border” or “brush”, two cases had narrowed canal; (4) Abnormal membrane and “cobblestone sign”: Six cases had thickened membrane and “cobblestone sign” on the surface of the abnormal membrane. The hyperemia of mucosa was covered tightly with yellow-white pseudomembrane spots. This was in accordance with the small cobblestone-like filling defect found by X-ray.      

Conclusions  If the AIDS cases have dysphagia, and X-ray shows that more than two sections of the esophagus are affected, with decreased motility, the walls in the sign of “brush” or “decorative edges”, thickened membrane with “cobblestone sign”, candidal esophagitis is highly possible.

     

Changing practice on confidentiality: further points for discussion

In the March 1982 issue of the Journal Dr Pheby, a community health doctor, was one of several writers to discuss medical confidentiality. Dr Pheby urged doctors to minimise subjective and judgmental comments in medical records and to make clear when their assessments were speculative. He also urged `vigorous reappraisal of the extent to which information about a patient needs to be circulated' to members of other disciplines, for instance, in child health practice. If doctors did not take such steps themselves legal changes might well be imposed upon them, giving patients the right of access to their medical records and perhaps making breach of medical confidentiality a criminal offence.

Mr Jacob, a lawyer, commenting on the papers by Dr Pheby and Mr Kenny, a health administrator, argued that increased legal intervention in medical ethics could quite possibly actually erode traditional medical ethical standards of confidentiality based on peer review and `the ethic of virtue'.