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Prostate cancer privacy vs. public right to know: Secretary of Defense Lloyd Austin’s dilemma

First, a disclaimer. I do not know Secretary of Defense Lloyd Austin, and I am not involved in his medical care. As an academic infectious disease physician, I am ignorant of the internecine hierarchy of the Defense Department. However, I listen to the news and thus am aware of his recent prostate cancer diagnosis and treatment. On National Public Radio, reporters were discussing why the secretary of defense did not reveal his prostate cancer diagnosis. In summary, he was diagnosed with prostate cancer, underwent surgery, and developed the complication of a urinary tract infection requiring hospitalization and intensive care, all without notifying some of his most important colleagues. Why is this notable? It drew attention because the executive and legislative branches of government were unaware of his illness, and the delegation of authority during his incapacitation was unclear.

Reporters kept repeating the same question, “Why did the secretary of defense hide his diagnosis and treatment?” The secretary is known to be an unusually private man, which provides a partial explanation. As a doctor with expertise in sexual health, I thought there might be more to his behavior than meets the eye. I hesitate to speculate and do not want to be likened to the psychiatrists who attempted to diagnose Donald Trump via media posts rather than through a standard medical interview. Thus, I would ask the reader to consider my musings as almost regarding a generic patient, an Everyman, rather than a specific individual. I claim no special insight into the secretary’s thought process.

What would be the rationale for avoiding disclosure of a medical condition? The patient may have been ashamed. Was he ashamed of being ill? Was he ashamed of having cancer? Was he ashamed of having prostate cancer in particular? The prostate is a walnut-sized organ in the male pelvis that releases seminal fluid during ejaculation. Prostate cancer is a disproportionate cause of death among African American men. There is controversy regarding screening for prostate cancer, with some arguing that the small cancers detected would not result in death and that aggressive treatment results in erectile dysfunction and urinary incontinence. Others counter that prostate cancer remains a leading cause of death and is easily treated when caught early. This is a man who is a four-star Army general who served in Iraq and Afghanistan. Yet perhaps he was afraid to reveal his condition.

Men fear appearing weak, and our culture views illness as a sign of weakness. This bias may influence a leader’s decision-making in a male-dominated military. In addition, there remains a stigma attached to a cancer diagnosis, even if the malignancy is limited and responsive to treatment. There is also reluctance to speak publicly regarding sexual organs, and this hesitation augments public health problems such as HIV transmission and teen pregnancy. If we can’t use proper terminology for genitals, how can we promote reproductive health? Given the susceptibility of African American men to prostate cancer and that the secretary is African American, there is a racial component here as well. He was motivated to receive prompt detection and treatment but was penalized for obtaining care and suffered complications, despite treatment at the esteemed Walter Reed Army Medical Center.

There is a right to privacy in medical care, enshrined legally in the Health Insurance Portability and Accountability Act (HIPAA). It is understandable why the secretary, his staff, and his physicians did not want to broadcast his personal information to the world. But this right to privacy must be balanced with the need for firm control of military interests in the United States and abroad, especially given the ongoing active conflicts in Ukraine and the Middle East. In future planning for similar situations regarding the health of high-level government figures, we need more transparency to ensure the safety of our citizens. However, we will not be able to achieve this goal without changing our attitudes. Just as HIPAA ensures the right to medical confidentiality, the Americans with Disabilities Act requires reasonable accommodation from employers. Yet, people who are ill are reluctant to ask for assistance in the workplace. As a society, we need to recognize cancer as a medical condition, not a moral frailty. We also must be able to talk about sexual health openly. Changing our culture around illness and sexual health will help not only the function of our government but our society.

Catherine Diamond is an infectious disease physician.

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