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Ethical and legal issues arise when a patient who is human immunodeficiency virus (HIV) positive lacks decision-making capacity and the HIV status must be disclosed to a surrogate decision maker to allow for informed medical decision making. This article discusses the special exceptions to confidentiality built into the Health Insurance Portability and Accountability Act privacy protections, the limitations on claims of common-law marriage, and public health laws that often require informing individuals who are either sex partners or needle-sharing partners of newly diagnosed HIV-infected individuals that they have been exposed to HIV infection.

Medical decision-making capacity, the patient's ability to exercise autonomy reasonably, is an essential component of both informed consent and informed refusal. The assessment of medical decision-making capacity is thus fundamental to the ethical practice of medicine. Medical decision-making capacity is not all or nothing but rather exists on a continuum and should be assessed on a decision-by-decision basis. Alzheimer disease and other neurocognitive disorders can affect a patient's medical decision-making capacity and may pose special challenges to capacity assessment. To illustrate some of these challenges, this article presents a case of a patient with Alzheimer disease who refused a recommended operation and discusses the components of capacity, a useful mnemonic and tools, the variability of state laws, and the roles neurologists and psychiatrists play in the assessment of capacity.

This article presents four hypothetical cases that demonstrate ways in which neurologists may be vulnerable to liability for how they manage patients they refer to other physicians for consultations. This article also discusses the importance of protecting neurologists from claims of negligence through documentation, which includes the rationale for ordering a consultation, deferring a consultation, or disagreeing with a consultant's recommendations. Lastly, the article discusses the importance of including patients in the decision-making process and detailing these conversations in the medical record.