Scenario for Analysis

Ellen P. is a social worker specializing in chronic medical problems. For several years she has been running a support/therapy group for people with chronic medical problems. The group often receives new members from people Ellen has seen first in individual counseling. Her group has instituted a rule that prohibits members from having romantic relationships with other people in the group, a rule that Ellen has championed for a number of important clinical and boundary reasons. Recently, a member of the group, Gary G., has stopped attending without providing the group or Ellen with any reason for his departure. Shortly after this, another member of the group, Jill C., also drops out of the group and asks to start seeing Ellen again in individual counseling for some “urgent things that have come up.” In the first individual session, Jill reports to Ellen that Gary had dropped out of the group because he wanted to begin a romantic relationship with Jill. Jill has since begun to date him, and they have gone out on a couple of occasions. Ellen is concerned, because, although Gary has acknowledged to the group that he has Hepatitis C, he did not disclose that he also has HIV. Ellen, however, is aware of his HIV status, since the information was disclosed in Gary’s individual sessions. Ellen is aware that, if the couple becomes sexually active, Gary’s HIV status holds serious risks for Jill. What are the leadership and ethical responsibilities here, and how should Ellen address them?

Scenario Purpose and Key Issues

Highlight need for expert knowledge in key areas

Highlight difference between legal and ethical dimensions

Highlight competing interests and principles of ethical decision making process

The leadership issues in this scenario will be very straightforward, and will be found in the Knowledge Stage of the ethical decision making process. It is important for a mental health clinician working with medical problems to be aware of the latest legal rulings with regard to confidentiality and protected categories of clients.

In this scenario, Gary is HIV+, and therefore falls into a category of clients with special rights with regard to confidentiality. In order to protect the integrity of the counseling profession, the clinician is under special obligations to protect the right to confidentiality that Gary is granted with this special status.

On the other hand, there may also be imminent risk of life-threatening harm coming to Jill if she engages in unprotected sexual relations with Gary. This imposes certain demands upon a clinician to break confidentiality in order to protect the life and safety of a client.

Adding another level of complexity to this scenario, it is very likely that Ellen could be sued whether she discloses Gary's HIV+ status. Jill could sue Ellen if she does not disclose, and Gary can sue her if she does! Outcomes for either law suit would be uncertain, given the current state of case law in this arena, and depending upon the venue in which the suit came to trial.

It is extremely important - when faced with a situation of this complexity - to have great clarity about the most current laws and statutes with regard to confidentiality and protected classes of clients. These laws may vary slightly from state to state, and may change without the clinician being aware of the change.

It may, on occasion, be necessary to request the advice of an attorney who specializes in this kind of law, so information may be current. This understanding of one's own limitations and the willingness to utilize other resources as a system of back-up operate in accordance with the idea that a good measure of humility is required to perform ethical practice.

There is, however, another issue here. As we have mentioned, the legal and ethical realms are not exactly the same. Whereas there is not a clear legal solution to this, the ethical solution may be easier to find.

In looking to identify our competing interests and principles, the first principle has to do with protecting the client from harm. This principle is even more important than protecting the integrity of the profession, under which guidelines for maintaining confidentiality are found. Even with the advent of better medications for treatment of HIV/AIDS, the harm that would come to Jill from possible transmission of HIV would in all likelihood outweigh Gary's right to confidentiality. A more ethical course would like be to place safety above confidentiality.

Ellen, of course, would first like to look for options in which both principles are followed during the identification stage of the ethical decision making process. She could, for instance, try to gather information from Jill about whether Gary has told her of his HIV status. She could also contact Gary to tell him of her intention to disclose to Jill his HIV status, and try to convince him to reveal this information first.

Ellen, however, will not necessarily have too much time in which she could explore the possible options. Once Jill reveals her information, Ellen would need to proceed very quickly to actions to address the dangers involved to her client. Experts, in their leadership role, need to accept the demand for quick decision making, and the responsibility and accountability that follow these decisions.

Ellen may want to discuss her difficult choice with another experienced clinician, who might be willing to share the burden of decision making. The choice, however, will still primarily be Ellen's, and it would be a difficult choice indeed. While patience may be useful as a leadership tool in other scenarios, in this one decisiveness is more important.

The primary purpose of adding this scenario was to highlight the very real importance of keeping abreast of changing information of which every clinician is expected to be aware. HIPAA guidelines have recently been put in place in a number of areas related to clinical practice. Each mental health clinician will be expected to have expert knowledge in every area as outlined in the HIPAA standards.

This expectation of expert awareness is a very heavy burden in terms of continuous learning. Just as the process of working through every ethical dilemma is a living, moving thing, so is the process of staying continually abreast of changes in information.

Without a willingness to accept the responsibility for staying abreast of these changes, however, the clinician will find him/herself unprepared to respond quickly to emerging ethical difficulties where decisiveness is needed to protect the well-being of the client.