As AIDS--acquired immune deficiency syndrome--makes its deadly way through society, Americans have become unwilling witnesses to moral, ethical and political dilemmas arising in the epidemic's wake. Parents and school boards agonize over whether to allow AIDS patients in schools as students or teachers. The issue of mandatory AIDS antibody testing has become a litmus test for politicians on both left and right. And a question challenges the basic contract between physician and patient: Do physicians have a "right" to refuse to treat patients on the basis of the nature of their illness, or of their sexual orientation?
As one who cares for AIDS patients, I am discouraged to see some colleagues refuse to take care of AIDS patients. There have even been instances where care was refused when the physician only suspected the patient was gay.
Because the first American AIDS cases occurred in social groups distinct from the majority--homosexuals and intravenous drug users--AIDS patients have been stigmatized in the minds of many Americans who willfully remain blind to basic facts about the disease. For some of these people, AIDS is God's way of punishing homosexuals for their perversion. For others, AIDS is not their problem, something they do not want to think about.
AIDS is an infectious disease of the immune system. The causative agent HIV--human immunodeficiency virus--is spread through sexual contact and blood contamination. Up to 2 million Americans have been infected with HIV; an unknown, but significant, number of them will develop AIDS. AIDS has a 90% mortality rate two years after diagnosis.
Three main reasons probably motivate physicians who refuse to care for AIDS patients. The first is fear of contracting the illness. A second is fear of economic loss if other patients leave the physician's practice because they learn that their doctor also cares for AIDS patients. Finally, some physicians have a basic antipathy toward the patients or their life styles. The first two issues can be argued against on both ethical and scientific levels; the third is inarguable because it is emotional.
The history of medicine tells us unambiguously that physicians have the ethical obligation to treat all patients regardless of personal risk. Recently, the American Medical Assn. reaffirmed the obligation: "The tradition of the AMA, 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 . . . . That tradition must be maintained." History is full of examples of physicians and nurses who courageously treated patients suffering from diseases known to be contagious, long before the germ-theory of infection was conceived. The irony of AIDS is that, compared with other infectious diseases such as tuberculosis or plague, the risk of contracting the disease by the care-giver is so low.
The rise of consumerism and negligence law has conditioned many people to expect a risk-free environment. Some physicians who entered medical practice in the '60s and '70s thought of their profession as protected and profitable--a ticket to the good life and a house in the suburbs. Hepatitis B, however, was a dirty secret especially among surgeons and dentists; little was said even when dentists infected their patients with that potentially fatal virus. Then AIDS made many medical workers confront occupational hazards they assumed did not exist.
The biologic behavior of the AIDS virus, coupled with inevitable human errors and accidents, makes it almost inevitable that some health-care workers become infected in the course of their duties; at the same time, it is quite clear that hospital-acquired infection is an extremely rare event.
Rarity is underscored by the avidity and sensationalism with which those events are reported: There have been only about a dozen hospital-acquired HIV infections documented despite millions of contacts with infected patients since the epidemic began. The few reported cases involve extraordinary exposure of broken or chaffed skin to large amounts of blood--or inadvertent self-injection of blood.
Experts could argue that the risk of a surgeon dying as a result of a slip of the scalpel might be greater if he is operating on a hepatitis B carrier than on an HIV carrier. Although HIV infection may have a higher mortality rate than hepatitis B, it takes far fewer hepatitis virus particles than HIV particles to cause successful infection; and hepatitis B can be deadly.