Mandatory HIV Testingfor Healthcare Workers: Is it Ethical? by Debbie Marie Beck, RN, MS
The AIDS epidemic has caused hysteria among the public and concern to many healthcare
Debbie Marie Beck, RN, M S , is a member of the clinical nursing faculty, University of Detroit/Mercy and House Supervisor, St. John Hospital, Mt. Clemens, MI.
workers in the past 12 years. Currently,
mandatory testing ethical? The author explores
S i n c e 1981 the AIDS epidemic has caused hysteria in the public sector and concern to many healthcare workers. Currently, legislation exists for mandatory AIDS testing in some populations but is not required of healthcare workers. The public is pushing hard for mandatory testing of healthcare workers to become a reality. Yet many ethical issues must be explored before we conclude that mandatory testing should be subject to routine.
the incidence and prevalence of AIDS among
Incidenceh'revalence
healthcare workers, discusses why mandatory
Between 800,000 and 1.2 million people in tlus country are now infected with the AIDS virus. More than 121,645 cases have been diagnosed in the U.S. and more than half of the dected have died (Centersfor Disease Control, 199Ob). Despite recent evidence that indicates a reduced incidence among homosexual and bisexual men and transfusion recipients, the incidence of AIDS continues to increase among heterosexuals via needle sharing, in partners of intravenous substance users, and partners of bisexual men (kkmann, Fahey, Gerberchg, & Henderson, 1990).
legislation exists for mandatory ADS testing in some populations. The questions remain: Should healthcare workers be routinely tested? Ifso, is
testing for healthcare workers is an issue, and examines the legal and ethical principles involved in mandatory testing.
Concerns of Healthcare Workers As the HIV infection has spread to different populations, healthcare workers have become uncomfortable with their perceived risk of acquiring the infection in the work place. In some hospitals healthcare workers are openly expressing their discomfort in caring for AIDS patients for fear of contracting the disease (Hagen, Klemens, Kopelman, & Pauker, 1989). Few healthcare workers have been occupationally infected by caring for patients. Of the total AIDS cases reported in the United States, there are 40 documented healthcare worker sero-conversions from occupational exposure (ANA, 1991). Some healthcare workers have contracted the disease because of sexual practices and/or Nursing Forum Volume 27, No. 4, October-December 1992
9
Mandatory HIV Testing for Healthcare Workers: Is it Ethical?
drug use, which helps to explain the estimated 5,000 documented AIDS cases in healthcare workers, 566 of whom are physicians (Breo, 1990).
a much greater chance of a medical worker being infected by a patient than the reverse” (p. 57). In the medical literature this point was also documented in the Journal of Infection Control Hospital Epidemiology (Rhame, 1990).
Causes of Public Concern Risk of Transmission On July 27, 1990, the Centers for Disease Control (CDC)published a Morbidity and Mortality Weekly Report that contained an article entitled, “Possible Transmission of Human Immunodeficiency Virus to a Patient During an Invasive Dental Procedure” (1990b).The article outlined the CDC’s investigation into the case of a young woman who claimed to have acquired the HIV virus from her dentist during a dental extraction. The CDC concluded that in the absence of obvious risk factors, the lab findings and epidemiological data supported the hypothesis that the woman had contracted the HIV vims from her infected dentist during the extraction of two molars 24 months before her being diagnosed with AIDS.
In January 1991, the Centers for Disease Control presented the risk of worker to patient transmission in the hospital environment (1991a).The risk of HIV transmission (including during invasive procedures) is 0.3% (3 in 1,000). The estimated risk from a noninfected healthcare worker would be lower since occupational transmission to the worker would require one event, while workerpatient transmission requires the occurrence of two events, the injury to the worker, and exposure of the patient. In July 1991 the American Hospital Association published that the ”probability of transmission from an HIV-positive surgeon to a single patient ranges from .0024% (1in 41,667) to 0.00024% (1in 416,667). Infected dentists: 0.0000038% (1in 263,158) to 0.00000038% (1 in 2,631,579) during a dental procedure” (Hardy, 1991, p.4).
Whatever the argument, public hysteria is gaining momentum.
Pros and Cons for Mandatory Testing in Healthcare Workers
In August of 1991 the CDC documented that the investigation revealed that “five of the approximately 850 patients evaluated strongly suggested that HIV was transmitted to them in the practice of their dentist with AIDS. The infection occurred during dental care, “although the precise mechanisms of transmission have not been determined (1991b, p. 3). As are all new developments relating to HlV infections, the CDC reports were covered by the press and caused further public hysteria. In response to the people canceling dentist appointments the press and demanding protection from the HIV +, attempted to provide the public with information about the likelihood of contracting AIDS from a healthcare worker. Time magazine, in January 1991, wrote: (’There is
A U.S. News and World ReportlCNN poll in 1987 revealed that there is strong public support for massive AIDS testing, and more than one in four adults wony that they might get AIDS. Some believe that mandatory testing should be a requirement for defined populations to help reduce the public hysteria and widespread epidemic. Supporters of AIDS testing document that testing can be compared to any other type of mandatory test that an in&vidual must succumb to, like years of mandatory testing for syphilis for hospitalized patients, and required testing of children before entering school. These tests were routinely done and never questioned by the public, or scrutinized for being unethical. Opponents of testing argue that the test results are not reliable and that mandatory testing will not prevent the spread of the disease. Whatever the argument, public hysteria is gaining momentum.
10
Nursing Forum Volume 27,No.4,OctobepDecember 192
Legal and Ethical Issues There are multiple legal and ethical prinaples to consider when discussing mandatory AIDS testing for healthcare workers. The principles involve autonomy, freedom, privacy, confidentiality, beneficence, fidelity, and justice. Autonomy is recognized as the ability to be ”free” to make decisions that impact on one’s life. Mandatory testing violates healthcare workers’ autonomy to decide for themselves if AIDS testing is necessary. The prinaple of autonomy is the basis for the legal doctrine of informed consent.Many stateshave enacted statutes that require written informed consent for HIV-antibody testing. Currently there is no legislation requiringwidespread screening of healthcare workers. In all AIDS testing (whether voluntary or mandatory) healthcare workers are entitled to be dormed of the need for the test prior to blood being taken. However, should a healthcare worker-topatient blood exposure occur, the patient has a ”right to know” the healthcare worker’s HTV status, which supers e d e s the employees right to privacy (Henderson, 1990). The issue of privacy/confdmtiality involves the right to be protected against any form of intrusive contact from others. Individuals infected with HIV are concerned with issues of confidentiality because of the association with sexual preferences and/or drug use. Protection of confidentiality is both a legal and ethical duty. If mandatory testing was required of all healthcare workers, test results would need to be stored in a special computer file by code to ensure confidentiality. According to Henderson (1990),many HTV reports on infected healthcare workers are stored in general patient information systems within the hospital; thus, any hospital employee could have access to another employee’s lab results. “Any healthcare worker who has medical information present in his or her own medical record that has been entered into the institution’s computer is at risk from inadvertent disclosure or inappropriate prying by a curious coworker” (Henderson, p. 651). Infected healthcare workers can remain employed and have no obligation to disclose their HIV status to patients unless a healthcare worker to patient exposure Nursing Forum Volume 27, No. 4, OctobepDecember 1992
occurs. Gostin (1989) indicates that modern statutes protect the identity of a healthcare worker seeking an H N test, although these statutes also permit disclosures of positive results for the health of the patient. ”Legally the right to privacy is not absolute, but subject to the welfare of others” (Wold, 1990, p. 259). Issues related to contact tracing have presented a new dimension in AIDS testing. Would dentists or physicians, knowing their positive HIV status, contact all patients who may have actually or potentially been exposed under their care? To maintain confidentiality in contact tracing, the exposed individual is notified without reference to the name or occupation of the HIVinfected individual. In cases of sexual transmission, the sexual partner is notified that there may be a need for follow-up H N testing. Beneficence is a method of relating to individuals for their benefit. It is a consistent attitude of good will toward another (Husted & Husted, 1991).Supporters of mandatory testing argue that testing in some populations would encourage early treatment and a more healthful lifestyle, which would benefit the individual. In the case of healthcare workers, the identification of a positive HIV status would prevent the worker from performing certain ”exposure-prone” procedures that might place the patient at a higher risk for contracting AIDS from such contact. Opponents of mandatory testing suggest that patient care would suffer if infected healthcare workers are driven from practice each time a potential exposure exists. Since the H N test can be falsely negative or positive, the hospital would need to request that staff “sit it out” for six or more months before the AIDS virus would show up in the tests (Toufexis, 1991). Legislation that supports beneficence includes education and counseling on the prevention of H N transmission to the general public, high-risk groups, healthcare professionals, and schools. The Food and Drug Administration has required that all blood donors be tested for antibodies to the HIV virus. Blood collection centers are responsible for isolating contaminated blood products, and to refrain from collecting more blood products from those individuals testing positive (Gostin,1989).
11
Mandatory HIV Testing for Healthcare Workers: Is it Ethical?
While healthcare workers in all institutions have been educated in universal precautions, some employees have failed to comply with the recommendationsfrom the CDC because they find gloves, goggles, and other protective gear cumbersome to wear and/or too time consuming to put on and remove. Such was the case for Barbara Fassbinder, an RN documented by the CDC to have contracted AlDs by using her finger to apply pressure to an emergency room patient’s IV site. Unfortunately, Fassbinder had cuts on her finger, leaving her exposed to the HlV virus.Fassbinder testified in 1991 before members of the House Energy and Commerce Subcommitteeon Health and the Environment that she would not have been at risk in 1986 when the exposure occurred if she had used universal precautions (AmericanNurses Association, 1991).
FideZity (holding to an agreement or promise) is an ethical principle that imparts making decisions about mandatory AIDS testing.
The problem for Fassbinder was that universal precautions were not taught to hospital employees or widely used in 1986. Fassbinder opposes mandatory testing of healthcare workers but believes in training them in the use of universal precautions. The use of proper infection control techniques by healthcare workers will benefit both the patient and the employee, she contends. Fidelity is another ethical principle that needs to be considered when making decisions about mandatory AIDS testing among healthcare workers. Fidelity is defined by Husted & Husted (1991) as holding to an agreement or promise. Legal issues that come into play involve employer discrimination cases where the employee who has just tested positive for AIDS is terminated. Hardy (1991) maintains in an “Aids Issues Update,” published by the American Hospital Association, that section 504 of 12
the Rehabilitation Act of 1973 and the Americans with Disabilities Act provide protection for HIV- infected employees, since they are “disabled, or handicapped.” Gostin (1989) writes that the Rehabilitation Act was amended to state that a person with a contagious disease or infection is not handicapped if he or she does not “constitute a direct threat to health or safety and is able to perform duties of the job” (p. 1628).Most statutes provide that ”qualified” individuals with handicaps or disabilities with ”reasonableaccommodation”can perfom the essential functions of the job and cannot be terminated because of a positive HIV status. The employer is also responsible for modlfymg a job to allow AIDS victims to work “safely and productively” on the job (p.5). The ANA (1991) also documents the need to support healthcare workers who test positive for HlV secondary to occupational exposure. The ANA suggests mochfymg the employee’s job where necessary, and to be ”tolerant of temporary performanceproblems: it takesone year for healthcare workers to get adjusted to being diagnosed with AIDS. If the employee has HIV because of an occupational exposure, the employer has an obligation to the employee. Husted & Husted (1991) discuss justice as an ethical principle in which healthcare is distributed by allocation of scarce resources. Living in a society where healthcare costs are astronomical,it becomes increasingly difficult to jushfy the cost of mandatory testing for all healthcare workers when test results aren’t always valid, and if they are valid they may be hue only for a short period of time. Wold (1990) states that mandatory testing might also give an individual a false sense of security, since the ELISA screening test has a 10%15% false positive rate, and that it may take from six to twelve weeks for the individual tested to develop AIDS antibodies while the carrier is contagious from the start. Opponents of mandatory testing believe that testing is only cost effectivein high-risk populations.
Recommendations The following guidelines should be utilized when considering ethical principles for AIDS testing for health care workers: Nursing Forum Volume 27,No. 4, October-December 1992
1. Consider mandatory testing only if the primary goal is to prevent the spread of AIDS. If the patient is deemed to be at a higher risk for contracting the disease from a healthcare worker in the future, then energies should be committed to testing healthcare workers. Until such time, HIV testing should be done only at employees' request for their own health reasons or voluntarily in the event of an occupational exposure. If an employee refuses to be voluntarily tested in the event of being exposed in the work place, the employee must realize that workman's compensationbenefits cannot be paid. 2. All testing must benefit those at risk. HIV testing should be considered a primary prevention for the purpose of partner notification with sexual or needle-sharing contacts (ANA, 1991).In addition, testing must benefit those at risk because of the stigma associated with a positive test result, whether falsely positive or not.
3. Health assessment and education must be done prior to the screening (Wold, 1990). All healthcare workers screened on a voluntary basis should be asked a series of questions about drug use, history of sexual practices, the reasons for needing the testing, any history of past exposures, and contact with possible HIVinfected individuals. Screening should also include an assessment of the healthcare worker's level of knowledge about the disease. It would be inappropriate for example, to assume that a physician knows more about HIV than an RN. It may be that the RN happens to be an infection control specialist. 4. HIV testing must remain confidential. Because of the
stigma associated with a positive HN test result, testing must remain confidential, and the laboratory facilities chosen must be dependable. The question now becomes: Should HIV results be in an employee's file? The employer has no absolute right to know this information unless the employee has possibly exposed a patient to the virus. If such a case exists, a special double coding system should be used to protect the employee if a test comes back positive. In addition, a separate medical Nursing Forum Volume 27, No. 4, OctobepDecember 1992
record should be used containing the HIV result and postexposure management. The file must have limited access and the employee must be informed of any information released from the file (ANA, 1991). If an employee presents herself or himself to the Employee Health Department and requests testing, perhaps testing should be done at another facility so that results can be stored outside of an employee's place of employment. 5. Informed consent must be obtained from those individuals who will be tested. Individuals who grant consent for testing must be aware of the reliability of the test and the implications of test results. 6. Offer counseling to individuals both before and
after the screening, and in the event of a positive HIV result. Support groups should be formed for healthcare workers with positive HIV results. These meetings should be held in a neutral location outside hospital grounds to ensure confidentiality. 7. Never use the information gained from testing for anything more than the protection of public health (Wold, 1990). Positive HIV results must never prevent upward mobility in an organization, or be used as criteria for layoffs, merit raises, etc. Employees with positive HIV results would, however, be prevented from practicing in areas that require exposure-prone procedures to be practiced routinely. 8. Healthcare workers must continue to adhere to uni-
versal precautions and comply with the recommended guidelines for disinfection and sterilization of reusable devices (AN& 1991). Employee evaluation records should include a section that describes the healthcare worker's ability to employ universal precautions effectively.Supervisory personnel must enforce the use of universal precautionsvia counseling sessionswhen they are not pradiced. 9. HIV-infected healthcare workers should refrain from performing exposure-prone procedures CCDC, 1991). Exposure-prone procedures include: "digital palpation 13
Mandatory HIV Testing for Healthcare Workers: Is it Ethical?
of a needle tip in a body cavity or the simultaneous presence of the healthcare worker‘s fingers and a needle or other sharp instrument or object in a poorly visualized or highly confined anatomic site” (CDC, 1991, p. 4).
American Hospital Association. (1991b, August). Technical briefing on management of healthcare workers infeted with human immunodt$cienq virus and hepatitis B Virus. Chicago:Author.
10. Postexposure management policies need to be developed for healthcare workers with positive HIV results (ANA, 1991). Guidelines for follow-up should be explicit and include protocols for: short-term illness disability! filing workman’s compensation claims, ensuring confidentiality of employee records, and job placement in an area where exposure-prone incidents are less likely to occur.
Beehann, S., Fahey, B., Gerberding, J., & Henderson, D. (1990).Risky business: Using necessarily imprecise casualty counts to estimate occupational risks for HIV-1 infection. Infection Control Hospital Epidemiology, 12(7), 371-379.
Conc1usion
Centers for Disease Control. (1990a). HIV AIDS surveillance report. Morbidity and Mortality Weekly Report, 2(13),1-18.
Mandatory testing is not legally or ethically required when considering issues related to autonomy, freedom, privacy /confidentiality, beneficence, fidelity, and justice. Mandatory testing would impose on a healthcare worker’s autonomy and privacy, while providing minimal benefit to the patient and/or employee. When employers are faced with these issues, they may choose not to engage in testing because of the threat of public disclosureand hospital liability. It just isn’t cost effective to test low-risk populations when resources are scarce. In addition to the legal and ethical principles cited above, mandatory testing is not recommended by the CDC (1991),the American Hospital Association (1991), Practitioners for Infection Control, the American Nurses Association (1991), or the Society of Hospital Epidemiologists (Henderson,1990). The AIDS epidemic has presented society with ethical and legal issues that must be considered when making decisions about mandatory testing, especially for healthcare workers. Despite public hysteria and political coercion, statistics clearly demonstrate that healthcare workers are a low-risk group in spreading the AIDS virus; thus mandatory testing should not be required.
Centers for b a s e Control. (1991a,January30). Draft: Estimates ofthe risk ~f endemic transmission ofhepatitis B Vm i and human i m m u w anis to patients by the percutaneous route during inwive surgical and dental p r i ~ cedures. Atlanta, GA Author.
References
American Nurses Association. (1991). A N A statements focus on HIV issues (pp. 24-27). Kansas City, M O Author.
Breo, D. (1990).The slippery slope: H a n d h g HIV infected health care workers. Journal of Ameiican Medical Association, 264,1464-1466. Carey, J., Qluck, B., & Riley, R. (1987, April 20). AIDS: A time of testing. US.News b World Report, 56-59.
Centers for Disease Control. (199Ob). Possible transmission of human immunodeficiencyvirus to a patient during an invasive dental procedure. Morbidity and Mortality Weekly Report, 39,489-493. Centers for Disease Control. (1991b). Recommendations for preventing transmission of human immunodeficiency virus and hepatitis 6 virus to patients during exposure-prone invasive procedures. Morbidity and Mortality Weekly Report, 40 (RR-8),1-9. Gostin, L. (1989). Public health strategies for confronting AIDS. Joumzl of American Medical Association, 261,1621-1629. Hagen, M., Klemens, B., Kopelman, R., & Pauker, S. (1989). Human immunodeficiencyvirus infection in health care workers. Archives if Internal Medicine, 149,1541-1543. Hardy, M. (1991). AIDS issues update. American Hospital Association. Chicago. Henderson, D. (1990). Position paper: The HIV infected health care worker. Infection Control Hospital Epidemiology, 11,647456. Husted, G., & Husted, J. (1991). Ethical decision making in nursing. St. Louis: Mosby-Yearbook. Rhame, F. (1990).Hospital-based routine HIV testing programs. Joumnl of infection Control Hospital Epidemiology, 21 (12),625-627. Toufexis, A. (1991, January 14). When the doctor gets infected. T i m , 52
American Hospital Association. (1991a, August). Early warning system. Chicago: Author.
14
Wold, J. (1990). AIDS testing, an ethical question. Journal ofNeuroscience Nursing, 22(4),25&20.
Nursing Forum Volume 27, No. 4,OctobeI.-December 1992
The AIDS epidemic has caused hysteria among the public and concern to many healthcare
Debbie Marie Beck, RN, M S , is a member of the clinical nursing faculty, University of Detroit/Mercy and House Supervisor, St. John Hospital, Mt. Clemens, MI.
workers in the past 12 years. Currently,
mandatory testing ethical? The author explores
S i n c e 1981 the AIDS epidemic has caused hysteria in the public sector and concern to many healthcare workers. Currently, legislation exists for mandatory AIDS testing in some populations but is not required of healthcare workers. The public is pushing hard for mandatory testing of healthcare workers to become a reality. Yet many ethical issues must be explored before we conclude that mandatory testing should be subject to routine.
the incidence and prevalence of AIDS among
Incidenceh'revalence
healthcare workers, discusses why mandatory
Between 800,000 and 1.2 million people in tlus country are now infected with the AIDS virus. More than 121,645 cases have been diagnosed in the U.S. and more than half of the dected have died (Centersfor Disease Control, 199Ob). Despite recent evidence that indicates a reduced incidence among homosexual and bisexual men and transfusion recipients, the incidence of AIDS continues to increase among heterosexuals via needle sharing, in partners of intravenous substance users, and partners of bisexual men (kkmann, Fahey, Gerberchg, & Henderson, 1990).
legislation exists for mandatory ADS testing in some populations. The questions remain: Should healthcare workers be routinely tested? Ifso, is
testing for healthcare workers is an issue, and examines the legal and ethical principles involved in mandatory testing.
Concerns of Healthcare Workers As the HIV infection has spread to different populations, healthcare workers have become uncomfortable with their perceived risk of acquiring the infection in the work place. In some hospitals healthcare workers are openly expressing their discomfort in caring for AIDS patients for fear of contracting the disease (Hagen, Klemens, Kopelman, & Pauker, 1989). Few healthcare workers have been occupationally infected by caring for patients. Of the total AIDS cases reported in the United States, there are 40 documented healthcare worker sero-conversions from occupational exposure (ANA, 1991). Some healthcare workers have contracted the disease because of sexual practices and/or Nursing Forum Volume 27, No. 4, October-December 1992
9
Mandatory HIV Testing for Healthcare Workers: Is it Ethical?
drug use, which helps to explain the estimated 5,000 documented AIDS cases in healthcare workers, 566 of whom are physicians (Breo, 1990).
a much greater chance of a medical worker being infected by a patient than the reverse” (p. 57). In the medical literature this point was also documented in the Journal of Infection Control Hospital Epidemiology (Rhame, 1990).
Causes of Public Concern Risk of Transmission On July 27, 1990, the Centers for Disease Control (CDC)published a Morbidity and Mortality Weekly Report that contained an article entitled, “Possible Transmission of Human Immunodeficiency Virus to a Patient During an Invasive Dental Procedure” (1990b).The article outlined the CDC’s investigation into the case of a young woman who claimed to have acquired the HIV virus from her dentist during a dental extraction. The CDC concluded that in the absence of obvious risk factors, the lab findings and epidemiological data supported the hypothesis that the woman had contracted the HIV vims from her infected dentist during the extraction of two molars 24 months before her being diagnosed with AIDS.
In January 1991, the Centers for Disease Control presented the risk of worker to patient transmission in the hospital environment (1991a).The risk of HIV transmission (including during invasive procedures) is 0.3% (3 in 1,000). The estimated risk from a noninfected healthcare worker would be lower since occupational transmission to the worker would require one event, while workerpatient transmission requires the occurrence of two events, the injury to the worker, and exposure of the patient. In July 1991 the American Hospital Association published that the ”probability of transmission from an HIV-positive surgeon to a single patient ranges from .0024% (1in 41,667) to 0.00024% (1in 416,667). Infected dentists: 0.0000038% (1in 263,158) to 0.00000038% (1 in 2,631,579) during a dental procedure” (Hardy, 1991, p.4).
Whatever the argument, public hysteria is gaining momentum.
Pros and Cons for Mandatory Testing in Healthcare Workers
In August of 1991 the CDC documented that the investigation revealed that “five of the approximately 850 patients evaluated strongly suggested that HIV was transmitted to them in the practice of their dentist with AIDS. The infection occurred during dental care, “although the precise mechanisms of transmission have not been determined (1991b, p. 3). As are all new developments relating to HlV infections, the CDC reports were covered by the press and caused further public hysteria. In response to the people canceling dentist appointments the press and demanding protection from the HIV +, attempted to provide the public with information about the likelihood of contracting AIDS from a healthcare worker. Time magazine, in January 1991, wrote: (’There is
A U.S. News and World ReportlCNN poll in 1987 revealed that there is strong public support for massive AIDS testing, and more than one in four adults wony that they might get AIDS. Some believe that mandatory testing should be a requirement for defined populations to help reduce the public hysteria and widespread epidemic. Supporters of AIDS testing document that testing can be compared to any other type of mandatory test that an in&vidual must succumb to, like years of mandatory testing for syphilis for hospitalized patients, and required testing of children before entering school. These tests were routinely done and never questioned by the public, or scrutinized for being unethical. Opponents of testing argue that the test results are not reliable and that mandatory testing will not prevent the spread of the disease. Whatever the argument, public hysteria is gaining momentum.
10
Nursing Forum Volume 27,No.4,OctobepDecember 192
Legal and Ethical Issues There are multiple legal and ethical prinaples to consider when discussing mandatory AIDS testing for healthcare workers. The principles involve autonomy, freedom, privacy, confidentiality, beneficence, fidelity, and justice. Autonomy is recognized as the ability to be ”free” to make decisions that impact on one’s life. Mandatory testing violates healthcare workers’ autonomy to decide for themselves if AIDS testing is necessary. The prinaple of autonomy is the basis for the legal doctrine of informed consent.Many stateshave enacted statutes that require written informed consent for HIV-antibody testing. Currently there is no legislation requiringwidespread screening of healthcare workers. In all AIDS testing (whether voluntary or mandatory) healthcare workers are entitled to be dormed of the need for the test prior to blood being taken. However, should a healthcare worker-topatient blood exposure occur, the patient has a ”right to know” the healthcare worker’s HTV status, which supers e d e s the employees right to privacy (Henderson, 1990). The issue of privacy/confdmtiality involves the right to be protected against any form of intrusive contact from others. Individuals infected with HIV are concerned with issues of confidentiality because of the association with sexual preferences and/or drug use. Protection of confidentiality is both a legal and ethical duty. If mandatory testing was required of all healthcare workers, test results would need to be stored in a special computer file by code to ensure confidentiality. According to Henderson (1990),many HTV reports on infected healthcare workers are stored in general patient information systems within the hospital; thus, any hospital employee could have access to another employee’s lab results. “Any healthcare worker who has medical information present in his or her own medical record that has been entered into the institution’s computer is at risk from inadvertent disclosure or inappropriate prying by a curious coworker” (Henderson, p. 651). Infected healthcare workers can remain employed and have no obligation to disclose their HIV status to patients unless a healthcare worker to patient exposure Nursing Forum Volume 27, No. 4, OctobepDecember 1992
occurs. Gostin (1989) indicates that modern statutes protect the identity of a healthcare worker seeking an H N test, although these statutes also permit disclosures of positive results for the health of the patient. ”Legally the right to privacy is not absolute, but subject to the welfare of others” (Wold, 1990, p. 259). Issues related to contact tracing have presented a new dimension in AIDS testing. Would dentists or physicians, knowing their positive HIV status, contact all patients who may have actually or potentially been exposed under their care? To maintain confidentiality in contact tracing, the exposed individual is notified without reference to the name or occupation of the HIVinfected individual. In cases of sexual transmission, the sexual partner is notified that there may be a need for follow-up H N testing. Beneficence is a method of relating to individuals for their benefit. It is a consistent attitude of good will toward another (Husted & Husted, 1991).Supporters of mandatory testing argue that testing in some populations would encourage early treatment and a more healthful lifestyle, which would benefit the individual. In the case of healthcare workers, the identification of a positive HIV status would prevent the worker from performing certain ”exposure-prone” procedures that might place the patient at a higher risk for contracting AIDS from such contact. Opponents of mandatory testing suggest that patient care would suffer if infected healthcare workers are driven from practice each time a potential exposure exists. Since the H N test can be falsely negative or positive, the hospital would need to request that staff “sit it out” for six or more months before the AIDS virus would show up in the tests (Toufexis, 1991). Legislation that supports beneficence includes education and counseling on the prevention of H N transmission to the general public, high-risk groups, healthcare professionals, and schools. The Food and Drug Administration has required that all blood donors be tested for antibodies to the HIV virus. Blood collection centers are responsible for isolating contaminated blood products, and to refrain from collecting more blood products from those individuals testing positive (Gostin,1989).
11
Mandatory HIV Testing for Healthcare Workers: Is it Ethical?
While healthcare workers in all institutions have been educated in universal precautions, some employees have failed to comply with the recommendationsfrom the CDC because they find gloves, goggles, and other protective gear cumbersome to wear and/or too time consuming to put on and remove. Such was the case for Barbara Fassbinder, an RN documented by the CDC to have contracted AlDs by using her finger to apply pressure to an emergency room patient’s IV site. Unfortunately, Fassbinder had cuts on her finger, leaving her exposed to the HlV virus.Fassbinder testified in 1991 before members of the House Energy and Commerce Subcommitteeon Health and the Environment that she would not have been at risk in 1986 when the exposure occurred if she had used universal precautions (AmericanNurses Association, 1991).
FideZity (holding to an agreement or promise) is an ethical principle that imparts making decisions about mandatory AIDS testing.
The problem for Fassbinder was that universal precautions were not taught to hospital employees or widely used in 1986. Fassbinder opposes mandatory testing of healthcare workers but believes in training them in the use of universal precautions. The use of proper infection control techniques by healthcare workers will benefit both the patient and the employee, she contends. Fidelity is another ethical principle that needs to be considered when making decisions about mandatory AIDS testing among healthcare workers. Fidelity is defined by Husted & Husted (1991) as holding to an agreement or promise. Legal issues that come into play involve employer discrimination cases where the employee who has just tested positive for AIDS is terminated. Hardy (1991) maintains in an “Aids Issues Update,” published by the American Hospital Association, that section 504 of 12
the Rehabilitation Act of 1973 and the Americans with Disabilities Act provide protection for HIV- infected employees, since they are “disabled, or handicapped.” Gostin (1989) writes that the Rehabilitation Act was amended to state that a person with a contagious disease or infection is not handicapped if he or she does not “constitute a direct threat to health or safety and is able to perform duties of the job” (p. 1628).Most statutes provide that ”qualified” individuals with handicaps or disabilities with ”reasonableaccommodation”can perfom the essential functions of the job and cannot be terminated because of a positive HIV status. The employer is also responsible for modlfymg a job to allow AIDS victims to work “safely and productively” on the job (p.5). The ANA (1991) also documents the need to support healthcare workers who test positive for HlV secondary to occupational exposure. The ANA suggests mochfymg the employee’s job where necessary, and to be ”tolerant of temporary performanceproblems: it takesone year for healthcare workers to get adjusted to being diagnosed with AIDS. If the employee has HIV because of an occupational exposure, the employer has an obligation to the employee. Husted & Husted (1991) discuss justice as an ethical principle in which healthcare is distributed by allocation of scarce resources. Living in a society where healthcare costs are astronomical,it becomes increasingly difficult to jushfy the cost of mandatory testing for all healthcare workers when test results aren’t always valid, and if they are valid they may be hue only for a short period of time. Wold (1990) states that mandatory testing might also give an individual a false sense of security, since the ELISA screening test has a 10%15% false positive rate, and that it may take from six to twelve weeks for the individual tested to develop AIDS antibodies while the carrier is contagious from the start. Opponents of mandatory testing believe that testing is only cost effectivein high-risk populations.
Recommendations The following guidelines should be utilized when considering ethical principles for AIDS testing for health care workers: Nursing Forum Volume 27,No. 4, October-December 1992
1. Consider mandatory testing only if the primary goal is to prevent the spread of AIDS. If the patient is deemed to be at a higher risk for contracting the disease from a healthcare worker in the future, then energies should be committed to testing healthcare workers. Until such time, HIV testing should be done only at employees' request for their own health reasons or voluntarily in the event of an occupational exposure. If an employee refuses to be voluntarily tested in the event of being exposed in the work place, the employee must realize that workman's compensationbenefits cannot be paid. 2. All testing must benefit those at risk. HIV testing should be considered a primary prevention for the purpose of partner notification with sexual or needle-sharing contacts (ANA, 1991).In addition, testing must benefit those at risk because of the stigma associated with a positive test result, whether falsely positive or not.
3. Health assessment and education must be done prior to the screening (Wold, 1990). All healthcare workers screened on a voluntary basis should be asked a series of questions about drug use, history of sexual practices, the reasons for needing the testing, any history of past exposures, and contact with possible HIVinfected individuals. Screening should also include an assessment of the healthcare worker's level of knowledge about the disease. It would be inappropriate for example, to assume that a physician knows more about HIV than an RN. It may be that the RN happens to be an infection control specialist. 4. HIV testing must remain confidential. Because of the
stigma associated with a positive HN test result, testing must remain confidential, and the laboratory facilities chosen must be dependable. The question now becomes: Should HIV results be in an employee's file? The employer has no absolute right to know this information unless the employee has possibly exposed a patient to the virus. If such a case exists, a special double coding system should be used to protect the employee if a test comes back positive. In addition, a separate medical Nursing Forum Volume 27, No. 4, OctobepDecember 1992
record should be used containing the HIV result and postexposure management. The file must have limited access and the employee must be informed of any information released from the file (ANA, 1991). If an employee presents herself or himself to the Employee Health Department and requests testing, perhaps testing should be done at another facility so that results can be stored outside of an employee's place of employment. 5. Informed consent must be obtained from those individuals who will be tested. Individuals who grant consent for testing must be aware of the reliability of the test and the implications of test results. 6. Offer counseling to individuals both before and
after the screening, and in the event of a positive HIV result. Support groups should be formed for healthcare workers with positive HIV results. These meetings should be held in a neutral location outside hospital grounds to ensure confidentiality. 7. Never use the information gained from testing for anything more than the protection of public health (Wold, 1990). Positive HIV results must never prevent upward mobility in an organization, or be used as criteria for layoffs, merit raises, etc. Employees with positive HIV results would, however, be prevented from practicing in areas that require exposure-prone procedures to be practiced routinely. 8. Healthcare workers must continue to adhere to uni-
versal precautions and comply with the recommended guidelines for disinfection and sterilization of reusable devices (AN& 1991). Employee evaluation records should include a section that describes the healthcare worker's ability to employ universal precautions effectively.Supervisory personnel must enforce the use of universal precautionsvia counseling sessionswhen they are not pradiced. 9. HIV-infected healthcare workers should refrain from performing exposure-prone procedures CCDC, 1991). Exposure-prone procedures include: "digital palpation 13
Mandatory HIV Testing for Healthcare Workers: Is it Ethical?
of a needle tip in a body cavity or the simultaneous presence of the healthcare worker‘s fingers and a needle or other sharp instrument or object in a poorly visualized or highly confined anatomic site” (CDC, 1991, p. 4).
American Hospital Association. (1991b, August). Technical briefing on management of healthcare workers infeted with human immunodt$cienq virus and hepatitis B Virus. Chicago:Author.
10. Postexposure management policies need to be developed for healthcare workers with positive HIV results (ANA, 1991). Guidelines for follow-up should be explicit and include protocols for: short-term illness disability! filing workman’s compensation claims, ensuring confidentiality of employee records, and job placement in an area where exposure-prone incidents are less likely to occur.
Beehann, S., Fahey, B., Gerberding, J., & Henderson, D. (1990).Risky business: Using necessarily imprecise casualty counts to estimate occupational risks for HIV-1 infection. Infection Control Hospital Epidemiology, 12(7), 371-379.
Conc1usion
Centers for Disease Control. (1990a). HIV AIDS surveillance report. Morbidity and Mortality Weekly Report, 2(13),1-18.
Mandatory testing is not legally or ethically required when considering issues related to autonomy, freedom, privacy /confidentiality, beneficence, fidelity, and justice. Mandatory testing would impose on a healthcare worker’s autonomy and privacy, while providing minimal benefit to the patient and/or employee. When employers are faced with these issues, they may choose not to engage in testing because of the threat of public disclosureand hospital liability. It just isn’t cost effective to test low-risk populations when resources are scarce. In addition to the legal and ethical principles cited above, mandatory testing is not recommended by the CDC (1991),the American Hospital Association (1991), Practitioners for Infection Control, the American Nurses Association (1991), or the Society of Hospital Epidemiologists (Henderson,1990). The AIDS epidemic has presented society with ethical and legal issues that must be considered when making decisions about mandatory testing, especially for healthcare workers. Despite public hysteria and political coercion, statistics clearly demonstrate that healthcare workers are a low-risk group in spreading the AIDS virus; thus mandatory testing should not be required.
Centers for b a s e Control. (1991a,January30). Draft: Estimates ofthe risk ~f endemic transmission ofhepatitis B Vm i and human i m m u w anis to patients by the percutaneous route during inwive surgical and dental p r i ~ cedures. Atlanta, GA Author.
References
American Nurses Association. (1991). A N A statements focus on HIV issues (pp. 24-27). Kansas City, M O Author.
Breo, D. (1990).The slippery slope: H a n d h g HIV infected health care workers. Journal of Ameiican Medical Association, 264,1464-1466. Carey, J., Qluck, B., & Riley, R. (1987, April 20). AIDS: A time of testing. US.News b World Report, 56-59.
Centers for Disease Control. (199Ob). Possible transmission of human immunodeficiencyvirus to a patient during an invasive dental procedure. Morbidity and Mortality Weekly Report, 39,489-493. Centers for Disease Control. (1991b). Recommendations for preventing transmission of human immunodeficiency virus and hepatitis 6 virus to patients during exposure-prone invasive procedures. Morbidity and Mortality Weekly Report, 40 (RR-8),1-9. Gostin, L. (1989). Public health strategies for confronting AIDS. Joumzl of American Medical Association, 261,1621-1629. Hagen, M., Klemens, B., Kopelman, R., & Pauker, S. (1989). Human immunodeficiencyvirus infection in health care workers. Archives if Internal Medicine, 149,1541-1543. Hardy, M. (1991). AIDS issues update. American Hospital Association. Chicago. Henderson, D. (1990). Position paper: The HIV infected health care worker. Infection Control Hospital Epidemiology, 11,647456. Husted, G., & Husted, J. (1991). Ethical decision making in nursing. St. Louis: Mosby-Yearbook. Rhame, F. (1990).Hospital-based routine HIV testing programs. Joumnl of infection Control Hospital Epidemiology, 21 (12),625-627. Toufexis, A. (1991, January 14). When the doctor gets infected. T i m , 52
American Hospital Association. (1991a, August). Early warning system. Chicago: Author.
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Wold, J. (1990). AIDS testing, an ethical question. Journal ofNeuroscience Nursing, 22(4),25&20.
Nursing Forum Volume 27, No. 4,OctobeI.-December 1992
