Read the Case-Based Curriculum for Neurology Residents.

Case
Samuel Smith is a 4l-year old computer specialist who has been referred by his primary
care physician, Dr. Richard Blue, to Dr. Alice Whire, a neurologist, for evaluation of a recent
seizure and an abnormal findings on a CT scan. Mr. Smith became Dr. Blue's patient when he
began work for a new employer. Both Dr. Blue and Dr. White have conracts with WeCare, the
managed care plan in which Smith is enrolled, and WeCare has approved the referral. Dr.
White's contract with WeCare call for reimbursement on a discounted fee-for-service basis; she
is eligible for a year-end bonus if she achieves the srarus of "efficient providers" for any
particular year. One criterion for this designation is "prudent" ordering of diagnostic and
treatment measures for plan enrollees.
Mr. Smith has HIV disease. Prior ro the seizure, he had been doing well on triple-therapy
that includes 2 protease inhibitors. over the months preceding the seizure, he began a new fulltime
job as a compurer troubleshoorer, regained weight that he had previously lost, and his
plasma HIV-RNA titres are now undetectable. Smith engages in sexual acrivity, including an ongoing
heterosexual relationship with a woman who is employed by one ofhis company's clients,
and occasional homosexual activity with various panners at a private club. He always uses
condoms in hererosexual acrivity, but only "sporadically" in his bomosexual activities. He has
not told any of his sexual panners of his HfV status.
Smith has nor informed his currenr employer of his Hrv starus. He did not tell Dr. Blue
he has HrV disease, bur did inform Dr. white because of a concem the seizure "might have
something to do with HrV." Mr. Smith is currently relying on his salary and accumulated
savings to pay for his antiretroviral drugs that iue being prescribed - at a discounted rate - through
an HIV clinic at a public hospital. The only health insurance claims he has submitted to WeCare
have been for a visit to Dr. BIue after he had his seizure and for the subsequent cr scan.
on examination by Dr. whire, Smith appeared generally well, was afebrile and had no
abnormal neurological findings. The brain CT films that are available reveal an enhancing 2- to
3-cm. lesion in the right frontal lobe and suggests a smaller nonenhancing lesion in the left
temporal lobe. A waking EEG in white's office was normal. whire has informed Smith that the
seizure was probably caused by one of the brain lesions: that the differential diagnosis includes
lymphoma, toxoplasmosis or TB; and thar toxoplasma serology rnay offer clarification. white did
not propose performing a spinal tap or MRI of the brain, but rccommended to Smith that he
begin taking a "first line" anticonvulsant such as phenyoin, carbamazepine or divalproex. Smith
has informed White that "I donl w:rnt any tesrs that might tip off my employer or anybody else
that I have HIV."
He also has told White that if he concludes thar Sm.ith's has HlV-rclated brain disease.
"I
want you to give me a medicine that will stop my seizures but which, if I take enough of it, I
could use to kill myself." Srnith explains that he can't endure the thought of living with an illness
that "will affect my mental functions or ability to work."
What ethical issues are presented? How should Dr. White proceed in his care of Smith.