THE JOHNS HOPKINS Hospital must deal with difficult and frightening topics. We accept risks that come with our responsibilities. We have hoped that reports of our involvement will be accurate. That has not been the case with some of the news stories and opinion columns about the surgeon who died recently of AIDS and the actions the Johns Hopkins Hospital took to address the concerns of his -- our -- patients.
Solving the problems raised by this surgeon's story depends on courage and commitment from all of the medical community, the media and the public. We are not the enemy. Nor are our messages. AIDS is.
As the AIDS epidemic has evolved, we at Hopkins have worked hard to care for many patients and discover more about the nature of the disease. We also have worked hard to take responsible positions that balance the needs and expectations of our patients with those of the hospital staff. We realized that whatever we said or did might bring condemnation. On the one hand, letters and opinion columns criticize us for telling the media and patients what we knew. And on the other, we are the apparent target of multimillion-dollar lawsuits for not knowing and disclosing more information at an earlier time.
Ironies aside, what are the issues?
* Absence of information. Information about AIDS is incomplete. These information gaps impede policy decisions.
For example, the risk of physician-to-patient transmission is very low but we do not know just how low. Should society require testing of physicians or nurses or termination of their careers on the basis of a positive HIV test? The risk of patient-to-health-care-worker transmission from contact with patient blood or body fluid is much greater, but we do not truly know how great. Should society require patients to be tested?
How do we decide if we have an obligation to start routine or mandatory HIV screening of any group? What would we do with the results, given restrictive privacy and discrimination laws? Because there may be a six-month or greater lag between infection and positive readings on a blood test for HIV, should all physicians -- or patients -- be required to tell each other if they are in a high-risk group? Because we know that 2 to 4 per 1,000 people in the U.S. are HIV positive, do we screen every applicant to medical school for HIV? If so, should we screen every barber? They, too, hold sharp instruments.
* People want and expect zero risk. Life presents certain risks and we all want to minimize them. Going to a doctor, driving to work, and flying on an airplane all expose us to some risk.
We know a great deal about how AIDS is transmitted. Sharing needles and unprotected sexual contact confer high risk. Fortunately, according to the best information available, being operated on by a competent surgeon with AIDS seems to be very safe. Conversely, the risk of an HIV-positive patient transmitting disease to a physician, nurse or worker is much higher and we strive to protect our staff against that risk. With AIDS, just as in life generally, we cannot escape all risk. We can -- and do -- strive to minimize it.
* Politics and the policy vacuum. AIDS and all policies related to it are highly politicized. Existing federal and state policies are vague and in conflict with each other. Neither the U.S. Centers for Disease Control, state or local health departments or physician specialty groups have developed useful policies for HIV-positive workers. We are trying to balance the rights of privacy and protection for both patients and health-care workers in ways that work and make sense. Public health agencies and professional societies must attempt this balancing as well, and provide practical guidelines for hospitals and health-care workers.
* Disease has always been a risk -- for doctors and patients. AIDS is hardly the first health issue to pose dilemmas for public-health policy makers. Forty years ago, we had no definitive treatment for tuberculosis, then an often fatal disease that could be and was transmitted from doctor to patient and patient to doctor.
As a result, public-health policy required that patients and infected people, including health workers, be quarantined for long periods of time. Patients often lost their jobs, while physicians lost their careers. TB testing became mandatory, as did reporting results of such tests.
But AIDS is not a highly communicable disease in the same way TB is. There are few patients, physicians or HIV-positive individuals who would find such harsh treatment necessary or desirable. Nevertheless in an earlier time, such treatment was the rule.