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What is the difference between an HIV and a CBC?

What is the Difference between an HIV and a CBC?

COMMENTARY by Joel D. Howell

Yet hospitalized patients, like any other persons, should be asked to consent before having blood drawn to determine their HIV antibody status. One could argue, of course, that however theoretically ideal it might be to obtain consent for every test, it is neither practical nor common procedure to do so in a hospital setting. Hospitalized patients have their blood drawn regularly. Physicians do not ask their consent to check a blood count, to monitor antibiotic levels, to assess thyroid status, or to do other "routine" tests. In the interest of efficiency, we do not ask specific consent for each laboratory examination. Despite this, we generally acknowledge that competent adult patients--and certainly G.L. would be included in this group--have the right to know what tests are being drawn, to refuse them, indeed, to refuse hospitalization.

Unlike the situation for routine blood tests, physicians do ask consent before inserting tubes into patients' hearts, seeking consent because such invasive procedures involve an element of significant risk to the patient. Thus, physicians ask permission for procedures that could harm the patient.

Into what category does drawing blood for an HIV antibody test fall? It is a procedure for which physicians should obtain consent from the patient, because it places the patient at greater risk for adverse consequences than other blood tests. First, there is the risk of a false-positive test result, the magnitude of which depends on the pretest probability that a patient has been infected with the HIV virus. In G.L.'s case this probability is quite low. A false-positive test should be detected by additional testing, but in the interim the patient would suffer. Graver risks would come from true-positive test results: risks to G.L.'s relationships (both sexual and social if test results were inappropriately disclosed), to her treatment by medical personnel, to her insurability, to schooling, to housing, and were she employed, to job security.

On the hand, there are potential benefits to drawing an HIV antibody test. The results could give G.L. information about her prognosis and possibly save her the indignities or hazards of further diagnostic evalution. Knowledge of a positive test result might prompt her to alter her behavior to decrease the probability of transmitting the HIV virus to sexual partners and, were she in her childbearing years, to her potential children. Society, too, could benefit if she refrained from donating blood. Society could also benefit from an increased knowledge about the clinical presentation of AIDS and from a small increment in knowledge about its epidemiology.

Unfortunately, because we have little hope for palliation or cure, the clinical benefits to G.L. of a positive HIV test would be small. The benefits of testing would more likely accrue to physicians. Probably the most powerful motivation behind testing in this case is physicians' natural desire to make a diagnosis, thus fulfilling both role expectations to which they are socialized and the intellectual curiosity that underlies much of medical practice. Those directly involved in caring for G.L. might also perceive some personal benefit from knowing the results. Were the results negative, they might have less sense of personal risk while caring for her. Were they positive, caregivers might take additional precautions, though studies have failed to demonstrate an increased risk of infection among clinicians working with AIDS or HIV-positive patients. Universal secretion precautions are more effective than screening patients thought to be at risk.

Thus, the risks and benefits involved in performing the HIV antibody test must be balanced. In assessing the complex and competing priorities involved, the patient should actively participate in the decision-making process. And here, as always, informed consent means just that; it implies more than a technical exposition and platitudes about confidentiality. It requires an honest effort by the patient's physican to make her aware of the full range of potential risks and benefits, and to counsel her both prior to and following testing. Aware of the potential results of their actions, patients--such as G.L.--can then choose what they wish to do.

Unfortunately, G.L. was not given the opportunity to make this choice. What should the attending physician do now? If the test has not yet been performed, he or she must decide if any HIV test may be indicated. If the answer is no, the attending physician should countermand the resident and cancel the test. If the answer is yes, he or she should, together with the resident, explain to G.L. what has occurred, and after properly informing her of the risks and benefits, request permission to perform an HIV antibody test. The physicians should then abide by her wishes.

If, however, results are obtained before the attending physician can intervene, G.L. should be told of the results even though she did not know that an HIV antibody test was being drawn. For her caregivers to know G.L.'s HIV status while she does not would only compound the initial error made in her care. Finally, this incident should (and did) prompt discussion with house staff about the need to obtain consent before drawing an HIV test.

AIDS has forced us to reassess traditional hospital practice. This new disease should make physicians think about their patients within a larger social context, rather than an exclusively scientific context, the latter a goal toward which American medicine has strived during much of the twentieth century. The purely technical risk to having a blood test drawn may be minimal, be it a CBC or an HIV, but the social risk for having an HIV drawn is considerable. Hence, the correct response is to obtain hospitalized patients' consent before drawing an HIV antibody test.

COMMENTARY by Carl Cohen

This cas presents two district issues. First, may the test for antibodies to HIV be performed without the specific consent of the patient? Second, must the patient be informed of her HIV antibody status once that is determined?

The latter question is the easier. The patient has entered the hospital to determine the cause(s) of a long-continued illness; investigation has been "intense"; many lab tests will have been run, and the patient will very likely be anxious about their results. Whatever her state of mind, G.L. surely has a right to full and truthful disclosure of what is known, or has been concluded with high probability, that may help to explain her jaundice, weakness, and other symptoms.

Should G.L. test positive for anti-bodies to HIV, this may prove difficult for her to accept. The task of informing her of such test results should be approached with care and compassion, in the most constructive and supportive way possible. That it is unpleasant is no reason for keeping the truth from her.

The more difficult question concerns the permissibility of such testing without specific consent of the patient. Its fatal outcome and social stigmatization give ground for treating routine AIDS testing among healthy persons (even supposing all risk of false positives could be eliminated) with the greatest caution.

But G.L. is not healthy; she suffers from anemia and has received an unscreened blood transfusion. Under such circumstances, it is the duty of the health professionals to whom G.L. has committed her care to undertake the laboratory tests that may help to identify the problem. Failing to determine her antibody status might leave a critical gap in the medical understanding of her condition.

Must the doctors ask her first, however, before testing for antibodies to HIV? No, unless the tests for this disease are different from tests for other conditions routinely tested, in ways that make specific consent a necessary condition of the inquiry.

The patient's consent--to have blood drawn and tested and to have various laboratory tests performed upon tissue taken from her--must certainly be obtained before invasive procedures are initiated. But G.L. gave that consent, in general form, when she voluntarily entered the hospital for diagnosis.

Normally, we do not think it essential to receive the patient's specific consent for inquiry into each possible condition from which she may be suffering. The complexities of indirect causation, of complicated probability calculations, and of various possible responses to the test outcomes encountered, make explaining to the patient why each test is being run a practical impossibility in the normal hospital setting. The practice of not seeking specific consent for testing each possible condition is a recognition of the different levels of medical understanding normally possessed by doctors and their patients, and should not be viewed as a form of condescending paternalism. It also protects the patient from unwarranted fears and anxieties arising from the physician's need to eliminate certain improbable but nonetheless possible causes.

Why might one think that specific consent for HIV antibody testing is nonetheles required? Is it because of the gravity of AIDS? The possibility that it may prove necessary to convey very bad news to a patient surely provides no reason for failing to determine her condition. Is specific consent deemed necessary because of the special stigma associated with AIDS? G.L., a sixty-seven-year-old who has received an unscreened transfusion, is not likely to suffer the aversion and revulsion experienced by some patients with AIDS or HIV infection even in the unlikely even that she does test positive.

The chief point, however, is that the proper task of those who care for G.L. is to diagnose her disease, and that it is their duty to perform those tests and make those inquiries that are reasonably called for to achieve that end. Had G.L. stipulated on her admission to the hospital that she not be tested for antibodies to HIV, her specific consent before performing such a test would of course be required. Since her admission presumably conformed to standard procedures, it is no infringement upon her interests or her rights to proceed with the laboratory tests that might normally be undertaken--thus doing for her what she came to have her doctors do.

Joel D. Howell is assistant professor of internal medicine, history and health services management and policy at the University of Michigan, Ann Arbor, MI.

Carl Cohen is professor of philosophy in the Residential College and in the Medical School at the University of Michigan, Ann Arbor, MI.
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Author:Howell, Joel D.; Cohen, Carl
Publication:The Hastings Center Report
Article Type:column
Date:Aug 1, 1988
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