Many Doctors in Poll Averse to Treating AIDS : Medicine: Bias against gays, drug users contributes to attitude that flouts professional principles, AMA says.
Nearly one-third of all primary-care physicians do not agree that they have a responsibility to treat people with AIDS--a view revealed today in a survey that the American Medical Assn. says flouts basic principles governing the role of doctors in society.
The survey results, published in the Journal of the American Medical Assn., traced the doctors’ position in part to bias against the groups hardest hit by the disease. Specifically, they cited homophobia and discomfort with intravenous drug users.
More than one-third of those answering the nationwide survey of 2,004 internists and general and family practitioners said they would feel “nervous” among homosexuals and view homosexuality as “a threat to many of our basic social institutions.”
“I think there is an attitude among many physicians that they’re absolutely free to take whoever they want as patients,” commented Dr. Robert Conley of the AMA. “ . . . But there are limitations, and that principle does not extend to give cover to discrimination.”
Since its inception, the AMA has said that a physician’s responsibility during an epidemic is to treat the sick without regard for the risk. In 1988, it stated explicitly that it is unethical to refuse treatment just because a patient is infected with the AIDS virus.
Those principles are based in part on what medical ethicists say is the “social contract” between the medical profession and society: Society grants physicians a unique position in return for a promise that physicians will treat people in need.
“To say, ‘My helping you would be too costly for me, therefore I won’t help,’ is a complete abrogation of the relationship between medicine and society,” Albert R. Jonsen, a medical ethicist and professor of medicine at the University of Washington, said Tuesday.
The survey, by researchers at UC San Francisco, focused on so-called primary care physicians, a group likely to be called upon increasingly to treat patients infected with the AIDS virus as the epidemic expands beyond the reach of traditional AIDS specialists.
Fifty-nine percent of the doctors surveyed answered the 1990 poll. Eighty-seven percent were men and 13% were women. More than 70% had graduated from medical school before AIDS was identified, and 75% said they had treated one or more infected patients. On average, women had treated more AIDS patients than had men.
Sixty-eight percent of the doctors surveyed agreed with the statement that they had a responsibility to treat people with AIDS. The remaining 32% did not: 17% disagreed and the rest did not take a position. Fifty percent said they would not work with AIDS patients if given a choice. The survey traced their reluctance not only to fear of catching the disease but to attitudes toward many people who have it.
For example, 35% agreed with the statement that they “would feel nervous among a group of homosexuals,” 55% said they would be uncomfortable having intravenous drug users in their practice and 26% said dying patients made them feel uneasy.
But the physicians had other reservations as well: Eighty-three percent said they believed they needed more information about the disease, and 84% agreed with the statement that “caring for people with AIDS puts extra demands on a physician’s time.”
Relatively few--29% of those polled--said they derive more intellectual stimulation from the practice of medicine as a result of caring for infected patients--a finding that one of the authors found especially disconcerting.
“Earlier studies had looked at physicians treating many people (with the virus) and found they were finding some rewards,” said Barbara Gerbert. “So we were hoping to show that it was intellectually stimulating or rewarding. Unfortunately, we didn’t find that.”
Experts in the field said they were surprised and saddened by the results of the survey, described as the first comprehensive, nationwide look at the subject.
William B. Rubenstein, director of the American Civil Liberties Union’s national AIDS project, said he was particularly shocked by the fact that 10 years into the epidemic doctors would openly admit that they would not care for infected patients.
Rubenstein suggested that such a position could be not only unethical but illegal. He said state and federal laws protecting people with disabilities against discrimination in “public accommodations” have in some cases been found to cover physicians’ offices.
“Of course we have a responsibility to take care of people irrespective of their disease or of potential hazards to physicians,” said Dr. David Rogers, vice chairman of the President’s AIDS commission. “I guess I’m old enough to feel that went with the territory.”
Rogers and Jonsen, the ethicist, said that for centuries, physicians confronted diseases such as plague, cholera and tuberculosis when embarking upon a medical career. But the advent of antibiotics in the 1940s eliminated much of the risk doctors traditionally faced.
In an editorial accompanying the report, Conley and another AMA official stated bluntly that “practitioners are not free to ignore (their ethical duties) simply because it entails a small degree of personal risk” or because they don’t like their patients.
“Nor can physicians expect less medically sophisticated members of the public or government officials to react to health crises with reason and compassion when they themselves do not demonstrate these characteristics,” they wrote.
Doctors’ Survey
UC San Francisco researchers surveyed 2,004 internists and general and family practitioners to explore attitudes on treating people infected with the human immunodeficiency virus (HIV), which causes AIDS. Almost 60% responded. Here is a sample of responses, including the differences between those who had treated infected patients and those who had not.
QUESTION TOTAL TREATED NO 1-10 HIV MORE THAN 10 RESPONSE HIV PATIENTS PATIENTS HIV PATIENTS I would feel nervous among a group of homosexuals. + Agree 35% 41% 36% 26% + Disagree 43% 34% 42% 56% Homosexuality is a threat to many of our basic social institutions. + Agree 35% 41% 36% 27% + Disagree 44% 39% 43% 54% I am uncomfortable having IV drug users in my practice. + Agree 55% 68% 55% 42% + Disagree 28% 18% 27% 39% I have a responsibility to treat people with AIDS. + Agree 68% 53% 69% 82% + Disagree 17% 29% 16% 9% If I had a choice, I would not work with AIDS patients. + Agree 50% 60% 50% 39% + Disagree 28% 16% 26% 43% Prefer to refer people with HIV infection to other physicians. + Agree 48% 64% 50% 24% + Disagree 31% 15% 28% 54%
NOTE: Figures may not add up to 100%; other response choice was “neither agree nor disagree”
SOURCE: Journal of the American Medical Assn.
