The Fragile Web of Responsibility: AIDS and the Duty to Treat

By Arras, John D. | The Hastings Center Report, April-May 1988 | Go to article overview
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The Fragile Web of Responsibility: AIDS and the Duty to Treat

Arras, John D., The Hastings Center Report

The Fragile Web of Responsibility: AIDS and the Duty to Treat

Do physicians, by virtue of their role as health care professionals, have a duty to treat HIV-infected patients? Must they subject themselves to the very small, but nonetheless terrifying, risk of becoming infected themselves in order to live up to the ethical demands of their calling? For most physicians toiling in the front lines against AIDS, this is a new and totally unanticipated moral question that has yet to receive a clear and satisfying answer.

The current generation of physicians has experienced very little exposure to serious occupational risk. Well protected by antiseptic techniques and antibiotics for a period of roughly thirty years, doctors in developed countries have come to believe (with some justification) that they are exempt from the riskier aspects of medicine that had claimed the lives of so many of their predecessors. Prior to this pax antibiotica, risk and fear accompanied physicians daily, especially during the all-too-frequent periods of plague and virulent infectious disease. For many, if not most, of these physicians, to be a doctor meant that one was willing to take personal risks for the benefit of patients. One entered the profession with a keen appreciation of the hazards. By abruptly dispelling this perception of relative safety, AIDS has compelled today's physicians to reopen the traditional inquiry into the moral relationship between hazard and professional duty.

AIDS has likewise highlighted the limits of most contemporary bioethical inquiries into the physician-patient relationship. In their singleminded campaign against the excesses of medical paternalism, most bioethicists have been content merely to refute physicians' claims to moral expertise and special prerogatives based upon their Hippocratic duty to benefit the patient. In undermining this claim, bioethicists have completely ignored the question of whether physicians might still have special responsibilities as healers.

Moreover, the bioethicists' favorite metaphor for describing the physician-patient relationship, the contract between free and equal moral agents, has further obscured the issue of physicians' obligations to place themselves at risk in the service of their patients. By stressing the voluntary nature of the physician-patient "contract," bioethicists have inadvertently reinforced the notion that physicians, as free moral agents, have a perfect right to choose whomever they wish to serve. This claim to contractual freedom, enshrined in the 1957 AMA Code of Ethics, [1] likewise fails to address the question of whether physicians have a special duty to enter into contracts with hazardous patients.

Although there are many ways in which physicians can fail to discharge their putative duty to care for HIV-infected patients, ranging from outright refusal to foot-dragging, I shall focus on the central problem of categorical refusal to treat due to fear of infection. Do all physicians have an ethical duty to treat HIV-infected patients in spite of the risk, or can physicians fully discharge their moral duty to such persons by referring them to other physicians who are willing and capable of treating them? In short, is voluntarism an ethically acceptable basis for medical practice in the age of AIDS?

Protecting the Vulnerable: Individual Rights and

Professional Obligations

One promising starting point for our inquiry is to focus on the medical need of HIV-infected patients. These persons harbor a potentially lethal virus and may already be manifesting symptoms of ARC (AIDS Related Complex) or AIDS. They may require treatment of AIDS related conditions--such as Kaposi's sarcoma and pneumocystis pneumonia--or they may incidentally have other health problems requiring attention, such as kidney failure, heart defects, or dental problems. Although the diagnosis of HIV disease renders their plight particularly poignant, these patients resemble all patients with serious illnesses insofar as they are sick, vulnerable, and needy.

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