Ethical and Legal Aspects of AIDS Psychiatry

From confidentiality, contact notification, and disclosure to decisional capacity, advance directives, and end-of-life care, AIDS presents special bioethical challenges to caregivers. Stigma, fear of rejection, and discrimination play significant roles in the bioethical aspects of the care of persons with HIV and AIDS. As a consequence, caregivers are often faced with bioethical dilemmas and conflicts. While many persons with HIV and AIDS are comfortable with disclosure to partners and family members, some persons with HIV refuse to disclose their serostatus even to sexual partners. Many persons with HIV and AIDS are able, especially with support, to come to safer and healthier decisions about disclosure and about their health and medical care. In this chapter, we will explore these dilemmas and provide suggestions on how to deal with them. Strategies for dealing with ethical dilemmas, determining decisional capacity, addressing end-of-life issues, and maintaining confidentiality in the care of persons with HIV and AIDS are also presented. To begin a discussion of ethics as applied to clinical care, it is important to define the terms used in this context. The definitions of the terms used in this chapter are based not only on formal definitions as published in bioethics texts and articles but also their use in common medical practice. Table 13.1 provides definitions of some of the bioethics terms that are relevant to this discussion. Within the doctor–patient relationship, physicians are expected to understand and relate to their patients as their own primary decision-makers. Patients are presumed to be autonomous and to have decisional capacity. However, at times, decisional capacity can be called into question, such as when a medical condition impairs the patient’s capacity to understand the illness or results in impaired judgment. Since autonomy is such a protected right, multiple criteria must be fulfilled in order to substitute another person’s judgment for that of the patient in cases where the patient is unable to make an appropriate decision for him- or herself. This assessment is called an assessment for capacity and is specific for each decision—a separate assessment must be performed for each decision to be made if the patient’s decision-making ability is under question.