Stigma, Risk and the Florida AIDS Dental Cases : Health: Should dentists and doctors have to tell patients they have AIDS? The decision should not be clouded by stigmatizing stereotypes.

The public has been terrified by the specter of infection with AIDS from a visit to the doctor or dentist ever since the Centers for Disease Control reported last summer that a Florida dentist with AIDS probably infected one of his patients. That fear intensified in January, when the agency announced that two more of the dentists’ patients had been infected.

The CDC, which has twice held hearings with experts to determine whether its findings require a change in policy, is expected to recommend any changes to the secretary of the Department of Health and Human Services shortly. At issue is whether restrictions should be placed on the right of infected health-care workers to perform invasive procedures.

To anyone terrified at the prospect of becoming infected while seeking health care, the answer is easy: Forbid all infected health-care workers from doing anything that might transmit infection.

But like so much about AIDS, the issue is anything but simple. As we approach the 10th anniversary this week of the first government AIDS-case report, the Florida cases present us with complex challenges.

In response to the CDC’s announcement about the two additional patients, the American Medical Assn. and the American Dental Assn. reversed longstanding policy and declared that health-care workers infected with HIV, the virus that causes AIDS, should disclose their infection to their patients before performing invasive procedures.

However, many other professional groups, including the New York State Department of Health and the California Medical Assn. representing regions of the country hit hardest by the epidemic, object to such a change. They argue that disclosure of such private information is not warranted by evidence regarding a single practitioner.

To anyone frightened of unwittingly being infected, arguments about the niceties of privacy and the sufficiency of evidence ring hollow compared with the risk of contracting AIDS. We fear acquiring AIDS because it is fatal. But we have learned to assess other risks--undergoing anesthesia or driving on the highway--in cost-benefit fashion. Why not AIDS?

AIDS feels like a special case because it is so stigmatizing. Society abandons, isolates and judges those who have it. The stigma attached to AIDS distorts our perceptions, causing us simultaneously to over- and underestimate risk.

We minimize the low, yet well-documented, risk that health-care workers assume caring for AIDS patients, but overestimate the risk infected health-care workers pose to us. The CDC established that at least 40 health-care workers have become infected while caring for persons with AIDS. Yet of the more than 170,000 cases studied by the agency, there are only the three patients believed to have been infected by one caregiver who can’t be interviewed because he is dead, and whose office did not strictly maintain proper infection control.

Society headlines the three dental patients yet overlooks the 200 health-care workers who die each year from occupationally acquired hepatitis B infection. We discount the impact of stigma upon already-infected persons--the shame and isolation it creates--and overreact to its threat to ourselves.

When Los Angeles enacted the nation’s first AIDS civil-rights law in 1985, the direction in which AIDS legal doctrine would evolve was unclear. At that time, proposals to isolate and stigmatize infected persons were offered. Until Los Angeles’ ordinance, law had often served in past epidemics to justify the primitive human impulses to find scapegoats.

But it is now clear from court decisions and statutes across the nation that law has broken from the past by insisting that decisions be based upon medical facts, not stereotypes, and that policies be based upon principles of fairness, not fear. That has occurred by drawing upon the same commitment to separate prejudice and fear from fairness and equality embraced by American society as it struggled to free itself from the divisiveness of race 30 years ago.

Now the law prohibits burdening the infected with the stigmas imposed by society. The U.S. Supreme Court, in a 1987 civil-rights case, articulated this basic principle. While “few aspects of a handicap give rise to the same level of fear and misapprehension as contagiousness,” the court said, such powerful feelings cannot form the basis for policy unsupported by medical facts. Privacy law forbids such intrusions as well, as demonstrated in cases in New Jersey and California.

Even the legal doctrine of informed consent, upon which proponents of mandatory disclosure base their argument that patients have a right to know their providers’ status, does not support the singling out of AIDS as a special case. Informed consent means that patients must knowledgeably agree to medical procedures that pose some risk. But that has not meant risks posed by the caregiver but by the procedure--the likely complications of an appendectomy, for example, not the blood-alcohol level of a surgeon before surgery. Risks posed by the practitioner have traditionally been dealt with by review boards, licensing agencies and malpractice insurers.

Proposals that patients have the right to know their surgeon is infected open the door wide to assertions that patients are entitled to know a whole range of other facts about the practitioner. Consumers may welcome such a change. But it is certain that fairness and equality protections will not permit infected health-care workers to be singled out, to the exclusion of all other risks doctors and dentists might pose.

The Florida AIDS dental cases have brought the epidemic home to Americans who until now have managed to say, “It isn’t me, AIDS is happening to them.” Our identification with the unsuspecting patient in the dental chair shatters our defense against identifying with the misery and tragedy of an epidemic no one anticipated.

Final federal regulations mandating effective infection control in all health-care settings have yet to be issued. Infected health-care workers need careful monitoring and counseling amid atmospheres of trust, privacy, non-discrimination and support to ensure that they deliver care only when they are physically able. We must resist the primitive impulse to recoil from the stigmas of AIDS--its association with matters of sex and blood, with already stigmatized groups and with death--if we are to grapple with these challenges well.