DIFFICULT MORAL QUESTIONS
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Question 61: May a physician treat a wife’s syphilis without her informed consent?
Some years ago, in the days before AIDS, I was the only physician serving a remote, island community. The nearest hospital with surgeons and other specialists was in a city on the mainland, a half day’s trip from my clinic. Having been trained for family practice, I took care of everything I could. People always were reluctant to go to the mainland for care, and I sent them off only if they needed surgery or better facilities were essential for adequate diagnosis and treatment. While serving that community, I once had a case that seemed to me to involve a real conflict of duties, and I would like to know what you think of the way I handled it.
Since the islanders were culturally conservative and quite religious, I had been there more than three years before encountering a case of venereal disease. Then one of my patients, a married man, turned up with syphilis. The couple were middle-aged, and the man was quiet, hardworking, and generally a decent person. He did not know what he had, and, when the test results came back and I told him, he was reluctant to discuss how he could have become infected. Wanting to find out whether there were likely to be other cases on the island, I pressed him, and he finally told me. Four months before, while in the city for a few days on business, he had stayed with a wealthy friend, an old college roommate who had been recently divorced. Late one night while the men were drinking, two attractive young women arrived. Since the friend had arranged the party without asking him, my patient was caught off guard and, he shamefacedly admitted, he spent the rest of the night with one of the women.
I started the patient on the usual course of treatment with penicillin, explained the importance of carrying it through fully, and made a follow-up appointment. One problem remained—he probably had infected his wife. He was terrified that she would find out and seemed sincerely repentant. He swore he had not been unfaithful before or since, and never would be again. I believed he meant it. Fortunately, the wife was due to come in soon for her annual checkup. When I examined her, I found the typical chancre of first stage syphilis. Like her husband, she had no difficulty taking penicillin, so I also started her on the usual course of treatment.
I told her only that she had an infection that would have become very serious without treatment, but we had caught it in good time. As with her husband, I emphasized the importance of carrying the treatment through fully, and made a follow-up appointment.
While my explanation was true, it hardly provided the information I usually would have thought it necessary to give a patient. However, the woman asked no questions, and I expected that, if I told her the whole truth, she would draw the obvious conclusion that her husband had been unfaithful, and he would feel I had betrayed his confidence. Moreover, she was a fastidious woman and devoted wife, and I felt sure she would be devastated if she learned of her husband’s infidelity.
Analysis:
This question concerns conflicting duties: to preserve the secret confided by the unfaithful husband and to inform the wife about the infection as a basis for obtaining her consent to treatment. Neither duty is absolute. Consideration of the two duties’ grounds and their relevance in the situation suggests that the questioner’s solution probably was morally acceptable. However, the questioner should, but may not, have taken special care to forestall possible bad consequences of not fully informing the wife.
The reply could be along the following lines:
Someone might argue that telling the wife she had been infected with syphilis would not, strictly speaking, have betrayed the husband’s confidence, but would only have provided her with information regarding herself to which she was entitled—information only incidentally enabling her to infer her husband’s infidelity. However, while she was entitled to information about her condition, that right was no greater than your duty to inform her; and normally you would be breaking confidentiality in exposing a patient’s secret by giving a third party information from which it is likely to be inferred. The argument would err by focusing on one relevant duty and ignoring the other; and it seems to me you are right to think you had conflicting duties.
Still, neither duty is absolute, as consideration of their grounds makes clear.
Normally, you should keep patients’ confidences. Besides the basic obligation everyone has to protect others’ privacy by keeping their secrets, you have a special and much stronger professional responsibility. If patients had to worry about confidentiality, their communication with physicians would be greatly impeded, and effective cooperation requires free communication (see q. 70, below).
Normally, too, you should inform competent patients rather fully of your diagnosis and proposed treatment. They bear primary responsibility for their own health care, while your role as a physician is only to assist them. Patients usually need to be informed in order to make decisions both about their health care and other aspects of their lives—for example, whether to consult another professional, whether to accept the treatment you propose despite its impact on their lives as a whole, how meticulously to follow your directions, and whether to regard possible side effects or recurrent symptoms as indications that they must see you again. Failing to provide patients with adequate information generally is likely both to impede their efforts to deal with their health problems and to infringe upon their authority over their own lives, whose other dimensions they must integrate with their health, the proper object of your concern, and their interest in caring for it.
Though lying to conceal adultery would be wrong, married people who have been unfaithful without raising their spouses’ suspicions are not obliged to confess the infidelity to them.216 Moreover, the man’s reluctant admission to you is exactly the kind of thing patients are least likely to communicate unless they trust their physician. Thus it is the sort of secret in regard to which the duty of confidentiality is most relevant and most stringent. Then too, though you may have been wrong in assuming the wife would be devastated if she learned of her husband’s unfaithfulness, there undoubtedly was a significant risk of serious consequences for their marriage. So, it seems to me, you had good reasons to try to maintain confidentiality. Still, the course you adopted involved the risk that the wife would ask questions. Had she done so, you could not have lied, since lying is always wrong (see LCL, 405–12).
As it turned out, you were able both to keep the man’s secret and to provide appropriate care for your other patient, his wife. Even if you had told her more about her infection, she would have had no reason to see another physician or any realistic alternative to the standard treatment you offered, which, moreover, is not risky or otherwise difficult. So, it was not as important as usual to provide her with information about her condition. Therefore, the solution you adopted, in my judgment, probably was morally acceptable.
I say probably, because a patient treated for syphilis ordinarily should be warned to watch for symptoms that the infection has not been completely eliminated, and you also should have made the usual subsequent tests. I suppose that, in instructing the husband, you told him also to watch his wife for problems, and perhaps you remained on the island long enough to be sure the couple were entirely free of the disease. If not, contact the man and urge him to arrange tests for both himself and his wife. If he has died and she is still living, take whatever steps are necessary to ensure that she has received or receives adequate treatment, even if that requires informing her now of the nature of the infection.