The HIV-Positive Health Care Worker - Should Their Employer Be Informed? University of Missouri - St.

Louis NS3804 Ethical and Legal Dimensions of Nursing Practice Adrienne Hurst

Abstract The following paper is going to focus on whether or not HIV/AIDS infected health care workers should be obligated to inform their employer of their positive status. Focus will be placed on a particular case study in which heightened exposure could have been reduced, and multiple health care workers could have taken better precaution, if divulgence of test results had been mandatory upon employment. Virtue ethics will be used to analyze and discuss the rules that summarize the obligations health care workers hold to not harm patients. Nursing virtues such as moral courage, practical reasoning, and justice are those that pose as the strongest virtues used to defend against this information being withheld from employers and co-workers alike. Virtue ethics also sees moral considerations within the community of nursing as practical concerns that arise to consider how to promote mutual human welfare, growth, and meaning in their particular communal contexts (Volbrecht, 2002). In the end, it will come to the conclusion that, statistically speaking, the odds of transmission of this blood borne disease is too low to make testing, and divulgence of the results, mandatory to each and every health care worker.

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The HIV-Positive Health Care Worker - Should Their Employer Be Informed? Introduction HIV-related stigma is one of the most formidable obstacles facing people living with HIV and their advocates, including peers and co-workers. Stigma is defined as a mental or physical mark that is characteristic of a defect or disease. HIV-related stigma is a significant public health problem; it creates very real obstacles for people living with HIV in obtaining treatment, housing, education, and employment, all of which are essential to their health. Because HIV is very much stigmatized, confirming or disclosing ones HIV status is still widely perceived as socially dangerous. This stigma often has a tendency to discourage testing, and has played a major factor in determining whether or not states have passed laws to make testing upon employment mandatory. As of March, 2008, The Center for HIV Law & Policy reported that not one single state has decided to make testing of health care workers mandatory. They have, however, put limitations on the procedures that may or may not be allowed to be performed by those that are positive with HIV/AIDS. These restrictions are state legislated, but decided by the individual whether or not he/she feels it is a good idea for them to carry on with the performance of them. Therefore, if a health care worker decides not to inform their employer that they have the disease, they will not be allowed to refuse to proceed with the task and will be placing the patient at a higher incident of exposure.

Case Study A 27 year old female paramedic goes unresponsive and codes in a clients home during a routine 911 call. Upon arrival to the ED, CPR is in full progress. She is accompanied by multiple city workers, paramedics, firefighters and police. Among those are her boss, partner, mother and immediate family. The ED staff continues CPR and works to do everything they can to save her life as not only a patient but a friend and peer. The patient is intubated and put on the ventilator. Due to the injury suffered to her heart, she develops severe, culminating pulmonary edema which is now spewing from her lungs, making ventilation difficult. A foley catheter was put in. Multiple peripheral IV lines are put in by the nursing staff as well as a central line to her groin, which will be utilized for maximum fluid replacement and specific medication administration. The rapid infuser was initiated to maintain proper blood/fluid volume by running in fluid and pints of unmatched blood products. She is prepped by the surgery team for emergency placement of a chest tube, used to relieve her left sided pneumothorax that she acquired from aggressive chest compressions. The environment was hectic. Specific safety violations may or may not have occurred as a result of the team trusting the fact that because the patient was considered one of their own, it was not necessary. Multiple body fluids were scattered about the trauma room. At one point, the patient was taken off the ventilator and bagged by the respiratory therapist. Upon removal of the endotracheal tube from the ventilator circuit, the pulmonary edema erupted from

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the patients airway and into the face of the therapist. This young lady was cared for intently in the emergency department for hours before being rushed to the cardiac cath lab and placed in the intensive care unit. Her care continued in the ICU for several weeks until she eventually suffered multi-system organ failure, sepsis, and death. This was an otherwise healthy, fit, young adult. She did not smoke, drink alcohol or use illicit drugs. She was both a high school and college graduate. She was raised in a home with both parents who were still married and all members were active in their church. She had been married but already divorced. She had a 4 year old daughter. Her past medical history was significant for asthma, seasonal allergies and HIV. The HIV was confirmed during the time the time of her pregnancy. Her sister was the only one aware of this diagnosis. This pertinent medical information was withheld from the hospital staff until three days after her admission to the ICU. Identify the Problem The first ethical problem identified in this case is the apparent lack of principle exhibited by the health care team simply due to the fact that they felt a personal connection to her. Prejudice to the fact that she was free of disease simply because she worked in the medical field and with the team taking care of her, led to them believing that they had a right to put their guard down, placing them at increased risk of infection and disease. Being careless with medical instruments, not wearing proper isolation equipment and doing tasks beyond

their scope of practice was ignored because of this. The second ethical problem that is identified as a cause for concern, and has become the focus of this paper, is the lack of knowledge by so many people of this patients very serious health history. The stigma that comes along with living with HIV caused this patient to inadvertently place everyone caring for her at greater risk for contraction of the disease. The majority of fault falls on the healthcare team for being negligent, but for the sake of argument of this paper, we will be analyzing the problem of non-divulgence of health history/information to the employer of the patient. The involved parties include the patient herself, her employer, and the health care professionals that risked their lives to save hers. Virtuous characteristics of focus include moral courage, practical reasoning and justice. Analyze the Context The critical factors used to understand the case and resolve the problem focus on this patients autonomy and stigmatic factors that would cause her to withhold valuable medical information. There are cultural aspects within the health care community that make individuals feel as though they will be separated from the group if others know they are walking around with a life threatening illness. Friends that could have been made do not open up to people if they fear contraction of the disease. Distance grows between co-workers and help to the infected person is put off, which may or may not become detrimental to the clients they are caring for. Legal aspects regarding mandatory HIV testing

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for all health care workers arose in 1991 and 1993 in response to a Center for Disease Control (CDC) directive. Although there were legitimate reasons for bringing this to the attention of the CDC, it has been solidly confirmed that the limited ways in which HIV is transmitted poses little to no threat to health care patients. In 2000, Professor Larry Gostin called for a revision of the national policy restricting the practices of HIV-positive health care workers, concluding that such a policy is not necessary because of the little risk of transmission and that, because of stigmatization, health care workers might avoid or delay testing, or leave the medical profession altogether (HIV Law & Policy, 2008). Political aspects arise when the infected person begins to look at the situation as a violation of the Health Insurance Portability and Accountability Act (HIPAA), which protects the privacy of individually identifiable health information (HHS, 2012). Explore Options A few options come to mind when exploring ways to handle these types of situation. The option of mandatory HIV testing first comes to mind because it seems to be the most obvious, legal way to make it known. However, as mentioned before, this is not feasible and/or deemed necessary as stated by the CDC. Although all of the options include disclosing the information to someone, it is more specific as to whom the information is given and in what context. Upon finding out she was positive for HIV, she could have talked more in depth with her physician about the stigma associated with the disease and how greatly it was

going to affect not only her lifestyle, but her work. She could have obtained more sound advice and ways to cope. They could have discussed with whom this information should be shared. A trusting family member and/or pastor would have been helpful in this case as they were all present from the time of her arrival to the ED. The patient could have given these people specifications as to situations in which it would be pertinent to divulge the information, such as this one. As the main topic of this problem analysis, the patient should have informed her employer upon hire. This doesnt mean that everyone in her unit should be informed, just her chief. In a situation such as this, where a community health worker is injured or falls ill on the job, the chief is always present at the scene as soon as he/she is made known of the situation. Had he/she known that one of his medics was working with HIV, he could have told the doctors at the ED before family arrived - protecting both the health care workers from higher risk of infection and the patient from embarrassment or shame to their family and friends. In this situation, the patients HIPAA rights were not violated and the safety of the professionals taking care of her was maintained. Apply the Virtue Ethics Decision Process The health care community is the only community important to the topic under analysis. In this case, that community includes the patients work community of paramedics, all of the nurses involved in her care, as well as every

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other specialty group (respiratory, radiology, PT/OT, patient care technicians, etc.), and each and every physician from the time of her entry into the emergency department. The moral considerations of non-maleficence (not inflicting harm unto our patient) and beneficence (promoting the well-being of others) are among those that this patient should have considered upon being diagnosed with HIV. The increased risk of exposure of a fatal disease to her clients puts them at greater risk for harm and does not promote their well-being, but further expose it to something lethal. Three relevant virtues come to mind as the most appropriate to apply to the context of this case. The first, moral courage, is defined as the willingness to risk personally in the effort to protect patients safety and to promote patient well-being (Volbrecht, 2002). The second relevant virtue, practical reasoning, can be defined as the ability to identify relevant moral considerations within the context of particular situations, and to actively interpret and adapt these considerations to new situations (Volbrecht, 2002). And lastly, justice, is defined by Volbrecht as giving what is due to each person including equal respect and promotion of patient well-being. Being able to adapt her new diagnosis with her work and patient care by identifying her moral character of being the best person she could be for herself and her community, and looking past the personal risks of divulging this information to someone, may have worked to promote the safety and well-being of every one of her patients, peers and co-workers, past, present, and future tense.

Implement a Plan and Evaluate the Results The plan that I am most in favor of implementing is that which mandates health care workers to be tested for HIV and if positive, inform their employer. It promotes the value of virtue ethics by exhibiting the character of honesty and implementing that of moral truths. It sets aside our own individual feelings of shame and regret and puts the respect of patients and their well-being first and foremost. It enhances a sense of community by forcing everyone in the health care field to follow the same rules and look within themselves for the same characteristics. Although evaluation of the results of this plan look to be harmful to the number of emerging health care professionals, it forces them to be more conscious of their decisions before they decide to become part of such a strong, trustworthy, and important community. Conclusion Living with HIV as a health care worker is a very difficult thing to face. Although the Center for HIV Law & Policy does not govern health workers to inform their place of work their health status, there are principles in effect that say an HIV positive person has the responsibility not to infect or put another person at risk of infection. Under civil law a person may also be sued for damages by an infected person, for deliberately, negligently, or recklessly infecting them (HALC, 2008). The laws of each and every state do, in fact, say that any health care worker who performs exposure prone procedures will not be allowed to perform these procedures if testing positive for HIV. How, then, is one expected to go

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about doing this without informing their employer? If you abide by the law and make the obligation to your community to not perform procedures where there is potential for contact between the skin of the infected person and any sharp surgical instruments, needles, bones, or confined body sites, like the mouth (HALC, 2008), how can you get away with not telling your place of employment? Patients hold an undying trust in the individuals who take care of them, and by being honest with yourself and your employer, regardless of the level of humiliation, you become a bigger, better person than they ever deemed possible.

We[Heads of State and Government and representatives of States and Governments participating in the comprehensive review of the progress achieved in realizing the targets set out in the Declaration of Commitment on HIV/AIDS] commit ourselves to intensifying efforts to enact, strengthen or enforce, as appropriate, legislation, regulations and other measures to eliminate all forms of discrimination against and to ensure the full enjoyment of all human rights and fundamental freedoms by people living with HIV and members of vulnerable groups, in particular to ensure their access to, interalia, education, inheritance, employment, health care, social and health services, prevention, support and treatment, information and legal protection, while respecting their privacy and confidentiality; and developing strategies to combat stigma and social exclusion connected with the epidemic. -Handbook on HIV and Human Rights for National Human Rights Institutions

References Center for HIV Law & Policy, The. (2008). Guidelines for HIV-Positive Health Care Workers. Retrieved from http://hivlawandpolicy.org. Handbook on HIV and Human Rights for National Human Rights Institutions. (2011). HIV and Human Rights and International Standards. Switzerland. Office of the High Commissioner for Human Rights. HIV/AIDS Legal Centre (HALC). (2009). Disclosing Your HIV Status. Retrieved from http://www.halc.org.au. U.S. Department for Health and Human Services. (2012) Understanding Health Information Privacy. Retrieved from http://hhs.gov. Volbrecht, Rose Mary. (2002). Nursing Ethics: Communities in Dialogue. New Jersey. Pearson Education LTD.