AMA Journal of Ethics^®

Case

Mr. Seabrook, a telephone company employee, decided to visit the health clinic near his workplace because he had a burning sensation when urinating and occasional discharge. Dr. Ellis was staffing the clinic and welcomed him into his office. Mr. Seabrook was a young man in his 20s, and Dr. Ellis recognized his patient's symptoms as probable signs of a sexually transmitted disease. When Dr. Ellis took a sexual history, Mr. Seabrook answered that he had a girlfriend of 3 months who lived in the same town. Dr. Ellis then tested Mr. Seabrook for gonorrhea and chlamydia.

"I'll prescribe some antibiotics to treat the infection, which I think is very likely to be a sexually transmitted disease," said Dr. Ellis. "There are two different pills—one you take just once, and the other you continue taking twice a day for 7 days. Once the test comes back and we know for sure what the infection is, we can discontinue one of those pills." Mr. Seabrook nodded his head, took the prescription, and stood to walk out of the doctor's office.

But Dr. Ellis asked Mr. Seabrook to stay because he wanted to discuss another important matter. Dr. Ellis explained that it was critical that Mr. Seabrook's girlfriend also get medical care because it was very likely that she had been infected with chlamydia, and if she didn't get treatment, she would pass the infection right back to Mr. Seabrook once he finished his course of antibiotics. Furthermore, Dr. Ellis explained that the infection could cause more serious problems for Mr. Seabrook's girlfriend, such as infertility, ectopic pregnancy, and chronic pelvic pain. "Can we schedule an appointment for her to come in and see me Monday? It will be a brief exam, the same test I did for you, and I could give her a similar prescription if she turns out to have the infection too."

"Actually," said Mr. Seabrook, "I don't think she'll come in to see you. She works two jobs and we live about 45 miles from here. I only came here because it's near my job. Oh, and she doesn't have health insurance."

Dr. Ellis knew the importance of treating Mr. Seabrook's girlfriend and thought of giving Mr. Seabrook a "partner packet"—a course of antibiotics that Mr. Seabrook could give his girlfriend. He feared, however, that Mr. Seabrook might miscommunicate the necessary medical information in delivering the drugs to his girlfriend. Maybe Mr. Seabrook would be too embarrassed to talk about STDs and never give her the drugs. Moreover, Dr. Ellis felt ambivalent about prescribing for someone he had never met or examined before, and whose medical history and drug allergies he did not know.

Commentary 2

This case outlines a number of issues that have long concerned thoughtful practitioners: issues of trust, effectiveness, safety, confidentiality, liability, and public health. While there has been a recent flurry of policies and publications in this area, the concerns are not new, though perhaps newly nuanced [1-3].

Physicians have a proud tradition of commitment to provide ideal care. They also have obligations to do no harm and help patients whenever they can. As is obvious from this case, it is not always possible to honor those commitments at the same time. Failure to treat both this patient and his partner will continue to expose the patient to chlamydia if their relationship continues, and, even if it does not, his partner is a reservoir of disease that presents a threat to public health. Ideal care would be the simultaneous medical evaluation and treatment of the patient and all of his sexual contacts. The patient in this case has told Dr. Ellis that his partner will not seek medical evaluation. Thus, the practitioner is faced with a choice of less-than-ideal strategies. Which professional imperatives should be honored and which should be ignored?

The provision of therapy for sex partners of patients with certain sexually transmitted diseases, primarily chlamydia, without an intervening medical evaluation or professional prevention counseling is known as expedited partner therapy—named because the treatment is delivered at the discretion of the patient [1, 2].

For years, practitioners surreptitiously provided double doses of therapy to patients with STDs, intending that one-half would be taken by the patient's partner. This was generally done in circumstances where the partner would be unlikely to seek medical attention. The strategy was assumed to be the best practical way of preventing disease recurrence from exposure to a known source of infection. Frequently it was undertaken in violation of state licensing laws that explicitly required an established patient-physician relationship as a condition of treatment. It was also usually performed in the absence of prepared educational material and with great variety in the content and quality of patient instruction. Even today, less than one-quarter of state medical practice laws explicitly approve expedited partner therapy [3].

In the last few years, the Centers for Disease Control and Prevention [1] and the American Medical Association [2, 4] have collaborated on a series of recommendations that clearly outline the circumstances and requirements for the appropriate use of expedited partner therapy. These recommendations are: (1) use only in certain circumstances—currently gonorrheal and chlamydial infections in heterosexual women and men—when other management strategies are impractical or unsuccessful; (2) do not use for the treatment of syphilis or trichomoniasis or for men who have sex with men; (3) encourage the intended recipient of expedited partner therapy to seek medical attention in addition to accepting therapy; (4) educate the recipient through written materials that accompany medication, by counseling of the index case, and, when practical, through personal counseling by a pharmacist or other professional; and (5) be aware of state practice laws and regulations and public health requirements that limit the use of expedited partner therapy.

In addition to providing quality care for their individual patients, physicians have a health policy role. Principle III of the AMA's Code of Medical Ethicsstates, "A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient" [5]. With the increasing recognition of medical and public health benefits of expedited partner therapy, physicians are encouraged to work with their state legislatures and public health agencies to remove legal and regulatory impediments to its use.

How do these policies pertain to the care of Mr. Seabrook in the above case? Certainly Dr. Ellis was correct to inquire about Mr. Seabrook's sexual partner. Yet, he should not assume that Mr. Seabrook has a single, heterosexual partner. A more open-ended inquiry, such as, "Can you tell me about your sexual activity," could have opened a door to possible acknowledgement of more than one partner or same-sex experiences that would have influenced management significantly. For instance, expedited partner therapy is not recommended for partners of men who have sex with men even if they also have heterosexual partners.

How should Dr. Ellis consider the observation that Mr. Seabrook's girlfriend lacks health insurance? This should not change the clinical recommendation that she receive medical evaluation and treatment, although it may influence her decision of where to seek care.

Dr. Ellis is fortunate to have a "partner pack" available. This implies that some forethought has been given to expedited partner therapy on the health clinic's behalf. The educational packet for the patient and his partner regarding infection with gonorrhea and chlamydia should include information to facilitate the sensitive discussion between a naive patient and his or her partner that encourages the partner to seek medical care.

If Dr. Ellis concludes that expedited partner therapy is the best course of action in this situation, he must give some thought to how the therapy will be delivered. He could write a prescription in the name of the person that Mr. Seabrook identifies as his partner. If Mr. Seabrook is uncomfortable providing such identifying information, Dr. Ellis might be tempted to double the dosage of the medication he prescribes for Mr. Seabrook, but this could be a violation of state regulation and perhaps even insurance fraud. A third option is to write a prescription for the indicated medication(s) while leaving the name of the patient blank. Unfortunately, this, too, may be a violation of state regulation.

The ideal decisions for Dr. Ellis to make are: (1) obtain as complete a sexual history from Mr. Seabrook as possible; (2) review the partner pack to assure that it contains thorough and sensitive clinical information intended to persuade the partner to seek medical care for the exposure and evaluation of possible concomitant health problems; (3) write a prescription for an unnamed patient for the indicated medications in the event that the partner elects not to seek medical attention; (4) report Mr. Seabrook's infection in compliance with pertinent regulatory requirements; and (5) advocate for changes in a state law or regulations, if necessary, to remove impediments to expedited partner therapy.