Safeguarding: Ethnicity and Ethics

This situation is more of a hypothetical, whilst based on a real situation the patients confidentiality is assured by the fact I cant remember most of the specific details and as a result have confabulated. I should also stress the question I am exploring is not related to the safeguarding concern for which I was supporting the patient.

Because referring to her as “the patient” is going to get very annoying very quickly, lets call her Debbie.

Debbie entered the country three years ago but did not enter through any of our ports. As such she had no visa and the home office and other authorities were completely unaware of her. She was living with a family somewhere up north and in exchange for room and board was providing domestic services and childcare. I can feel daily mail readers everywhere raging at this situation but I need to stress this is a genuine safeguarding concern. An individual in this situation is at extremely high risk of abuse and exploitation. If the authorities are unaware of her she doesn’t have access to health or social care or any form of legal protection. In the eyes of the state at this point she doesn’t exist. This specific situation is tragically extremely common. It is so common that I am certain summarising Debbie’s situation does not constitute a breech of confidentiality.

Debbie had a one night stand with a gentleman whose name remains unknown to her and fell pregnant. I am unconvinced there hasn’t been an element of sex work or sexual exploitation however was unable to verify this feeling. Because of the pregnancy the family she was staying with decided to ask her to leave. I suspect because the birth of a child and the need for antenatal care would probably draw attention to their exploitative relationship with a young lady who was residing in their house illegally. With no money, no friends or family in the country and no means of accessing housing she went to London and presented to a hospital where he was found to be about 30 weeks pregnant.

There is a lot more to this story however this is where my question comes in. Debbie is from an African country where a reported 20% of women have HIV. We know that reporting in this particular country is sub-optimal and the real number of women with HIV is likely to be significantly higher. She presents to a hospital having not seen a health practitioner since childhood and is now pregnant. Would you routinely screen her for HIV?

The reason I am questioning this is because the basis for an HIV screen would be entirely one of ethnicity and should we be treating one person differently to another based entirely on where they come from? However there are implications for her unborn baby and her mysterious Casanova. You could simply ask her if we could perform a viral screen however how would you respond if she declined? We don’t insist on any tests in a capacitous patient if they decline, it would be a tremendous violation however there are implications beyond the rights of this individual. If we test without her knowledge or consent we still need to overcome the unethical basis for the test.

This isn’t a matter of Safeguarding or Mental Capacity but a matter of Clinical Law so thankfully I would never be asked to advise on a situation like this. I would however be interested in the thoughts of my readers so please comment below.

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