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AIDS and the Physician's Fear of Contagion

1986; Elsevier BV; Volume: 89; Issue: 3 Linguagem: Inglês

10.1378/chest.89.3.325

1931-3543

Erich H. Loewy,

Ethics in medical practice

The fear of contagion has prompted some physicians to refuse to care for AIDS patients. Fear of coming to harm as a consequence of medical practice has been of concern to physicians at least since contagion has been recognized to exist. The balance among duty, fear, and courage has been a necessary part of medical practice ever since. Physicians are not asked to risk certain death or infection. The community, however, expects us to take “reasonable” risks—reasonable, at least, within the context of our community and its situation. Even during times of severe, poorly understood epidemics, most physicians stayed with their patients, and many survived.1Amundsen DW Medical deontology and the pestilential diseases in the late Middle Ages.J Hist Med Allied Sci. 1977; 32: 403-421Crossref PubMed Scopus (33) Google Scholar Only rarely were community expectations expressed in explicit law or contract. Most societies relied on the much weightier strictures of conscience induced by tacit social contract. During the “Black Death” of the 14th century, Guy de Chauliac, physician to the Pope and noted surgeon of his time, wrote: “… and I, to avoid infamy, dared not absent myself but with continual fear preserved myself as best I could …. ”2Campbell AM The black death and men of learning. AMS Press, New York1966Google Scholar True, Galen in the 2nd and Sydenham in the 17th centuries fled.3Walsh J Refutation of the charges of cowardice against Galen.Ann Med Hist. 1931; 3: 195-208Google Scholar, 4Veith I Medical ethics through the ages.Ann Bull NWU Med Sch. 1957; 31: 351-358PubMed Google Scholar The necessity to evolve multiple excuses for what even they saw as a dereliction of duty speaks for itself. And yet today, with the dangers more clearly understood, with precautions more effective, and with cures more promising, we seem less willing to assume personal risks. We faced greater risks in treating infection before effective protection or treatment was available. What then underlies our fears, and what has changed our sense of duty? There are, of course, many explanations. The society in which physicians function and from which they arise is no longer the “tight little island” of yesteryear. It is in many respects more egocentric, more hedonistic, less community oriented, and more dedicated to personal gain, advantage, and comfort. The individual has lowered his moral expectations for himself while raising these expectations for those around him. We have been bombarded with the type of propaganda that extols “rugged individualism” while demeaning social action. Running risks for social benefit does not sit well with us. Further, we physicians have been spoiled. In general, when we deal with potentially fatal contagion, we are used to curing. The hidden assumption is that should we become infected—a possibility at once rejected by our assumed bravado—we can readily be cured. Infectious disease not yet subject to cure elicits an unaccustomed fear and also challenges our God-like invincibility. It brings us face to face with two facts: we are finite, and we are mortal. And we—great men and women that we are—don't like it. Such considerations may explain but do not change the implicit contract, nor do they exculpate our actions when we violate it. AIDS, of course, poses a special category within this greater category. It falls into the category of “venereal” disease (even though, as with other diseases, its transmission is certainly not exclusively venereal). There is all the moral and sham-moral repugnance of such a disease with a special fillip—it is “venereal” under especially “repugnant” circumstances. There is the tacit, unexpressed but very real, flavor of sin and God's punishment (strangely enough inflicted mainly on males—be they homosexual or hemophiliac); the feeling of “just desserts;” and the very real feeling even without this of aesthetic repugnance. And, of course, this sense is either not realized or not admitted. Often, such feelings augment the primary fear of contagion and induce the physician to violate the contract and to seek justification in a series of arguments generally considerably worse than Sydenham's. There has been an enduring social contract intimately involving the healer with his community. This contract has been pervasive throughout diverse ages and societies, and it seems as alive today as in ages past. It is a tacit contract, and it assumes that the physician—endowed by his community with immense privileges, prerogatives, rights, and power, as well as with considerable material rewards—will merit that trust. Society assumes that the contract will be honored and the trust kept in time of need. Its expectations of “reasonable risk” necessitates courage without demanding heroism. A definition of what is reasonable is inherent within the context of the situation abroad at the time. The contract is reasonable. It has endured over the ages and has been hallowed by use. We abrogate it at our peril and at our shame. If we honor it, to that extent may we be deserving of honor; if we break it, to that degree are we worthy of shame—worthy, as de Chauliac would say, of “infamy.” The current trend in our society to forget duty in pursuit of personal pleasure may explain but does not exculpate our actions in violation of that contract. We have a choice—we can contribute further to society's decay by evading our contract in pursuit of comfort, or we may contribute to a renaissance of society by salvaging that which seems valuable. A new, a compassionate, a “better” society stands in need of our help and our reconstruction. We physicians may be privileged to partake.