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By Tom Smith, Ph.D.
Introduction
HIV/AIDS is a treatable disease, but still a fatal disease; that is to say, there is no cure. This being the case, when one receives a diagnosis of being HIV positive it can be devastating. Seeking out counseling for this life changing circumstance can prevent a host of problems down the line. However, there are ethical issues that arise in the therapeutic relationship due to the nature of the disease.
Firstly, it is a disease associated with sex and intravenous drug use, modes of transmission that most people have difficulty discussing. Often the infected person is a member of a stigmatized group (being poor or indigent, gay, African American, a drug user, unschooled, etc.) that is even more marked due to having the disease. There are fears, biases and prejudice by all parties concerned that are both covert and overt. Additionally, health care providers might have a value system or countertransference issues that hinder or even rule out the possibility of working effectively with the HIV/AIDS client.
This course intends to address the laws and ethics and clinical complexities that surround treating the HIV positive individual. Keep in mind that what is right or ethical may not be legal and legal injunctions may not appear to be ethical. However, since the emergence of the disease over 25 years ago, codes of ethics of the various health disciplines, the laws in the various states, informed clinical judgment and common sense can help resolve ethical issues without too much handwringing.
Overview
Firstly, HIV/AIDS, the law and human rights are addressed, focusing on what are “good” and “bad” laws regarding infection, reporting, testing, transmission and treatment. Federal and California law are considered specifically with other state law regarding criminal statues listed. International issues regarding criminalization of HIV/AIDS and guidelines for human rights are discussed.
The above is followed by the specific codes of ethics of various professional disciplines regarding competence and limits of confidentiality in treatment of clients with HIV/AIDS.
Regarding counseling, the practitioner must be informed. One must know the laws and the ethics of one’s profession and be educated regarding transmission, infection, testing, treatment, properly informing partners who are vulnerable to being infected and how to prevent the transmission of HIV. Also, issues regarding informed consent, confidentiality (the system, partners, family, other practitioners), clarity regarding the duty to protect both the client and potential parties who are vulnerable to infection through sexual intercourse or intravenous drug use, duty to treat (this for the counselor would be providing psychotherapeutic services, emotional support, education, information, resources and referrals) and finally, the determination of the patient’s capacity (educational level, issues of reduced cognitive functioning, dementia, etc.) and the probability of suicide, including arguments for and against assisted suicide and reasons to offer palliative care are discussed.
We must also attend to the “special populations” which are Black and Latino women, youth, older adults and MSM (men having sex with other men). Data from the Center for Disease Control are presented. To quote the Fall 2008 issue of The Foundation for AIDS Research News: “Released on August 4 (2008) during the XVII International AIDS Conference, the report paints a picture of collective denial and inaction fueling a worldwide public health crisis. According to the report, the HIV/AIDS epidemic appears to be expanding significantly among MSM, but in many countries surveillance data remain scarce and funding for MSM-specific programs is inadequate or nonexistent. In addition, HIV services are rarely extended to MSM, and the human rights of these men are regularly threatened.” (author’s emphasis) It goes on to say that, “In the U.S., a new report by the Centers for Disease Control and Prevention shows that HIV infections among MSM have risen 75 percent over the last 15 years.” This statistic is staggering. Worldwide HIV among MSM is 19 times greater than the general population.
We conclude with a few simple steps to ethical decision making in the treatment of clients with HIV/AIDS.
References
The Newsletter of amfAR, The Foundation for AIDS Research, Fall 2008. amfar.org 120 Wall Street, 13th Floor, New York, NY 10005-3908