Saturday, June 20, 2009

H1N1 (aka American flu) - naming...not shaming

The Sunday Times carried an article about naming those who have been infected. This was in the context of the German researcher from the Biopolis who had gone socializing and carried on normal activities even though he was not well.

Doctors have come out to defend the need for patient confidentiality. And they are right. It is wrong to name patients publicly because they are entitled to a certain level of confidentiality about their condition. I say a certain level, because this entitlement is not absolute.

The American Medical Association in their Code of Medical Ethics say:

"that the information disclosed to a physician during the course of the patient-physician relationship is confidential to the utmost degree. As explained by the AMA's Council on Ethical and Judicial Affairs, the purpose of a physician's ethical duty to maintain patient confidentiality is to allow the patient to feel free to make a full and frank disclosure of information to the physician with the knowledge that the physician will protect the confidential nature of the information disclosed. Full disclosure enables the physician to diagnose conditions properly and to treat the patient appropriately. In return for the patient's honesty, the physician generally should not reveal confidential communications or information without the patient's express consent unless required to disclose the information by law.
There are exceptions to the rule, such as where a patient threatens bodily harm to himself or herself or to another person"

The Singapore Medical Council Ethical Code and Ethical Guidelines states:

" A doctor shall respect the principle of medical confidentiality and not disclose without a patient’s consent, information obtained in confidence or in the course of attending to the patient. However, confidentiality is not absolute. It may be over-ridden by legislation, court orders or when the public interest demands disclosure of such information. An example is national disease registries which operate under a strict framework which safeguards medical confidentiality.

There may be other circumstances in which a doctor decides to disclose confidential information without a patient’s consent. When he does this, he must be prepared to explain and justify his decision if asked to do so."

So there are exceptions to the code.

The question here is whether the conditions here qualify to be exempted. In this case, the condition is not really life threatening, and although it was rather socially stupid and irresponsible to expose others to the risk if you think you are infected, this doesn't really go beyond being stupid and socially irresponsible. Naming is little more than a vindictive,punitive act.

On the other hand, it this were a really serious epidemic and a real risk of fatal consequences, then it might qualify for naming - not as a punitive act but for epidemic control.

For example, under current conditions, there is a real gap between exposure and effective contact tracing and quarantine/treatment. This gap can be in terms of days before the contact team can track down named contacts. This delay can be shortened if case contacts can self identify and come forward for advice/quarantine/treatment. But self identification requires that people know who the cases are and if they have had exposure to the case. In the case of the German researcher, I can only know if I have been exposed if I knew who he was and where he worked.

In the case of NUS' Prof Lee (reported in TODAY yesterday), he was only able to self identify because he could identify Case 73 by flight and seat details, and because of this, he was able to inform MOH and self impose home quarantine. If he had waited for MOH contact tracing team and track him down and serve the quarantine orders, there could well have been up to 2-3 days delay and otherwise preventable exposure to colleagues and family members.

We need to be mindful of the negative consequences of naming. Above all we should never do it out of vindictiveness. But we need to keep in mind the possibility that at some point in time (with some other epidemic) appropriate naming may actually save lives.


Clarence said...

seems that H1N1 is not as serious as it is, else why would the doc at TTSH refuse to screen me for H1N1 when I told him i had proxy contact?

I think it is not so much of the community mindset, but for the medical professionals (like yourself) to step out and make a stand on this.

If this doesn't warrant attention, and should be treated like seasonal flu, then no need to raise alarm. Fever can also be spread by close contact, but no one will be quarantined just cos he/she has fever. Do we take that kind of attitude, or not?

gigamole said...

yep, there are a lot of inconsistent approaches out there, mainly because of the conflict messages flying around the place.

Hopefully this will somehow blow over soon. Perhaps when we move to the mitigation stage, which frankly should occur any time really soon, things will be able to settle down to something a bit more reasonable and sensible.