Ethical dilemmas in care for HIV infection among French general practitioners

doi:10.1016/0168-8510(94)00698-E

Health Policy

Volume 31, Issue 3, March 1995, Pages 197-210

https://doi.org/10.1016/0168-8510(94)00698-E Get rights and content

Abstract

A survey was carried out in May–June 1992, in the city of Marseille (South-Eastern France), to analyze attitudes towards ethical issues associated with the care of HIV-infected patients in a random sample of general practitioners (GPs) (telephone interviews; answer rate = 78.6%; n = 313). A total of 70.6% were consulted by HIV carriers and 48.9% regularly took care of these patients over the past year. Multi-dimensional analysis showed that support for HIV mandatory screening was related to lack of knowledge and experience with HIV infection, high perception of risks associated with HIV care, and the individual characteristics of GPs, such as religious beliefs and intolerance to uncertain situations. GPs with experience of regular care of HIV carriers had the same opinions than the rest of the sample about ‘creation of specialized hospitals for AIDS patients’ and similar attitudes toward HIV testing ‘without patients’ consent' or breaching of confidentiality of HIV diagnosis. Debates on ethical issues among GPs cannot be reduced to a simplistic division of a ‘liberal group’ highly involved in prevention and HIV care and a ‘conservative’ majority more or less inclined to stigmatize HIV-infected patients. Ambiguous messages on these issues from health authorities and professional ethical bodies may have very negative impacts on the attitudes of primary care physicians regarding the acceptability of HIV-infected patients.

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Citation Excerpt :
As a result, confidentiality loses its meaning in cases where lives may be endangered because of non-communication of information. In France, however, it has been shown that general practitioners are systematically hostile to the idea of breaking confidentiality (Moatti et al., 1995). In this country, medical confidentiality is, like the secrecy of confession, unqualified.
Confidentiality is essential for the establishment of trust between physicians and their patients.
The circumstances under which it is acceptable to young Kuwaiti for a physician to break confidentiality to protect the spouse of a patient with a sexually transmitted disease (STD) were examined.
A sample of 263 young Kuwaiti indicated the acceptability of breaking confidentiality in 48 scenarios that were all possible combinations of five factors: disease severity, time taken by the physician to discuss with the patient, the patient's intent to inform the spouse about the disease, the patient's intent to adopt protective behaviors, and the decision to seek the advice of an expert in infectious diseases before breaking confidentiality.
Through cluster analysis, four qualitatively different positions were found: Quite never acceptable (6% of the sample, mostly males), Depends on husband's willingness to inform (3%), Depends on husband's protective behavior (29%, mostly females), and Quite always acceptable (32%). The remaining participants did not express any clear view.
In Kuwait, students’ trust in the medical profession is, therefore, not likely to be seriously undermined if, from time to time, and in well-specified cases, individual physicians decide to break confidentiality when facing dilemmas of the kind examined in the current study.
Le secret médical est essentiel au maintien de la confiance entre patients et médecins.
Les circonstances à propos desquelles les jeunes Koweïtiens considèrent qu’il est acceptable pour un médecin de rompre le secret médical ont été examinées.
Un échantillon de 263 jeunes Koweïtien a jugé du secret d’acceptabilité de la rupture du secret dans 48 cas de figures représentant toutes les combinaisons possibles de cinq facteurs : la gravité de l’infection, le temps pris par le médecin à en discuter, l’intention du patient d’informer son épouse, l’intention du patient de protéger son épouse et le fait de solliciter l’avis d’un expert en infectiologies avant de rompre le secret.
Une analyse en cluster a permis de mettre en évidence quatre positions qualitativement différentes : Jamais très acceptable (6 % de l’échantillon, surtout des hommes), Dépend de l’intention d’informer (3 %), Dépend de l’intention de protéger (29 %, surtout des femmes), et Presque toujours acceptable (32 %). Quelques participants n’ont pas exprimé de position que l’on puisse caractériser.
Au Koweït, la confiance placée par les étudiants dans les médecins ne risque pas d’être sérieusement diminuée si, de temps en temps, et dans des circonstances particulières, certains médecins décident de rompre le secret médical pour protéger la vie d’une personne.
Is it acceptable for a psychiatrist to break confidentiality to prevent spousal violence?
2009, International Journal of Law and Psychiatry
When is it acceptable for a psychiatrist to break confidentiality to protect the wife of a potentially violent patient?
153 lay persons, 13 nursing personnel, 10 physicians, and 10 psychologists in France indicated this acceptability in 48 scenarios. The scenarios were all combinations of 5 factors: gravity of threat (death or beating), certainty of mental illness (certain or not), time spent talking with patient (considerable or little), his attitude toward psychotherapy (rejection, indecision, or acceptance), and whether the physician consulted an expert.
Lay people favored breaking confidentiality more than did nursing personnel or psychologists. Consulting an expert had greatest impact. Lay participants were composed of groups that found breaking confidentiality “always acceptable” (22 participants), “depending on many circumstances” (106), requiring “consultation with an expert” (31), and “never acceptable” (27).
Lay people in France are influenced by situational factors when deciding if a psychiatrist should break confidentiality to protect a patient's wife.
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Europe is currently experiencing the fastest rate of growth of HIV of any region of the world. An analysis of policy and health system responses to the HIV epidemic in Europe and central Asia (hereafter referred to as Europe) over the last 25 years reveals considerable heterogeneity. In general, while noting hazards of broad generalisations and the differences that exist across countries in a particular grouping, effective policies to control HIV have been implemented more widely in western than in central and eastern Europe. However, the evidence suggests persistence of inequalities in access to preventive and treatment services, with those at highest risk, such as commercial sex workers, prisoners, intravenous drug users, and migrants often particularly disadvantaged, despite many targeted programmes. Responses in individual countries, especially in the early stages of the epidemic, were influenced by specific cultural and political factors. Strong leadership and active involvement by civil society organisations emerge as important factors for success but also a limiting factor to the response observed in eastern Europe, where civil society or NGO culture is weak as compared to western Europe. Scaling up of effective responses in many countries in eastern Europe will be challenging—where increased financial resources will have to be accompanied by broader changes to health system organization with greater involvement of the civil society in planning and delivery of client-focused services.
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Occupational health is a major public health problem in France. However, the level of investment of general practitioners and specialist physicians in this field is not well documented. We aimed at studying elements moving closer or differentiating groups of professionals (notably physicians) in the field of occupational health in terms of conceptions of their roles (prevention and care) and of practices (in particular detection and notification of occupational diseases and perceived barriers).
We conducted a qualitative study in south-eastern France which consisted of in-depth interviews of physicians and actors involved in the prevention of occupational hazards or in their indemnification. Then discourse analysis was carried out on the corpus collected. Content analysis grouped the data into themes.
Several reasons could explain the low investment of physicians in the field of occupational health: insufficient detection of occupational causes of diseases, complexity of administrative procedures of declaration and bias of causal interpretation for the patients exposed to other risk factors such as smoking. The fear that notifying an occupational disease might have repercussions on patients' socio-professional situations places physicians in a situation of ethical dilemma: inducing a social risk on one side, ignoring his rights on the other. Physicians are not sufficiently prepared to deal with these situations, because they lack appropriate knowledge and support from specialists in the field, due to an important bulk-heading of actors and their practices.
To sensitize and train physicians to occupational health and to support multi-field practices are essential.
La santé au travail constitue un problème de santé publique majeur en France, mais le niveau d'investissement des médecins praticiens dans ce domaine est peu documenté. L'objectif de ce travail était d'étudier les éléments rapprochant ou différenciant divers groupes d'acteurs (notamment médicaux) dans leurs conceptions de leurs fonctions (prévention et prise en charge) et leurs pratiques (repérage, déclaration des maladies professionnelles, barrières perçues) vis-à-vis des problèmes de santé liés au travail.
Une étude qualitative a été conduite dans le sud-est de la France : 19 entretiens semi-directifs ont été réalisés auprès de médecins praticiens et acteurs de la prévention des risques professionnels et/ou prise en charge administrative. Les données recueillies ont fait l'objet d'une analyse de contenu de type thématique.
De nombreux freins peuvent expliquer le faible investissement des médecins praticiens en santé travail : le repérage insuffisant des maladies professionnelles, la complexité administrative des procédures de déclaration et un biais d'interprétation causale pour les patients ayant d'autres facteurs de risque, tels que le tabagisme. La crainte des répercussions de la déclaration d'une maladie professionnelle place le médecin dans une situation de dilemme éthique : risque social versus non-reconnaissance des droits du patient. Les médecins sont mal armés face à ces situations, en termes de connaissances et de recours possibles à des réseaux de compétence, du fait d'un cloisonnement important des acteurs et de leurs pratiques.
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These results are discussed within the framework of critical studies on mass media and studies discussing the links between experienced stigmata, stress and psychological distress. Some limitations of our study are also considered.
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Ethical dilemmas in care for HIV infection among French general practitioners

Abstract

Social Science and Medicine

Human Immunodeficiency Virus and the Acquired Immune Deficiency Syndrome in general practice

Journal of the Royal College of General Practitioners

Human Immunodeficiency Virus and the primary care physician

Journal of Family Practice

Primary care and HIV disease

Journal of General Internal Medicine

Primary care physicians and AIDS: attitudinal and structural barriers to care

Journal of the American Medical Association

Survey of general practitioners' attitudes to AIDS in the North West Thames and East Anglian regions

British Medical Journal

Understanding physicians' response to AIDS

Canadian Medical Association Journal

HIV infection and AIDS in Danish general practice

Scandinavian Journal of Primary Health Care

Attitudes, knowledge, and behaviour of general practitioners in relation to HIV infection and AIDS

Medical Journal of Australia

AIDS and Austrian physicians

AIDS Education and Prevention

Attitudes of health care workers towards AIDS at three Dutch hospitals

AIDS

Determinants of care for HIV-infected persons among French GPs

HIV infection and AIDS: the ethics of medical confidentiality

Journal of Medical Ethics

Physicians, AIDS, and occupational risk (historic traditions and ethical obligations)

Journal of the American Medical Association

Do physicians have an obligation to treat patients with AIDS?

New England Journal of Medicine