My patient, a 26-year-old native of the Dominican Republic, had been seeing me for only a few months when I determined that he had been infected with HIV. He didn't seem surprised but was close-mouthed about his sexual orientation or where he might have contracted the virus.
I began to caution "Miguel" about unprotected sex, but he insisted that he didn't have, or plan to have, a lover.
As his T-cell counts dropped and his viral counts rose, I referred him to an infectious disease expert who began treatment with anti-retroviral drugs. After several months of this treatment, the counts stabilized, and he remained relatively healthy, though he was frequently depressed.
Four years later, he sent "a close friend" to see me. The friend, also a Dominican, had been brought into the country three years before by Miguel, who had then helped him establish citizenship. Now the friend was returning the favor by marrying Miguel's sister so she could become a U.S. citizen.
The friend, "Carlos," and the sister had come to see me at the same time. In my visit with her, she immediately revealed that the marriage was in name only and that her husband was gay. I saw Carlos next, and he openly acknowledged being gay and asked me to test him for HIV as part of his routine blood work.
The test came back positive, and I called him back to my office to discuss the results. During that visit, Carlos readily admitted that Miguel was his lover -- and feared that he had unintentionally put Miguel at risk. At that point, I realized Miguel had never told his lover that he had the virus.
The truth slowly dawned on Carlos as well. Although initially afraid that Miguel would be angry, he then recalled that he had tested negative for HIV just nine months before. "Did Miguel give me this?" he asked. "Does he have it?"
"You have to ask him," I replied. "I can't say."
Although Carlos may have thought I was communicating the necessary truth by not denying it, I not only owed my patients confidentiality, I was bound by law from revealing one patient's information to another.
Carlos was surprisingly calm, saying he still loved Miguel despite having been seduced into becoming his condom-less lover years before.
My office nurse, who had spoken with Carlos and knew the circumstances, described Miguel's apparent silence on his HIV status as attempted murder. That comment caused me to examine the laws regarding HIV disclosure more closely -- and my own actions.
My hospital's legal counsel informed me that I wasn't under any legal obligation to inform someone at risk, though I was required to report HIV patients and known partners to the health department. On the other hand, according to the American Medical Assn.'s code of ethics, "If a physician knows that a seropositive individual is endangering a third party, the physician should, within the constraints of the law (1) attempt to persuade the infected patient to cease endangering the third party; (2) if persuasion fails, notify authorities; and (3) if the authorities take no action, notify the endangered third party."
Ultimately, in Carlos' case, the point was moot -- it was too late to warn him. He already had acquired the virus.
The state law of New York, where I was practicing, allowed for prosecution of people who were deliberately spreading HIV, but for a physician to suspend his code of confidentiality and turn a patient in would seem to require certain knowledge that such an act was about to take place.
If I believed that Miguel intended to do this again with someone else, then I would have considered whether I had an obligation under the law to report it. But I didn't know. I still don't.
I felt horrible for the man manipulated into posing as a husband for his lover's sister while receiving HIV for histroubles.
I also felt uneasy in my role as messenger.
Meanwhile, I still had to be careful about what I said about Miguel's HIV, while he himself was forgiven and even loved. His sister, who remained my patient, luckily had been a wife in name only, so she was spared.
But I wondered -- and still do: What would I have done if I had surmised this situation before the virus had been transmitted?
I'd had many patients with HIV over the years, and had warned these patients on several occasions about the risk of transmission, but this was the first time I suspected one had refused all responsibility for his partner's safety.
If I had known in advance, would I have found the legal and ethical basis to warn Carlos? Or would I have had to let it happen?
Further, going forward, how can I find an effective way to warn potential victims if I don't always know who they are? Sometimes medicine is too complicated to be practiced fairly -- or with any moral gratification.
Dr. Marc Siegel is an internist and an associate professor of medicine at New York University's School of Medicine. He is also the author of "False Alarm: The Truth About the Epidemic of Fear." He can be reached at firstname.lastname@example.org.