contamination - for those who have a needlestick accident at 6monthly intervals they might become virtually continual. If we really believe in universal precautions, then they must be universal; if we believe in tailoring precautions to risks we need to know the risks. I disagree fundamentally with Kluge when he says "It is unethical for a physician to have a patient tested for HIV status if the test is done solely for the physician's benefit." The morality of medicine does not extend to a demand for total self-sacrifice. In my professional life, as in the rest of it, I am entitled to know of the diseases to which I am exposed: tuberculosis, viral hepatitis, diphtheria, HIV infection or whatever. It is time we stated very firmly a fundamental truth: patients infected with HIV do not have a unique moral status because of their infection. They face special risks - societal as well as healthrelated - and need special protection from them and from prejudice and discrimination born of ignorance, homophobia and the like. But their rights in this regard do not exclude or cancel mine and those of my family. The words "duty" and "obligation" are unfashionable in health care ethics, but I think that they and the beliefs they express must be considered. Do patients have the duty to permit me to know their HIV status if this directly affects my behaviour and the risks to me and if this knowledge is limited to those who need to know? I think they do. Finally, the risks of exposure to HIV from patients are not limited to physicians: nurses, laboratory technologists and others are at risk of as great or greater exposure. Kluge limits his statements to physicians. Does he intend our professional morality to apply to all health care workers? I know many would repudiate it most strongly. How far is our self812
CAN MEDASSOCJ 1992; 146(6)
imposed morality meant to extend into the wide field of health care? Harry E. Emson, MA, MD Professor of pathology Royal University Hospital Saskatoon, Sask.
Dr. Kluge's recent article demonstrates several unreasonable attitudes toward Canadian physicians. Although Kluge correctly points out the physician's many responsibilities to the patient he says nothing about the patient's responsibility to the physician. This unfortunate attitude is not unfamiliar to physicians, but I am disappointed to see it expressed by the CMA's former director of ethics and legal affairs. Kluge presents a well-reasoned argument that the health status of physicians should not expose patients to iatrogenic risks. He then generalizes that "patients have the right to assume that their physicians will not expose them to risks they would not encounter if they did not go to the doctor." Surely Kluge acknowledges that all medical therapies and even some diagnoses carry with them various degrees of risk. Rather than "the right to assume" no risk should the patient not expect a discussion of the risks and benefits of any proposed therapeutic option? Indeed, it is this very discussion that lays the foundation for informed consent - a widely accepted concept. Kluge's statement perpetuates an obsolete concept that fosters unrealistic expectations; it may not be possible for physicians to fulfill them. Richard W. Bullock, MD Emergency physician Chedoke-McMaster Hospital Hamilton, Ont.
I am concerned about the implications of the article by Dr. Kluge. There is no doubt that physicians must provide appropriate medical services regardless of the patient's health status. But we also have a
social responsibility for the management of the HIV epidemic. The ethical issue is only one of many important facets of the problem. Until more information is available regarding the treatment of HIV-infected patients the most important issue in the management of AIDS is still prevention. This includes proper diagnosis, the reduction of transmission through education, and improved compliance with infection control precautions. Universal precautions against HIV infection are not part of a practical solution to the problem but would certainly have a tremendous impact on health care costs. Addressing the ethical issue of HIV status alone without practical considerations is inadequate and perhaps a disservice to health care personnel. Orlando R. Hung, MD Department of Anaesthesia Victoria General Hospital Halifax, NS
How right Dr. Kluge is to state in his article that "patients have the right to assume that their physicians will not expose them to risks they would not encounter if they did not go to the doctor." That being true, it is essential that physicians be free to protect patients and medical personnel (including themselves) from the risks of unknowingly contracting and so inadvertently transmitting potentially lethal disease by testing for evidence of disease, even when the test done is not directly "necessary for the care of the patient." Wena V.P. Williams, MB, ChB 412 Russel Woods Tecumseh, Ont.
[The author responds.] The obvious and immediate reply to Dr. Emson is to point to clause 7 of the CMA's Code of Ethics,' which states that "an Ethical Physician will recommend only diagLE 15 MARS 1992
CAN MEDASSOCJ 1992; 146(6)
imposed morality meant to extend into the wide field of health care? Harry E. Emson, MA, MD Professor of pathology Royal University Hospital Saskatoon, Sask.
Dr. Kluge's recent article demonstrates several unreasonable attitudes toward Canadian physicians. Although Kluge correctly points out the physician's many responsibilities to the patient he says nothing about the patient's responsibility to the physician. This unfortunate attitude is not unfamiliar to physicians, but I am disappointed to see it expressed by the CMA's former director of ethics and legal affairs. Kluge presents a well-reasoned argument that the health status of physicians should not expose patients to iatrogenic risks. He then generalizes that "patients have the right to assume that their physicians will not expose them to risks they would not encounter if they did not go to the doctor." Surely Kluge acknowledges that all medical therapies and even some diagnoses carry with them various degrees of risk. Rather than "the right to assume" no risk should the patient not expect a discussion of the risks and benefits of any proposed therapeutic option? Indeed, it is this very discussion that lays the foundation for informed consent - a widely accepted concept. Kluge's statement perpetuates an obsolete concept that fosters unrealistic expectations; it may not be possible for physicians to fulfill them. Richard W. Bullock, MD Emergency physician Chedoke-McMaster Hospital Hamilton, Ont.
I am concerned about the implications of the article by Dr. Kluge. There is no doubt that physicians must provide appropriate medical services regardless of the patient's health status. But we also have a
social responsibility for the management of the HIV epidemic. The ethical issue is only one of many important facets of the problem. Until more information is available regarding the treatment of HIV-infected patients the most important issue in the management of AIDS is still prevention. This includes proper diagnosis, the reduction of transmission through education, and improved compliance with infection control precautions. Universal precautions against HIV infection are not part of a practical solution to the problem but would certainly have a tremendous impact on health care costs. Addressing the ethical issue of HIV status alone without practical considerations is inadequate and perhaps a disservice to health care personnel. Orlando R. Hung, MD Department of Anaesthesia Victoria General Hospital Halifax, NS
How right Dr. Kluge is to state in his article that "patients have the right to assume that their physicians will not expose them to risks they would not encounter if they did not go to the doctor." That being true, it is essential that physicians be free to protect patients and medical personnel (including themselves) from the risks of unknowingly contracting and so inadvertently transmitting potentially lethal disease by testing for evidence of disease, even when the test done is not directly "necessary for the care of the patient." Wena V.P. Williams, MB, ChB 412 Russel Woods Tecumseh, Ont.
[The author responds.] The obvious and immediate reply to Dr. Emson is to point to clause 7 of the CMA's Code of Ethics,' which states that "an Ethical Physician will recommend only diagLE 15 MARS 1992
