Risks, Ethics & Sexually Transmitted Diseases
NYU Langone’s High School Bioethics Project offers a learning scenario covering the basics of sexually transmitted diseases (STDs), including types of infections, symptoms, and treatments. Students gain an appreciation of the importance of minimizing risk factors for sexually transmitted diseases and discuss the ethical questions raised by the real-life practice of expedited partner therapy, the clinical practice of treating sex partners of patients diagnosed with chlamydia or gonorrhea by providing prescriptions or medications to the patient to take to his or her partner without the healthcare provider first examining the partner.
Curriculum Integration Ideas
This primer may be used in life sciences and health classes during units that cover the following topics:
- human reproduction
- STDs and prevention strategies
- public policy discussions on physician practice
Types of STDs
STDs are a real and unfortunate result of unsafe sexual practices. They can be transmitted through oral, vaginal, or anal intercourse or contact. There are three main categories of STDs based on what kind of organism is infecting the human body—bacterial, parasitic, and viral. Bacterial infections include chlamydia, gonorrhea, and syphilis.
Ethical Concerns for Physicians Treating STDs
Imagine you are a primary care physician. One day, a long-time patient, Ms. S. who is 18 years old, comes in complaining of a vaginal discharge. After examining and testing the discharge, you determine that she has chlamydia and treat her with a course of antibiotics.
Two months later, Ms. S. comes in again with a similar complaint. Again, it’s chlamydia, and again, you treat her. You remind her that her partner needs to be treated for the infection as well or her treatment will be ineffectual. She assures you that he agreed to be treated. She suggests that perhaps she was reinfected before his treatment took hold.
A few months later Ms. S. shows back up at your office with similar symptoms. You have told Ms. S. to tell her boyfriend to receive treatment every time she has come in. Ms. S. now tells you that her boyfriend has been refusing to go to the doctor. He does not have any symptoms of chlamydia, he doesn’t like doctors, and he doesn’t have health insurance. You tell Ms. S. that there are plenty of public health clinics that can provide the tests and medication at a reduced charge, if not for free. Still, her boyfriend does not want to go.
What should you do? One option is to hand Ms. S. two antibiotic prescriptions—one for her and one for her boyfriend. This way, he will finally get treated and she will not be reinfected. This is called expedited partner therapy (EPT).
A wide variety of ethical issues have been raised by EPT, including patient safety, informed consent, and confidentiality.
EPT requires physicians to prescribe medications to patients they have not actually examined. Although this has the potential to treat STDs in people who are reluctant to see a doctor, EPT also has drawbacks: Ms. S.’s boyfriend might have a more complex health problem requiring a physician’s input and advice. The boyfriend misses out on the opportunity to ask questions about the disease or treatment and present relevant medical history. What if Ms. S.’s boyfriend is allergic to the drug prescribed?
In some states, EPT is legal, and in others it is not because of these safety concerns. In fact, the physician can be sued if anything goes wrong with the patient’s partner. However, the Centers for Disease Control and Prevention (CDC), the branch of the federal government that looks after public health, recommends EPT in most cases since you cannot effectively treat an STD in a patient without treating his or her partner.
What do you think? Is the potential risk for a patient’s partner worth the benefit to the patient and the potential benefit to the patient’s partner?
Another problem with EPT is that the patient’s partner cannot provide informed consent. Normally, a doctor explains directly to a person what the disease is, what its symptoms and complications are, how the treatment is disbursed, and treatment risks. The person then can choose whether he or she would like to engage in this treatment. In EPT, the doctor never actually meets with the patient’s partner. If Ms. S. doesn’t give all the proper information to her boyfriend, then he cannot make a truly informed decision. Further, without the opportunity to ask any questions of the physician, he cannot give informed consent before deciding to take the treatment. Is this fair?
A third potential ethical problem with EPT is confidentiality. When Ms. S. provides the name of her partner to her doctor, or discusses any health problems he has, she violates his confidentiality. The doctor might also ask Ms. S. whether her boyfriend has any health problems before giving her a prescription for her partner. His confidentiality is being compromised if he is forced to discuss his health problems with Ms. S.
What do you think? Do you think it is OK to violate a person’s confidentiality so that their partner can receive treatment? Do you have the right to confidentiality when your actions may harm someone else?
Chlamydia can cause lifelong complications, including chronic pain and infertility. Are confidentiality violations acceptable in cases of chlamydia and gonorrhea, but unacceptable in cases of other diseases like trichomonas that are less likely to cause long-term complications?
If there is a public health concern that a person engages in risky behavior without concern for others’ wellbeing, should the individual still have a right to his or her confidentiality? For example, if a woman is aware that she has HIV but does not want to tell her partners, should her right to confidentiality protect her from having to tell her sexual partners? The CDC and World Health Organization (WHO) do not protect confidentiality in this case because testing, safe sexual practices, and medical treatment are necessary for prevention and survival. Do you agree with the CDC and WHO?
Here are some sample questions to review during this lesson:
- List the three categories of sexually transmitted diseases.
- Which STDs are the most common? Which ones have long-term consequences?
- Identify three ethical issues that arise from the practice of EPT and discuss your stance on each of these.
- What is informed consent? How is it relevant to EPT?
American College of Obstetricians and Gynecologists: How to Prevent STIs
Centers for Disease Control and Prevention: Expedited Partner Therapy in the Management of Sexually Transmitted Diseases: Review and Guidance
Centers for Disease Control and Prevention: Sexually Transmitted Diseases (STDs): The Facts Brochures