LETTERS * CORRESPONDANCE
We will consider for publication only letters submitted in duplicate, printed in letterquality type without proportional spacing and not exceeding 450 words. All the authors must sign a covering letter transferring copyright. Letters must not duplicate material being submitted elsewhere or already published. We routinely correspond only with authors of accepted letters. Rejected letters are destroyed. Accepted letters are subject to editing and abridgement.
Seules peuvent etre retenues pour publication les lettres recues en double dont la longueur n'excede pas 450 mots. Elles doivent etre mecanographiees en qualite ((correspondance>> sans espacement proportionnel. Tous les auteurs doivent signer une lettre d'accompagnement portant cession des droits d'auteur. Les lettres ne doivent rien contenir qui ait ete presente ailleurs pour publication ou deja paru. En principe, la redaction correspond uniquement avec les auteurs des lettres retenues pour publication. Les lettres refus&es sont detruites. Les lettres retenues peuvent etre abregees ou faire l'objet de modifications d'ordre redactionnel.
Ethical issues concerning the HIV status of physicians and patients _
Eike-Henner Kluge's opinions are so unbalanced that they must be challenged (Can Assoc Med J 1991; 145: 518-519). He believes that if a physician's status with regard to human immunodeficiency virus (HIV) may put the patient at risk the patient has the right to know it but that there is no reciprocal right for the physician to know the patient's HIV status. The rights and duties of physicians and patients in this context are quite different. For the purposes of discussion let us accept that there is a two-way risk of HIV transmission: -
r.
For prescribing information see page 1089
from physician to patient and vice versa. The risks may not be equal, but they exist. Kluge states that "the ethos of medicine has always been to try to help patients, even if this might expose physicians to danger or death." This I accept, but the obligation does not extend to a wanton and reckless disregard for the physician's safety or that of his or her spouse and family. In our practice of medicine as in other aspects of life - we should be aware of the risks to which we are exposed. We have a right to this; we have an obligation to ourselves and to those with whom we have close and interdependent relationships. We need to know the precautions we should take to minimize risk; in the last analysis this preserves us for the care of future patients. The doctrine of universal precautions, to which Kluge does not refer, says that this is unnecessary: if we treat every situation as one of potentially lethal danger we do not need to know which situations are of greater or lesser risk. This is nonsense, and it breaks down as soon as it is put to practical test. We take precautions in all situations, and we take more precautions in situations that we know to be of greater risk. This is logical, practical and ethical, and it rests on as accurate a knowledge as possible of the risk involved. If the risk cannot be known, the need for precautions can be estimated; if the risk is knowable, it should be made known, not necessarily publicly but to those who need to know. "Once a physician-patient relationship has been established, the needs of the physician are relevant only if they influence the ability to provide appropriate
care - the physician's private needs do not enter this equation." With respect, this is utter nonsense. Entering into a professional relationship, even a fiduciary one, does not abrogate my autonomy or my right to justice. It is not total subjugation. The risk to the physician of becoming infected with HIV, contracting acquired immunodeficiency syndrome (AIDS) and ultimately dying is very relevant to the physician and cannot be so lightly brushed aside. Even in a fiduciary relationship both parties have rights and obligations, and the obligations must be proportionate to the risks. The doctrines of autonomy, confidentiality and privacy cannot be stretched to ultimate denial of the information needed by physicians to protect themselves while they tend patients. The risk to a physician exposed to contamination with a patient's blood is significant if the patient is at that time HIV seropositive. The risk if the patient is a virus carrier but not yet HIV seropositive is very much less. A physician who has been con-
taminated with -HIV-infected blood must take many significant precautions until his or her seroconversion can be confirmed or refuted. This is not a negligible obligation: the physician may need to change his or her type of practice if it is one that exposes patients to the physician's blood; sexual practices should be modified to eliminate the risk of transmission; and female physicians should probably not become pregnant during this time. If the physician has no right to know the patient's HIV status, then these precautions should logically follow every exposure to blood CAN MED ASSOC J 1992; 146 (6)
811
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
We will consider for publication only letters submitted in duplicate, printed in letterquality type without proportional spacing and not exceeding 450 words. All the authors must sign a covering letter transferring copyright. Letters must not duplicate material being submitted elsewhere or already published. We routinely correspond only with authors of accepted letters. Rejected letters are destroyed. Accepted letters are subject to editing and abridgement.
Seules peuvent etre retenues pour publication les lettres recues en double dont la longueur n'excede pas 450 mots. Elles doivent etre mecanographiees en qualite ((correspondance>> sans espacement proportionnel. Tous les auteurs doivent signer une lettre d'accompagnement portant cession des droits d'auteur. Les lettres ne doivent rien contenir qui ait ete presente ailleurs pour publication ou deja paru. En principe, la redaction correspond uniquement avec les auteurs des lettres retenues pour publication. Les lettres refus&es sont detruites. Les lettres retenues peuvent etre abregees ou faire l'objet de modifications d'ordre redactionnel.
Ethical issues concerning the HIV status of physicians and patients _
Eike-Henner Kluge's opinions are so unbalanced that they must be challenged (Can Assoc Med J 1991; 145: 518-519). He believes that if a physician's status with regard to human immunodeficiency virus (HIV) may put the patient at risk the patient has the right to know it but that there is no reciprocal right for the physician to know the patient's HIV status. The rights and duties of physicians and patients in this context are quite different. For the purposes of discussion let us accept that there is a two-way risk of HIV transmission: -
r.
For prescribing information see page 1089
from physician to patient and vice versa. The risks may not be equal, but they exist. Kluge states that "the ethos of medicine has always been to try to help patients, even if this might expose physicians to danger or death." This I accept, but the obligation does not extend to a wanton and reckless disregard for the physician's safety or that of his or her spouse and family. In our practice of medicine as in other aspects of life - we should be aware of the risks to which we are exposed. We have a right to this; we have an obligation to ourselves and to those with whom we have close and interdependent relationships. We need to know the precautions we should take to minimize risk; in the last analysis this preserves us for the care of future patients. The doctrine of universal precautions, to which Kluge does not refer, says that this is unnecessary: if we treat every situation as one of potentially lethal danger we do not need to know which situations are of greater or lesser risk. This is nonsense, and it breaks down as soon as it is put to practical test. We take precautions in all situations, and we take more precautions in situations that we know to be of greater risk. This is logical, practical and ethical, and it rests on as accurate a knowledge as possible of the risk involved. If the risk cannot be known, the need for precautions can be estimated; if the risk is knowable, it should be made known, not necessarily publicly but to those who need to know. "Once a physician-patient relationship has been established, the needs of the physician are relevant only if they influence the ability to provide appropriate
care - the physician's private needs do not enter this equation." With respect, this is utter nonsense. Entering into a professional relationship, even a fiduciary one, does not abrogate my autonomy or my right to justice. It is not total subjugation. The risk to the physician of becoming infected with HIV, contracting acquired immunodeficiency syndrome (AIDS) and ultimately dying is very relevant to the physician and cannot be so lightly brushed aside. Even in a fiduciary relationship both parties have rights and obligations, and the obligations must be proportionate to the risks. The doctrines of autonomy, confidentiality and privacy cannot be stretched to ultimate denial of the information needed by physicians to protect themselves while they tend patients. The risk to a physician exposed to contamination with a patient's blood is significant if the patient is at that time HIV seropositive. The risk if the patient is a virus carrier but not yet HIV seropositive is very much less. A physician who has been con-
taminated with -HIV-infected blood must take many significant precautions until his or her seroconversion can be confirmed or refuted. This is not a negligible obligation: the physician may need to change his or her type of practice if it is one that exposes patients to the physician's blood; sexual practices should be modified to eliminate the risk of transmission; and female physicians should probably not become pregnant during this time. If the physician has no right to know the patient's HIV status, then these precautions should logically follow every exposure to blood CAN MED ASSOC J 1992; 146 (6)
811
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
