‘INTIMACY: Part 2’
CAERS SUBSTACK ARTICLE #37
It may not be immediately obvious, but the notions of intimacy and risk are profoundly intertwined. If it is true that humans crave intimacy, why are we not prepared to share absolutely everything of a personal and private nature with everyone all of the time? You would think that our intense nature to socialize and be in community would demand that. But there is almost an inherent paradox in all of this, because the more we need something the more we fear losing it. At a deep, almost unspeakable level, we know both how insignificant and frail we are, and how far we are from being perfect. This fear of unworthiness leads to an innate insecurity: if I reveal my true self to others can I still be loved? How much risk of rejection are we willing to accept in order to obtain the intimacy, and sense of belonging, that we all desire?
We are more prepared to reveal intimate truths to those who have been sworn to respect our privacy and confidentiality. That greatly reduces the risk of our innermost selves being revealed publicly, but it does not eliminate it entirely. We want some aspects to remain more private than others. We may be comfortable revealing to a stranger than we have a minor cold, but understandably we might only reveal that we have a sexually transmitted infection to those closest to us. That level of privacy, or lack of transparency, can be acceptable provided that no one else is being put in harm’s way. If you are not planning to have sexual relations with someone, then there is no obligation for you to reveal that you have a sexually transmitted infection. But if you are, and that puts them at risk, the situation changes.
Often your medical status is no one else’s business, but not always. If it is someone else’s business, how that is communicated will vary with the circumstances. An airline pilot with a seizure disorder discloses that in the context of the privacy and confidentiality of the patient- physician relationship, one which allows the doctor to share that information only with the appropriate governing authorities in strictest confidence as well. On the other hand, only a potential sexual partner might be told about the sexually transmissible infection, and in a private, face-to-face manner. We are not expected to constantly wear a sign on our head advertising everything about our medical health for all to see.
It can get even more complicated. If you have had genital herpes for many years the frequency and severity of breakouts tends to decrease over time. Given that transmission tends to occur much more with active than quiescent herpes, how likely are you to transmit it if you have not had a breakout for years? How high does the risk of transmission have to be to justify sharing this information? Where on the spectrum is the line drawn?
The same can be said of asymptomatic transmission of many infectious diseases. We are covered in microbes all of the time; some live symbiotically with us, and some that could harm us are constantly being exterminated without us even knowing it. Occasionally one cannot be eliminated without us first becoming symptomatic. So, we can never guarantee that we are not harbouring any organisms that could be contagious just because we feel well at the moment. If we are going to be in contact with someone with a compromised immune system then we clearly must be more careful, even if we are well. But for most of our lives we must accept that there is a non-zero risk of transmitting, or acquiring, an infectious organism unwittingly. But how high is that risk in reality? If we are generally healthy, how much do we want to limit our contact and activities to bring that risk closer and closer to zero?
These issues of contagiousness, asymptomatic transmission, risk and confidentiality have been of central importance during the pandemic. It is certainly reasonable to request that someone who is genuinely unwell with COVID limit their contact with others, especially the vulnerable, regardless of their vaccine status. But how strong is the evidence that someone with a positive test only and no symptoms, regardless of vaccine status, has enough virus in them (referred to as viral load) to be a danger to someone else who is generally healthy? It is highly likely that there are many untested and equally asymptomatic individuals with identical viral loads wandering around freely all of the time. Do we prevent all movement of everyone until we are certain that the virus has completely disappeared from our midst?
How do we balance public safety and maintaining our normal lifestyles given the ubiquity of potentially transmissible infectious organisms? How do we quantify the risk of transmission from various levels of exposure? How low can we reduce the risk, especially with highly contagious respiratory organisms? How much harm might we produce in terms of social isolation and restriction of medical care for other conditions, for example, with such restrictions?
These are questions with difficult to discover answers, and they are at the heart of some of the most important decisions made during the pandemic. In particular, they explore the limits of privacy and confidentiality versus those of transparency. What do we reasonably owe one another? I’ll conclude my examination of intimacy in the next article.
J. Barry. Engelhardt MD (retired) MHSc (bioethics)
CAERS Health Intake Facilitator
Thought provoking. I’m inclined to believe that we have no obligation to share our health info with others unless the risk is significant. Now, how do we determine that? It gets more difficult when the risk increases. However, Covid-19’s risk to anyone under 70 is very close to zero, even less if you factor in early treatment. None of the government’s response (or anyone who hopped on that band wagon) was justified. Looking forward to the next article!