I am teaching a young nursing student who immigrated to the United States three years ago. She had the BCG vaccine as a child, and two previous purified protein derivative (PPD) tests were negative. However, her most recent PPD was positive (11-mm induration). Chest x-ray was negative. The patient was asymptomatic and refused isoniazid therapy for latent TB infection (LTBI). As a student, she will have clinical contact with patients in a hospital setting. LTBI is not on the list of reportable diseases. I am torn between maintaining patient confidentiality and my obligation to notify the nursing program of the student's condition. She specifically asked that no medical records be released without her written consent. —STEPHEN D. SYLVESTER, PA-C, Pearisburg, Va.
The reporting of communicable diseases is one of the few instances in which public good outweighs patient autonomy. The bioethical principle of autonomy is based on respect for others and the idea that patients should make their own decisions. The patient must understand the consequences of his or her decisions and make choices without controlling influences that would limit voluntary action. In this case, the patient is asserting this “right.”
The principle of justice involves ethical and legal concerns usually defined as a form of fairness. The reporting of communicable diseases is a form of justice because it considers what is fair to most rather than individual rights.
In this situation, counseling the student about the consequences of her actions is the most ethical thing to do. After that, the law and patients' rights prevail. —Claire Babcock O'Connell, MPH, PA-C and Jill Reichman, MPH, PA-C, associate director, University of Medicine & Dentistry of New Jersey physician assistant program (130-4)