To tell or not to tell?

The author took two very different approaches to two cases of genital herpes. What would you do?

By Elisa Payne, MD
Family Physician/Cuero, TX

As a medical student five years ago, I received little more than a cursory education in ethics. Toward the end of our fourth year, we had a two-week series of lectures covering ethics and other topics that didn't fit comfortably into the traditional curriculum. The lectures consisted of case studies illustrating issues like autonomy, compassion, and paternalism. The cases seemed contrived and silly, with obvious right and wrong choices.

Paternalism in particular struck me as an outdated concern. Given my age and gender, I figured I'd never make the error of deciding what my patients should or shouldn't know, or what they would or wouldn't understand. I'd definitely keep them fully informed. Two cases I encountered in my first year of practice showed me how naive I was.

Telling the patient what she doesn't want to hear

After graduating from residency, I worked at a small family practice clinic in South Central Texas. Since my patients there were new to me, I generally took a more complete history than their presenting complaints required. I'd been working at the clinic about four months when Maria Garcia (I'm not using real names) showed up with a painful "rash" on her bottom. She'd had the rash for several days, and, based on her description, I thought it was most likely a folliculitis.

Mrs. Garcia, a 54-year-old Latino woman, was basically in good health for her age. She had osteoporosis and mild hypertension that she controlled with an ACE inhibitor. Her three children were grown, and she was in a stable relationship with her husband of 34 years.

When I examined Mrs. Garcia, I realized my initial guess of folliculitis was wrong. Instead, I saw a cluster of clear vesicles on an erythematous base on her left buttock, about an inch from her anus. The findings were classic indicators of a herpes simplex type 2 infection. I unroofed a vesicle and took viral and bacterial cultures.

I tried to be compassionate and sensitive as I explained my findings to Mrs. Garcia and told her my probable diagnosis of genital herpes. To my surprise, she was shocked and angry at my suggestion that she could have a sexually transmitted disease. Unprepared for her anger, I recanted my presumptive diagnosis, telling her we'd know more when the cultures were complete.

She called me for the report once or twice each day until the culture results came back. Sure enough, they were positive for HSV-2. When I gave her the news, she listened silently, then told me I must have made a mistake, and hung up.

Although her reaction seemed unreasonable, it was understandable. She was in a presumably monogamous relationship with her husband. She had never engaged in an extramarital affair, and she couldn't accept the idea that he might have done so. It was easier to believe that my diagnosis was wrong.

I saw Mrs. Garcia several more times over the following years for the management of her hypertension and for her annual gynecologic and breast exams. Initially, I tried to discuss the herpes diagnosis with her, and told her she should be tested for other sexually transmitted infections. I wanted her to understand the treatment options in case she developed recurrent genital herpes. She refused to discuss the issue, however, and made it clear that she would stop seeing me if I persisted in bringing it up. So I stopped trying.

Using discretion to avoid confrontation

During the same period, I saw other patients with various sexually transmitted diseases. Most had complaints that suggested infection, such as dysuria or vaginal discharge, or had known exposure. I treated each of them without difficulty, and without a fleeting thought of Mrs. Garcia.

Then Jane White showed up, a 67-year-old woman who'd first come in a year earlier for her annual physical. Mrs. White had no serious health problems other than osteoarthritis. She had two grown children and had been married for 20 years to her second husband, an evangelical Baptist preacher. An avid fitness buff, she walked or bicycled daily, and she adhered to a strict vegetarian diet.

I was pleased to see Mrs. White; she was my first patient to return for a second annual physical. Her health and social status were unchanged. During the pelvic exam, however, I noticed a rash on her inner right buttock, close to the perineum. When I questioned her about it, she replied that it had appeared intermittently for about two years, usually lasting only five to seven days. She attributed it to pressure from her bicycle seat.

The rash was similar to Mrs. Garcia's, and very suggestive of HSV-2 infection. Again my clinical impression was genital herpes. I paused for a moment to think, however, then continued the exam without further comment on the lesion. When I finished, I pronounced Mrs. White in good health. I congratulated her on her healthy lifestyle, and told her to come back in a year.

Later, when I thought about what I'd done, I began to regret my dishonesty. It had been surprisingly easy to ignore my findings and let Mrs. White believe that her bicycle seat was the cause of her problem. I had slipped into the "old-fashioned" paternalism I'd so smugly rejected just a few years before, and that bothered me.

Should I call Mrs. White and have her come back for tests to pursue the herpes diagnosis, I wondered? Or should I just leave things as they were? Ultimately, I decided that pursuing the problem would be unnecessarily traumatic for her, so I did nothing.

The trouble with ethics: no easy answers

I continue to question the wisdom of my decision not to discuss my suspicions with Mrs. White. Of course, my unfortunate experience with Mrs. Garcia strongly influenced me. I still feel that objectively discussing the diagnosis with Mrs. Garcia was the right decision. Her irrational response, however, and her inability to accept the information meant that she didn't benefit from my diagnosis.

Her reaction showed me how traumatic the idea of herpes can be for some women. Because of her religious beliefs and moral code, she didn't have the option of leaving her husband, even if he had been unfaithful. Although the diagnosis must have caused her doubts about her relationship with him, she was unable to act on the information. So I had probably done her more harm than good.

I'm still not sure how Mrs. White would have reacted upon learning she could have a sexually transmitted disease. She might have responded as Mrs. Garcia did, or she might have taken the news with equanimity.

I don't think my decision not to tell her was right; but then I don't think it was wrong, either. I justify it with one thought: She hadn't asked me what the lesion was. If she had, I'd have told her my clinical impression and performed tests to confirm the diagnosis.

Perhaps Mrs. White didn't ask me about the lesion because she had her own suspicions and didn't want to hear the truth. Or maybe her suspicions prompted her to come in for her annual physical, guessing that I'd notice the lesion and pursue it. I'll never know.

No other ethical dilemma I've encountered has affected me as much as this one. I've found that the most difficult ethical issues aren't always the most dramatic, and the answers certainly aren't always obvious or simple.

Sometimes, it's just not easy to decide.

 

Elisa Payne. To tell or not to tell?. Medical Economics 2002;9:101.