The American Medical Assn., taking note of public statements by some doctors refusing to treat patients infected with the AIDS virus, advised physicians Thursday that it is unethical to deny care in such situations if the care required is within the doctor's normal range of practice.
And in a new statement on doctors' obligations in AIDS cases, the AMA ethics council also told physicians that if a patient carrying the AIDS virus refuses to discontinue dangerous sexual practices, a doctor should notify public health authorities and even take it upon himself to directly inform individuals who may be in danger of infection.
The requirement for informing authorities and endangered people, said Dr. Nancy Dickey, a spokeswoman for the AMA's Council on Ethical and Judicial Affairs, could conceivably justify a doctor's breaching local and state confidentiality laws to warn people who might be at risk of contracting AIDS from a patient who refuses to modify his or her behavior.
In a telephone interview, Dickey said that the notification provisions were drafted at least in part with restrictive California AIDS notification laws in mind. The new AMA strictures conflict with existing California law, under which it is illegal for a doctor, without the patient's consent, to tell anyone a person has tested positive for the AIDS virus or has AIDS.
"If you (a doctor) feel that there is someone in danger and you have counseled change in behavior and the (patient) still blatantly refuses," Dickey said, "then there may be times when you will be put in conflict with the law."
Under a new law signed by Gov. George Deukmejian earlier this year, it will be legal for a doctor to inform a patient's spouse of AIDS test results beginning Jan. 1. But there is some uncertainty over the use of the word "spouse" in the new law, and Dr. Gary Krieger, president of the Los Angeles County Medical Assn., said the group is advising doctors that "spouse" means any close acquaintance of the patient who may be at risk.
However, a spokesman for Atty. Gen. John Van de Kamp said that, although the wording of the bill had not been reviewed in detail, attorneys had "the strong sense" that the new California statute applies only to husbands and wives.
In warning doctors that they have no ethical right to decline to treat patients who test positive for the human immunodeficiency virus (HIV), the AMA ethics council noted that "the tradition of the American Medical Assn., since its organization in 1847, is that when an epidemic prevails, a physician must continue his labors without regard to the risk to his own health."
In the new AIDS statement, the council emphasized that "that tradition must be maintained."
"Neither those who have the disease nor those who have been infected with the virus should be subjected to discrimination based on fear or prejudice--least of all by members of the health care community."
Those who test positive for the AIDS virus have not always developed the disease but are considered infectious to others.
Dickey and local physicians agreed there is no evidence that large numbers of doctors have refused to treat patients who tested positive for the AIDS virus. But, Dickey said, "there have been physicians who have chosen to make public statements that they will not treat HIV-positive people. Those statements have generated tremendous amounts of discussion and debate."
The AMA ethics council also concluded that:
--Doctors confronted with a patient who has developed any of the critical illnesses identified with AIDS is obligated to refer the patient to a physician who can provide care if the original doctor does not feel competent to continue on the case.
--A doctor who knows he or she is HIV-positive should not engage in any medical activity that is likely to spread the virus. But Dickey noted that since the AIDS virus cannot be passed through casual contact, "the vast majority of medical practice creates no risk of transmission."
--A doctor who has AIDS or is HIV-positive should seek the advice of colleagues on patient care activities in which he or she can safely engage.