Sexually Transmitted Diseases
(STDs)
The ethical issues surrounding STDs have to do with partner notification, contact tracing,
and reporting requirements. Although reporting requirements vary somewhat from state to
state, certain diseases are reportable nationally such as syphilis, gonorrhea, and AIDS.
Herpes simplex is generally not reportable and there is no contact tracing for herpes. Contact
tracing is predominantly used to interrupt a cycle of transmission. Herpes cannot be
eradicated from the body; hence there is no utility in treating the partner. Gonorrhea and
syphilis, however, can be asymptomatically carried by the contacts of our patients and they
can be transmitted to additional partners even if the source patient is asymptomatic, In
addition, syphilis and gonorrhea can be eradicated (cured) with treatment.
For example, ‘Bob’ is a 32-year-old man in your clinic being treated for primary
syphilis. He is very embarrassed about his diagnosis and he asks you if his condition
will be kept confidential. What should you tell him?
Just because you must contact and treat partners of patients with STDs such as syphilis
does not mean you will breach his confidentiality and identify him as the source to his
contacts. There is a clear order of tracing and treating his sexual contacts. If there is a choice
that says “encourage him to notify his partners” or “ask if he has already told his contacts”
that should be the first thing to do. If that is not a choice, then you should offer to inform the
contacts for the patient if he does not want to do it. At all points you should be clear that you
will not contact his partners and say, “Bob gave you a disease.”
For example, Bob tells you that he is not comfortable informing his partners
himself and he does not want you to do it either. What should you tell him?
The Department of Health can compile a list of contacts of patients with STDs and notify
the contacts that they are at risk. The Department of Health does not divulge Bob’s name to
the contact. The Department of Health contacts the partners and says there is an important
health issue concerning them that has come to the department’s attention and then asks them
to come to the health department. When they arrive, the partners are told for, which disease
they are at risk, but they are not told the identity of the source. They are then encouraged to
seek testing and treatment. The majority of patients wish to be informed, tested, and treated
in order to protect their own health.
For example, Bob does not want to tell either you or the Department of Health the
names of his partners. He says he is monogamous now and, in fact, he is accompanied
by his pregnant wife. He has not told his wife of his condition. What should you do
now?
As always, you should answer “encourage him to disclose”, “offer counseling for partner
notification," or some statement that is gentle in terms of respecting the patient’s autonomy.
If these are not in the choices or the patient refuses then you must directly notify his pregnant
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wife immediately. Her testing and treatment is essential to protect both her own health as
well as to prevent perinatal transmission. Congenital syphilis is a serious and dangerous
disease but is entirely preventable.
For example, you politely inform Bob that you have a duty to protect both his wife
as well as his child and you are forced to notify her or have the Department of Health
notify her of her risk of syphilis if he will not do it. Bob becomes furious and threatens
to sue you if you violate his confidentiality. What should you tell him?
You are legally protected if you inform a person at risk of harm. In addition, there is a
duty to warn people at risk of harm. Bob can get as upset as he wants. You are not legally at
risk.