One further issue from this case - what about the issue of consent generally
? I know the patient specified she didn't want to be tested, but shouldn't
the clinician have refrained from requesting HIV testing ? And what about
laboratory policy ? Is consent implied from reception of the request card,
or do any laboratories require a copy of written consent prior to analysis ?
Philip Hyde

-----Original Message-----
From: g.challand [mailto:[log in to unmask]]
Sent: 04 June 2001 16:12
To: [log in to unmask]
Subject: Summary, Case 100 for Comment



To celebrate the 100th Case, an ethical dilemma.

A 21 year old married student nurse attends the antenatal clinic at 16
weeks' pregnancy for routine screening tests. She specifies that she does
not want to be tested for HIV, and this is clearly written on the request
card.
Owing to an error in specimen reception, this information is not passed to
Virology, who perform HIV testing as part of antenatal serology. The HIV
test is positive.

What is the appropriate action?

This real scenario attracted 47 participants. I particularly liked 'you
rotter, Gordon' (thank you Angela); 'Nasty one, Gordon' (ditto Mike), and
'You certainly didn't waste time finding the biggest Pandora's box' (ditto
Steve).

The problem involves both ethical and legal considerations. Although the
ethics are the same, the legal situation in different countries is
different, particularly in the balance between the individual's right to
privacy and the public's right to know. I have therefore not asked my
assessors to give formal marks, but insted give my own interpretation based
on a current reading of English law and my own ethics. From a legal
position, the laboratory has already committed a crime of battery - a type
of assault against the subject.

3 participants would obtain a new sample (using any excuse) to confirm HIV
status before doing anything else (this is both unethical and illegal!)

11 participants would pass the problem on to someone else: 5 to Head of
Virology, 4 to the Hospital's Medical Director; 2 to the Clinical Director
of Pathology.

20 would seek further advice: 10 from the Hospitals's legal department, 7
from the Consultant Obstetrician, 2 from a Medical Defence Society, and 1
from the Chairman of the local Ethics Committee.

5 would simply report the result to the requester, apologising for the
mistake, and leave further action to him (I think this is ducking the
issue!).

8 participants would destroy the result and any evidence that it existed.
Although superficially attractive and apprently in line with the subject's
wishes, I do not think that it is so simple. One cannot simply put the
result back in the sample bottle. A crime has been committed, and to conceal
evidence of a crime is itself a crime. Falsifying records is certainly not
good laboratory practice, concealing evidence of a serious transmissible
disease is professional misconduct for all of us, and there is a clear
clinical duty towards the subject, her baby, her husband, and to the medical
team looking after her. Furthermore I certainly would not like to appear
before a formal enquiry 5 years down the line, set up to investigate why a
nurse who has developed AIDS was allowed to work in a high risk of
transmission area of the hospital. If I told the truth, it is likely that a.
I would be struck off my professional register, b. that I would be
personally sued by everyone who has been in contact with the nurse and is
shown to have positive HIV status, c. I would be pilloried through every
national newspaper, d. I would be charged with an attempt to pervert the
course of justice by concealing evidence of a crime. I therefore think this
is highly inappropriate action.

4 participants would ask that the subject be further counselled/ pressurised
in an attempt to persuade her to have the test. I think this is unethical,
and what do you do if she refuses?.

10 would see the subject, explain how the error occurred, and apologise for
the mistake (4 mentioning the importance of involving a trained counsellor).
This is the only course of action.
2 participants would then ask her if she wanted to know the result. I think
this is unethical (what do you do if she says no?) and does not get one out
of the legal dilemma.
12 participants would then tell the patient the result. This is also the
only appropriate course of action. By doing so you can be sued by the
subject (but to win, she would have to prove damage which might be difficult
except in terms of mental anguish and possible damage to her future nursing
career).

6 participants mentioned the importance of subsequently following laboratory
policy for action after mistakes/ serious critical incidents have occurred.

1 participant would sack the specimen reception worker who made the mistake
- if we all did this for mistakes in specimen reception, we'd soon run out
of specimen reception workers in the UK!

This is a sad moment, because this concludes Cases for Comment in their
present form. Registration forms for the EQAS for interpretative comments in
clinical chemistry are now available through [log in to unmask]
<mailto:[log in to unmask]> , and will soon be distributed through this
mailbase. This new EQAS I hope will go live shortly.

It has been an interesting three years, and I have certainly learned a lot
from it. However I have to say that if I had known what Cases for Comment
would lead to, I would not have had the courage to start; and if I had known
how much work would be involved, I certainly wouldn't have started! But many
thanks to my collaborators Li Ping and Jacquie Osypiw, to all the assessors
who took on a thankless task without complaint, and most of all to all the
participants who have provided me with (almost) unending support.

Best wishes to all
Gordon