No Place for Doctors to Hide From AIDS

There is no place to run from the AIDS epidemic, but many health-care professionals are at least figuratively fleeing. The number of patients with AIDS continues to increase, but the number of doctors caring for them does not. A New York study found that one-quarter of the physician respondents believe that it is ethical to refuse care for AIDS patients, and one-third believe that the choice should be theirs.

Other health-care professionals are expressing their feelings more explicitly. A Huntington Beach nurse writes that she will “never care for an AIDS victim unless . . . convinced that it is an innocent heterosexual.” A Los Angeles dentist says that it is “foolish” to force dentists to provide care for those with AIDS. Pathologists decline to perform autopsies, and paramedics refuse calls from persons known to be carrying the HIV antibody. Emergency-room care has been denied for individuals whose “demeanor” was suspect and who could not prove that they did not have AIDS. New York state has had to issue guidelines saying that a diagnosis of AIDS is “not sufficient reason to refuse admission” to hospitals.

May physicians refuse to care for these patients? Or do they have a professional duty to care for the sick even at personal risk, especially when the risk is small? In the recent past, American physicians have cared for patients with polio, tuberculosis and hepatitis B. They took precautions and assumed the risk; it was part of being a doctor.

Society gives professionals special powers, authority and privileges. It assumes that they will use these to benefit members of society, not themselves. Although paid for their services, physicians historically have been motivated by altruism, not self-interest. We still expect that to be the case. Society must be able to trust physicians to exercise their skills in the patients’ best interests. That is what professionals profess : their promise to give the help that they are specially trained and legally authorized to give when it is needed.

In that spirit the 1847 American Medical Assn. Code of Ethics starkly enjoined the physician to “be ever ready to obey the calls of the sick.” The 1980 version says only that “a physician shall be dedicated to providing competent medical service with compassion and respect for human dignity.” Alas, it also claims that “a physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve.” In commentary, however, the AMA prohibits physicians from refusing to accept patients “because of race, color, religion, national origin or any other basis that would constitute illegal discrimination.”

Although physicians are refusing AIDS patients, the AMA has not clarified the obligation to provide care. Others have not been so reluctant. Last year the American College of Physicians and the Infectious Disease Society of America jointly said that “(d)enying appropriate care to sick and dying patients for any reason is unethical.” Dr. Robert Windom, deputy secretary of health and human services, says that any physician unwilling to take the risks involved in being a physician should get out of the field.

In England the General Medical Council of the United Kingdom has announced that “it is unethical for a registered medical practitioner to refuse treatment . . . on the ground that the patient suffers, or may suffer, from a condition which could expose the doctor to personal risk . . . . Unethical behavior of this kind may raise a question of serious professional misconduct.”

Despite our celebrated individualism, we human beings fear estrangement from society. Our lives are so complex that we must constantly depend on the help of others to meet our needs. If help is not forthcoming, if we must negotiate for it at every intersection, life becomes impossible. In crisis we depend on our friends and our families, and on the professionals who have sworn to care about us even though we may be strangers to them.

We may understand that physicians are afraid of AIDS. It is a frightening disease. Yet the reality is that work-associated infection has been documented in no more than five persons, none of them physicians, out of the many thousands of American health-care professionals who have cared for those with AIDS and with HIV infection.

Though we may understand and even share physicians’ fears and biases, we cannot sanction their acting on those feelings. We cannot accept their abandoning the social contract that we have with them as professionals. The sick need their help now. And those who are well must be assured that physicians will be there in their time of need.