In the recent episode, "Thy Will Be Done," we saw a very disturbing little subplot involving a gay couple, one of whom was HIV+ and one of whom was not--and the one who was not infected was trying to contract the disease, under pressure from his partner and apparently suffering from very low self-esteem.

My question is, would it have been feasible for Dave to have called for a psyche consult in this case? I would think he'd be presenting a pretty clear danger to self. If not--why? It's been bugging me.

Barring that, could the HIV+ man been brought up on any kind of endangerment charges? Since he knows of his disease, and does nothing to prevent spreading it...(Of course, they'd probably need his partner to press charges, and that didn't seem likely.)

-- Cecelia (evilstoat@hotmail.com), February 10, 2001

Answers

Good point. Dave should have called for a psych consult (they seem to call them for every little thing on this show), but I don't think it would have done any good. The HIV+ man was too dominant and heedless of the safety of his partner. Jeff (?) was endangering his life, but I don't think they would admit him involuntarily for this.

I don't think endangerment charges would apply, because he did inform his partner that he had the disease. It would be up to his partner to insist on condoms.

-- Kate (yfpy0050@yorku.ca), February 10, 2001.

What good would it do? You cannot hold a person against their will. He was not a danger to others. All he wanted to do was slowly commit suicide. Do you lock up smokers or bad drivers?

-- Zorbo (RDomino1@aol.com), February 11, 2001.

"You cannot hold a person against their will."

Of course you can, under certain circumstances. Hence the phrase "involuntarily committed."

But my question wasn't about holding him per se, but having psych come and talk to him, regardless of whether or not they have any power to hold him. (Legaspi: "He tried to harm himself. We're supposed to be called.") Someone who's just careless about their own health (such as a smoker or a bad driver) is, in my opinion, very different from someone who is actively seeking to contract a fatal, incurable disease. I fail to see how that's not at least somewhat psychotic (or some other technical term for mentally disturbed). I would think that this case would cross the line between indifference to one's health and actual intent to harm oneself.

I'd be interested to hear the opinions of anyone who works in health care/legal professions. If a doctor has knowledge that something like this is going on, can they really just throw up their hands helplessly after giving a PSA about condoms? Or do they have any obligations, legal or ethical, to step in?

-- Cecelia (evilstoat@hotmail.com), February 11, 2001.

In my state there is a 72-hour hold for eminent dangerousness to self or others. The key word here is eminent. I agree that psych should have been called so they could have at least documented that they had done every thing possible to protect and inform this man. This storyline reminded me of a one where Mark was trying to talk sense into a man being physically abused by his male partner. Does anyone know which episode that was?

-- violet (violet@pon.net), February 11, 2001.

Cecelia, Thank you for putting the comment that Malucci made as the heading for this thread. I listened to that comment, and I swear he called them "butt-chasers"!!!!! I couldn't beleive a comment like that would have gotten past the censors. I think I need a new tape in the VCR, the sound is getting fuzzy on the old one...... ;)

-- Lolina (lolina_69@hotmail.com), February 11, 2001.

Violet, the episode you're thinking of was "The Domino Heart"; and yes, that was my thought--that psych should be called so that at the very least, the situation could go on record. Presumably, it wouldn't be considered imminent danger--but that might be open to interpretation.

-- Cecelia (evilstoat@hotmail.com), February 11, 2001.

I'd be interested to hear the opinions of anyone who works in health care/legal professions. If a doctor has knowledge that something like this is going on, can they really just throw up their hands helplessly after giving a PSA about condoms? Or do they have any obligations, legal or ethical, to step in?

Legal, probably not. Ethical, absolutely. The primary duty of a physician is to prevent harm; contracting HIV is a pretty harmful thing, so we should do everything possible to prevent it. This can be hard to do in a society where we've decided that people have the right to go to hell in a handbasket if that's their choice, so a fine line has to be drawn between allowing everyone to slip into oblivion versus confining everyone who shows even remotely self-destructive tendencies.

The issue for me is one of choice -- I'm not certain that the guy trying to contract the disease was capable of making the distinction. I got the impression we were supposed to think that, at least superficially, he'd though this through and figured out exactly what was going to happen to him (carefully weighing the risks and benefits), but something twigged in the back of my mind and made me wonder exactly how much autonomy went into this decision. It reminds me a lot of a kind of sick combination between someone with a life- threatning eating disorder in an abusive relationship: The victim is trapped in a situation they don't know how to escape (dependence, real or imagined, on another person) and that entrapment will ultimately lead to their premature death.

It's not a perfect analogy, but it works because it illustrates how this kind of thing falls between two areas of fairly clear practice -- in domestic violence situations, there is an obvious course of action; in life-threatening eating disorders, there is an obvious course of action. No such clarity exists here, and while part of me would like to think it was deliberate, I don't think the writers are that smart.

The ethical responsibility, I think, is the same as for the aforementioned anorexic -- and the legal and medical remedies are about the same (i.e., virtually none). Given this, and the fact that we necessarily allow people a huge degree of autonomy in how they choose to live their lives, I have a hard time faulting Malucci's approach -- there's really nothing else that could be done. Would a psychiatric visit help? Sure. It might have helped the guy see the error of his ways with regards to his dependence on his partner (that was creepy), but that kind of transition takes a long time and by then it probably would be too late to matter. Is it possible that he would have been placed on involuntary hold? Nah.

I think the plot left many people with an icky feeling in their mouths because it draws a big red circle around the conflict faced by a lot of physicians feel when their patients knowingly engage in risky behavior. "I can't stop this, but I feel compelled to help them; what the hell do I do?" The answer, crass though it may seem, cold-hearted though it may be, is to let it go, fight the fights you can win, and hope the ones you have to lose are smaller than the ones you don't.

-- Mike Sugimoto (phloem@fumbling.com), February 11, 2001.

'Pick your battles...' I understand why that thinking would be neccessary, but that's hard enough for me to swallow in my profession! I *hate* throwing in the towel, and saying, 'Save it for another day.' I can't imagine being a doc dealing with life and death and trying to sell myself that one. I think I'd crack after a while...

I was too caught off-guard by the 'bug-chaser' termonology. Please forgive my ignorance, but is this a term exclusively used in a derogatory manner in reguard to H-I-V or does it apply to anyone trying to contract an illness?

:) Jenna

-- Jenna (JennaLunt@aol.com), February 11, 2001.

Mike's post reminded me of the episode "Loose Ends," in which a patient who is clearly anorexic/bulimic cannot be admitted because, according to De Raad, she didn't present an imminent danger to herself. (That truly baffles me, since she was looking fairly imminently ill, but I'm not a doc. Jesus, how far does it have to go before they look imminent enough?) This being "ER," Corday of course overstepped her bounds and contacted the (adult) patient's mother, to no avail. But, at least she made the attempt to get the woman help by calling the psychiatry department...

"The issue for me is one of choice -- I'm not certain that the guy trying to contract the disease was capable of making the distinction."

I got that impression as well; his use of phrases like, "He feels contaminated if I make him use a condom [paraphrasing]," and "He's all I have," seem to indicate a pretty domineering person controlling him--like, say, an abusive spouse. But we all know (some of us first-hand) what it's like trying to persuade someone who's being abused to get out of those relationships.

"The answer, crass though it may seem, cold-hearted though it may be, is to let it go, fight the fights you can win, and hope the ones you have to lose are smaller than the ones you don't."

Of course, this being "ER," we might see Dave go on a little Good Deeds Run a la Carol/Lucy/Abby/just about everyone else, and pay the boy a visit. You know, 'cause people can just take off in the middle of their shifts and do stuff like that all the time. ;)

-- Cecelia (evilstoat@hotmail.com), February 11, 2001.

Mike is right. There really isn't anything legally that Dave could do for this man. Even if you subscrib to the abuse theory, which this is, there are few states, California being one of them, where you are obliged by law to report interpersonal/domestic abuse. Everywhere else you just give them your best advice & hope they get out of the situation. If Dave could have gotten the guy to stay long enough to see psych, I doubt they could do any better. Stabbing oneself in the abdomen with a pair of scissors is a bit different from having unprotected sex with someone HIV+ in the eyes of the law. That the HIV- guy knew of his partner's HIV status, he is not being exposed without his consent. I think Dave did the best he could under the circumstances.

-- (ripwomam@aol.com), February 12, 2001.

I'm a little confused about that last post--are you saying that it is abuse, to which the HIV- man is submitting, or that it's consensual behavior into which he willingly entered? The word "consent" seems unusual to use here.

-- Cecelia (evilstoat@hotmail.com), February 12, 2001.

This may not come out worded right, so bear with me. Isn't it the law that medical professionals have to report cases of HIV infection to the Health Department? I remember my mother had to report me to the HD when I had the Chicken Pox - I think it's the law for all communicable infections, right? And I know there have been instances where charges have been brought against individuals who knowingly have unprotected sex while infected. I don't know if this changes the legal aspect of having to report this kind of activity, but it seems like the boyfriend is contributing to the spread of a very serious disease, whether it be consensual or not, and something should be done.

-- Cathy (cybercathy@wi.rr.com), February 12, 2001.

In Deb's first episode back, I'm thinking "Family Matters" when the guy had gonnerhea (sp) and she wanted to tell the wife. She wanted to call the health department because he had it, and have them tell the wife. I know close to nothing about this, but if they called for gonnerhea, I would think they'd call for HIV.

As for Dave, I don't think he could have done much else. He was the most sensitive we've ever seen him, and I can't help but think about "Truth and Consequences" when Dave couldn't help Quinn and got Lucy to explain the dangers and facts to her. I think he explained everything best as he could, and the patient seemed pretty set to continue doing what he was doing.

-- Joanne (bucklind@hotmail.com), February 12, 2001.

"Isn't it the law that medical professionals have to report cases of HIV infection to the Health Department?" Their patient (Jeff?) didn't have HIV. He said that his partner (Sean?) did, but Sean wasn't their patient and they didn't test him. For ethical discussions, http:// www.bioethics.net/ has an essay for each ER episode but they don't seem to be discussing this plot.

-- Driad (driad@mailcity.com), February 12, 2001.

this isn't necessarily in response to the post at the top, although the legal question set it off. was anyone paying attention when jeff and sean gave their ages? for some reason i have it in my head that jeff was 16 and sean was around 23. would that be statutory rape, then?

-- elizabeth (efields01@yahoo.com), February 15, 2001.

Elizabeth, there is no easy answer for that question. Almost every state has different rules about that, some states it is 12 others it is 18.

-- Kelley (takel@earthlink.net), February 15, 2001.

Actually, it was Jeff {the HIV- one} who said he was 23.

And, out of curiosity, what states are there in which having sex at 13 is not statutory rape? A cutoff of age 12 seems awfully young, even for the United States...

-- Cecelia (evilstoat@hotmail.com), February 15, 2001.

I think (but I'm not sure) that in Florida and a few other Southern states the cut off age is very young (like 15). I think Florida is 13 but again I'm not sure. In some states, like Massacusetts the legal age of someone is a grey area. For legal matters it is 17 but a for the age of majority it is 18, so parents are responsible for their kids until their 18th birthday. I think that makes the age of consent 18, even though someone can be charged with a criminal offense at 17 (of course there are special provisions for charging juveniles as adults in violent cases but those are special cases).

-- Kelley (takel@earthlink.net), February 15, 2001.

I know that in Iowa, the legal age is 13, unless the older partner is more than 6 years older than the younger; if that is the case, the younger partner must be 16 to consent. I know many states are this way. Also, in many states, statutory rape laws can only be applied where the underage party is female (which is constitutionally hunky-dory, according to the Supreme Court).

-- Laura Lindstrom (llindstr@law.harvard.edu), February 15, 2001.

As a 10 year survivor I hope I can help with a couple questions..When I was diagnosed in 1990,I was in the Marines.The health department was notified.A women from the Health department cam out to see me and I voluntarily filled out a questionaire...I was military as I said and I had to sign an agreement that I would always notify my partners,which in my case was a given anyway.I have heard the term bug cathcer and even dealt with a few,especially online.Things like IMs with people asking me to give them the virus etc,sickening really...I believe that since the kid knowingly slept with him there is no recourse.had he not been informed he could have pressed charges.In case anyone is wondering,my health is excellent.The virus is undetectable in my bloodstream and my tcells are around 400.I have not had worse then a cold in 10 years

-- Jennifer Mac Donald (Jennimomabc@aol.com), February 16, 2001.