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BernieMac

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Just my opinion, but:

-First, ensure that no mistakes have been made, and that it is not possible for the child to have this defect through other mechanisms (e.g. a new mutation)

- It will be important to talk to both parents separately. 

- Linda: Explain to her the significance of the results in terms of implications for paternity. Ask her if its possible that the father is someone else, is she already aware that the father could be someone else, has she spoken to her husband about this already. If not, explain to her that the child's biological father cannot be her husband. Reinforce that you will not break her confidentiality, and that there is no risk to future pregnancies with her husband. I would tell her that you recommend contacting the child's biological father since this could affect his other children as well, but I do not think its your responsibility/ethical to track him down w/o her consent/ force her to get in contact with him. I would try to convince her to explain things to her husband since not doing so will make things very complicated in the future if they want to have more children (I.e. the husband will wonder why the genetic defect is not a concern for future children) 

-Linda's husband: Talk to him separately, and explain that he is not a carrier of the genetic disease. I would also say that it's very unlikely that his future children could be affected. If Linda is willing to explain the child's paternity to him, then present all the relevant info about how that affects things. If not, leave out any information pertaining to Linda.

-Make sure that the follow up care for the child is completed properly, and that he is referred to the relevant specialists as needed, continue to do any follow up testing for him. 

-Ultimately, this is a difficult situation where none of the options are entirely positive. In my opinion, respecting Linda's confidentiality outweighs the husband's right to be told about the exact origin of the child's defect (any cheating that may have occurred), since that will be really disruptive for their family. It will be important to help Linda understand how to deal with this in terms of what her choices are regarding who she tells, and any consequences that can come from choosing to disclose or not disclose the child's paternity. Finally, this situation is especially complicated since you are the doctor for all three people here, and have to weigh options that may help some of the people involved here, but not everyone. 

 

I think you could also argue this in other ways, just make sure you explain your rationale behind your choice, acknowledge all the different options and stakeholders involved. 

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Just my opinion, but:

-First, ensure that no mistakes have been made, and that it is not possible for the child to have this defect through other mechanisms (e.g. a new mutation)

- It will be important to talk to both parents separately. 

- Linda: Explain to her the significance of the results in terms of implications for paternity. Ask her if its possible that the father is someone else, is she already aware that the father could be someone else, has she spoken to her husband about this already. If not, explain to her that the child's biological father cannot be her husband. Reinforce that you will not break her confidentiality, and that there is no risk to future pregnancies with her husband. I would tell her that you recommend contacting the child's biological father since this could affect his other children as well, but I do not think its your responsibility/ethical to track him down w/o her consent/ force her to get in contact with him. I would try to convince her to explain things to her husband since not doing so will make things very complicated in the future if they want to have more children (I.e. the husband will wonder why the genetic defect is not a concern for future children) 

-Linda's husband: Talk to him separately, and explain that he is not a carrier of the genetic disease. I would also say that it's very unlikely that his future children could be affected. If Linda is willing to explain the child's paternity to him, then present all the relevant info about how that affects things. If not, leave out any information pertaining to Linda.

-Make sure that the follow up care for the child is completed properly, and that he is referred to the relevant specialists as needed, continue to do any follow up testing for him. 

-Ultimately, this is a difficult situation where none of the options are entirely positive. In my opinion, respecting Linda's confidentiality outweighs the husband's right to be told about the exact origin of the child's defect (any cheating that may have occurred), since that will be really disruptive for their family. It will be important to help Linda understand how to deal with this in terms of what her choices are regarding who she tells, and any consequences that can come from choosing to disclose or not disclose the child's paternity. Finally, this situation is especially complicated since you are the doctor for all three people here, and have to weigh options that may help some of the people involved here, but not everyone. 

 

I think you could also argue this in other ways, just make sure you explain your rationale behind your choice, acknowledge all the different options and stakeholders involved. 

 

Ya done good up until here.

 

Absolutely not our place to convince the wife to tell her husband anything regardless of how confused he may be in the future.

 

False paternity is boring ethically.

 

Your job as a physician is to:

 

1) Inform both patients individually that they are not carriers of the gene.

2) Inform them that the risk of passing on this defect genetically is zero.

3) Unless this a reportable condition there is no obligation to inform the 3rd party, or public health, but you could suggest to the wife that she should inform the true father if she pleases. Given how this would only work if it was a autosomal dominant or one of the very few y-linked conditions the "other man" must have the condition and would likely be aware (unless there is variable penetrance and or expression).

 

You are not there to give them an intro to genetics course. The potential for the husband to find out he is not the father is there but that is out of your hands if you have done the above. 

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Ya done good up until here.

 

Absolutely not our place to convince the wife to tell her husband anything regardless of how confused he may be in the future.

 

False paternity is boring ethically.

 

Your job as a physician is to:

 

1) Inform both patients individually that they are not carriers of the gene.

2) Inform them that the risk of passing on this defect genetically is zero.

3) Unless this a reportable condition there is no obligation to inform the 3rd party, or public health, but you could suggest to the wife that she should inform the true father if she pleases. Given how this would only work if it was a autosomal dominant or one of the very few y-linked conditions the "other man" must have the condition and would likely be aware (unless there is variable penetrance and or expression).

 

You are not there to give them an intro to genetics course. The potential for the husband to find out he is not the father is there but that is out of your hands if you have done the above. 

 

I definitely see your point and find these ethics things fun, so just to rebut, I would clarify that I would want to discuss telling the father with her (maybe using the word convince was incorrect), but I think you need to discuss this since depending on the husband's knowledge of medical issues/level of education/general personality/inquisitiveness, there is a good chance he would find out anyway since he could connect the dots w/the information he has/ask you further questions about Linda's test results when he finds out he is negative that would essentially require you to lie to keep up the facade (not a good thing) or answer with statements such as "I can't discuss Linda's test results with you" or "I can't tell you without Linda's permission" or "go ask Linda", all things that would likely make him more suspicious. This is why you and Linda need to discuss the best approach to how/if to tell him since he may figure it out anyways, and she may have trouble understanding how everything will unfold since she likely does not have the medical knowledge you do. This is not a question of convincing her to do anything for ethical reasons, but rather to help her understand how things can play out since the ramifications of this situation will have real-life consequences for Linda and her family. Of course, it is ultimately her decision. Hope that clarifies my position! 

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I definitely see your point and find these ethics things fun, so just to rebut, I would clarify that I would want to discuss telling the father with her (maybe using the word convince was incorrect), but I think you need to discuss this since depending on the husband's knowledge of medical issues/level of education/general personality/inquisitiveness, there is a good chance he would find out anyway since he could connect the dots w/the information he has/ask you further questions about Linda's test results when he finds out he is negative that would essentially require you to lie to keep up the facade (not a good thing) or answer with statements such as "I can't discuss Linda's test results with you" or "I can't tell you without Linda's permission" or "go ask Linda", all things that would likely make him more suspicious. This is why you and Linda need to discuss the best approach to how/if to tell him since he may figure it out anyways, and she may have trouble understanding how everything will unfold since she likely does not have the medical knowledge you do. This is not a question of convincing her to do anything for ethical reasons, but rather to help her understand how things can play out since the ramifications of this situation will have real-life consequences for Linda and her family. Of course, it is ultimately her decision. Hope that clarifies my position! 

 

Actually you are required to keep these things a secret. If he really wants to know he can ask her and you should tell him that. Confidentiality is confidentiality regardless is its a spouse. Your job is to tell them the results and that they are okay to have kids, how they deal with the fallout is up to them, but as long as you inform them in a respectful manner and keep confidentiality you're all good I think. but hey I'm not a doctor so what do I know.

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Actually you are required to keep these things a secret. If he really wants to know he can ask her and you should tell him that. Confidentiality is confidentiality regardless is its a spouse. Your job is to tell them the results and that they are okay to have kids, how they deal with the fallout is up to them, but as long as you inform them in a respectful manner and keep confidentiality you're all good I think. but hey I'm not a doctor so what do I know.

 

I agree that you are required to keep these things secret. However, you have to be able to consider this situation realistically. When/if Linda's husband asks you "how is it possible that this condition will definitely not affect future pregnancies given that it's genetic?", or "why did our son develop this condition?", or "does this mean Linda has the gene that caused our son's condition?", you have to actually say something, and consider how whatever you say will play out. In my interview experience, interviewers will really press you on this type of thing since you could potentially being dealing with this situation in real life. 

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You are a genetic counselor. One of your clients, Linda, had a boy with a genetic defect that may have a high recurrence risk, meaning her subsequent pregnancies has a high chance of being affected by the same defect. You offered genetic testing of Linda, her husband, and their son to find out more about their disease, to which everyone agreed. The result showed that neither Linda nor her husband carry the mutation, while the boy inherited the mutation on a paternal chromosome that did not come from Linda's husband. In other words, the boy's biological father is someone else, who is unaware that he carries the mutation.

You suspect that Linda nor her husband are aware of this non-paternity. How would you disclose the results of this genetic analysis to Linda and her family? What principles and who do you have to take into consideration in this case? 

 

Thank you

 

Also, it could just be a de novo mutation :)

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Actually you are required to keep these things a secret. If he really wants to know he can ask her and you should tell him that. Confidentiality is confidentiality regardless is its a spouse. Your job is to tell them the results and that they are okay to have kids, how they deal with the fallout is up to them, but as long as you inform them in a respectful manner and keep confidentiality you're all good I think. but hey I'm not a doctor so what do I know.

 

This are always fun :)

 

You would tell the mom she is not a carrier in isolation (unless she wants him in the room), the father he is not a carrier in isolation (unless he wants her in the room), and tell them both the child does have the mutation.  If done in isolation the father is likely to think the mother is a carrier or it is a denovo mutation. That is fine ethically speaking. 

 

The real question is should the child know I think. Note the question says the doctor did test the child - that means that child is ALSO a patient and you cannot I think ignore that. Do  you tell him that neither parent gave him the mutation explaining that could mean it is a denovo mutation or there is another father (after all the child is your patient as well, and it is perhaps in his medical interest to know there is another person out there who is his father as that person's family medical history may be relevant to his future medical needs. Also it means that he won't have to worry about medical conditions that may be on the husband's family - and thus be not need certain screening tests. As we get more and more into the genetics of disease and have targeted treatments this sort of thing becomes important. 

 

Now if you are going to argue above that the child is not mature enough to know and make decisions based on that then you can perhaps decide to hold off telling him for now. The only issue about that is the parents are considered to be proxies until he is mature enough - and there may actually be cases where that knowledge is important medically to that child - let's say he now gets leukemia and a bone donor needs to be found. Once again knowing the background of the true father now becomes maybe medically important and both parents as proxies would need to know that information.

 

somewhat unrelated this is the big push coming down along the lines that people have the right to know their family history - this results in say sperm donors being "unmasked" as it were, or adoption records unsealed. If those are actual rights then does a child in such a case as this have a right to know? If so does that right override aspects our medical ethics? Nothing after all is truly absolutely in ethics ha :)

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I agree that you are required to keep these things secret. However, you have to be able to consider this situation realistically. When/if Linda's husband asks you "how is it possible that this condition will definitely not affect future pregnancies given that it's genetic?", or "why did our son develop this condition?", or "does this mean Linda has the gene that caused our son's condition?", you have to actually say something, and consider how whatever you say will play out. In my interview experience, interviewers will really press you on this type of thing since you could potentially being dealing with this situation in real life. 

Absolutely interviewers will push on you, and in this case they are trying to get you to say the wrong thing which in this scenario is anything along the lines of the husband finds out. This whole scenario is designed for you to withstand the pressure and stick to what is right which is 1) respecting your patient's individual privacy 2) safeguarding your patient's private information even in marriage 3) knowing what your role is.

 

This is designed to trip you up in exactly that way, they want you to get hung up on "he is going to find out anyway". Doesn't matter! There is no "practical" argument to me made here. There is your legal and binding duties to maintain this patient's secret, even from her husband.

 

You can't even tell the real father either because he may not even know about the kid's existence. 

 

If I am marking this station and any combination of words you make results in you 1) pressuring the mom to "come clean" 2) tell the real father 3) tell the husband he isn't the father, you fail. And I will make you uncomfortable, and I will say things like "he is going to find out anyway he isn't dumb, he can just google it". You need to know your professional obligations and your legal boundaries and you need some guts to know when you are right.

 

I remember an OSCE where the scenario was giving someone antibiotics for an URTI, it was 8 minutes of an actress pleading and she was really good. She got mad, threw things. You failed the second you caved.

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