Requiring Doctors to Treat AIDS Victims Invites Flawed and Hostile Care

The American Medical Assn.’s decision that it is unethical for doctors to refuse to treat AIDS patients establishes a foolish and dangerous precedent.

Put yourself into a position of being wheeled into an operating room to undergo a hazardous surgical procedure at the hands of a surgeon who is being forced to have you as a patient. Wouldn’t that make you just a bit uneasy?

Psychiatrists have recognized for years that doctors are no different from anybody else when it comes to harboring negative feelings toward others. Freud spoke of the psychiatrist’s counter-transference reaction: irrational dislikes, even hatred, that a doctor may quite unconsciously harbor toward a patient. Moreover, such responses run counter to the best interests of the patient. For instance, it would obviously not be wise for a potentially suicidal patient to be seeking help in fighting his suicidal impulses from a doctor who holds strongly negative attitudes toward him.

But, counter-transference feelings aside, there are other reasons why it’s bad policy to force doctors--other than in emergency situations--into caring for patients whom they don’t want anything to do with. For one thing, where does it stop? One doctor may prefer to pass the care of an AIDS patient on to another physician. Another doctor may not fancy treating people with incurable cancer (maybe he gets depressed around people with cancer, or maybe cancer patients remind him too starkly of his own mortality). What is going to be gained for such patients by forcing the sick into the hands of reluctant, even hostile, doctors?

Traditionally, the physician-patient relationship has operated through an informal selective process that on the whole has worked out pretty well. It begins when a person, feeling ill in some way, seeks out the services of a physician.

While the doctor is carrying out his examination, the patient is engaged in an examination of a slightly different sort. Does the doctor seem to know what he or she is doing? Is he understanding, compassionate, easy to talk to? Does he inspire confidence?

Not every doctor passes his patient’s examination, and the patient seeks care elsewhere.

From the physician’s point of view, things have worked out in a similar way. Most doctors are at least vaguely aware of the kinds of patients who raise their hackles. With some doctors it’s demanding patients who bother them; others are put off by clinging, overly dependent types who need increasing reassurance. There are even books available with titles like “How to Handle Difficult Patients” that the determined physician can consult. But for most doctors the time-tested, most satisfactory solution is a diplomatic referral elsewhere: “Mrs. Rosenberg, there is a nice doctor who is just down the street who has a particular interest in patients with your illness. Let my receptionist call and see if she can take you on as a patient.”

But now the AMA wants to throw a monkey wrench into all this. Since doctors don’t want to act unethically, they will presumably be forcing themselves to continue to treat patients with whom they cannot work comfortably. Of course, some good might come from a forced approach in the individual case. With a bit more effort things might turn out better than the doctor originally anticipated. But why should such extraordinary efforts be undertaken in a country like our own that is suffering from a doctor glut?

In addition, imposing patients on unwilling doctors ignores the perils involved in every physician-patient relationship. In the practice of medicine too many things can potentially go wrong even when the patient-doctor relationship works at its best. And doctors, like most other people, work at their best when they’re not angry, frustrated, frightened or hostile. This isn’t to suggest that a doctor would consciously or deliberately injure a patient--such a suggestion is simply unthinkable. But have you ever tried threading a needle or carrying out any other delicate procedure while you’re angry or otherwise upset?

The best medical care is rendered when intensely personal involvements are kept at a minimum. That’s why doctors don’t as a rule carry out potentially hazardous medical and surgical procedures on members of their own families. The same thing holds on the other end of the emotional balance--patients who arouse strongly negative reactions in a doctor don’t belong under the care of that doctor.

I, for one, wouldn’t want to see a scalpel in the hand of someone who disliked me any more than I’d want to see him holding a gun.