Screening for HIV Infection
One of the great advances in the fight against HIV has been the development of low-cost and accurate tests for the presence of antibodies that the body makes once it is infected with HIV. These tests can tell us whether asymptomatic individuals are infected with the virus.47
Although quite accurate, the test is not problem free. Diagnostic tests are evaluated according to their specificity and sensitivity. Sensitivity is usually not a large concern with HIV tests; however, specificity is very important. Specificity refers to the probability that the test will be negative, given that the disease stare is absent. A test lacking in specificity has a high false positive rate. Although the Point is somewhat complicated, it is important also to discuss the positive predictive value. This is the probability that a disease is present, given that the test is positive. Positive predictive value incorporates issues of specificity, as well as prevalence of a disease state. A specific test can have poor Positive predictive value in a Population in which the disease is not prevalent.48
The tests for HIV have increasingly good specificity. However, the Positive predictive value for the test is quite low in low-risk populations because the prevalence of the disease is so low.49 This means that
any mass screening will be troubled by numerous false positive test results: many people who are not infected with the virus will test positive. Given that most of us are now familiar with the biological and social repercussions of infection with HIV, it is easy to see that significant numbers of false positive results are an intolerable prospect. For this reason alone, mass testing of those admitted to hospitals is a bad idea.
But what if the tests for HIV continue to improve and the false positive rate continues to drop? And what if prevalence continues to increase, especially in certain emergency rooms,50 and at specific hospitals,51 as it has. And what if the estimates of the risk posed by occupational transmission of HIV continue to increase, as they have over the last four years? Is it then reasonable to argue that health care workers and institutions should be able to test all patients, regardless of whether they would freely consent to testing? Can the negative freedom of physicians (the right to take precautions when a patient is possibly infected) provide a foundation for mandatory testing? This is an issue that medical ethics as just doctoring must address.52
Certainly there are many health care workers who believe that mandatory testing is reasonable and appropriate. In Great Britain, for example, many feel that requiring consent for HIV testing is not a desirable social imperative.53 In this country there also appears to be a great deal of testing, at least in some states, of individuals without their consent.54 Many doctors, it seems, would argue that we often perform a battery of tests on individual patients without seeking their specific consent to the testing. Why is HIV any different, they ask, than a simple CBC (complete blood count)?55
The simple answer has been that the risks of a false positive result outweigh the benefits to the person who is tested. In the past we had very few good interventions for treating HIV infection or AIDS. A false positive result would lead to great and unnecessary personal suffering for a patient. Therefore, a risk-benefit calculus led to the conclusion that mandatory testing could not be justified. In light of this, the World Health Organization, the Centers for Disease Control, the American Medical Association, the American Hospital Association, and the Presidential Commission on the HIV Epidemic have all argued against mandatory testing for patients.56
But the assumptions underlying the risk-benefit analysis are changing. Consider that there are now more and more pharmacological agents that look as though they may prove to be useful in the therapy
for HIV infection.57 For instance, the drug AZT is recommended as therapy for those who are HIV seropositive but who do not yet have AIDS given certain other conditions, such as low T4 lymphocyte cell subsets. More experimental drugs are coming down the line. Thus it may be beneficial to treat HIV infection, and thus beneficial to test and treat people early.
In addition, assume that concerns continue to grow about the safety of those who must, as part of their work, come into close contact with individuals who are infected with HIV. These concerns could lead to mandatory testing. Indeed, they have begun to do so. In Missouri, for instance, a new AIDS statute requires HIV testing for all individuals who enter a correctional institution, presumably at least in part to protect correction officers.58 One should expect that similar statutes will be passed in other states, and the slippery slope leads from prisons to hospitals.
In view of these developments, should health care workers encourage mandatory testing of hospitalized patients? From my viewpoint of medical ethics, it seems the analysis must still center on the encumbrance on the patient represented by such testing. Physicians have negative freedom as well, but just doctoring requires that it must be weighed relatively less than the negative freedom of patients. The altruism that makes health care a sphere of ethical activity requires that the patient come first. This does not mean the physician must totally disregard her own welfare, but it does mean that her autonomy is of less concern in the calculus. Thus while we would grant that knowing the HIV status of a patient might afford marginally greater protection for the health care worker, we must weigh and assess the burden of the test results on the patient.
These burdens can be insurmountable. Consider the following case related by Dr. Renslow Sherer:
In 1985, I was the primary physician for a young man whose life was ruined by the inappropriate disclosure of a positive human immunodeficiency virus (HIV)—antibody test. A physician ordered the test without consent and no-tiffed the local health department of the positive result. The health department notified the individual's employer and he was promptly fired. These events became common knowledge at his workplace and in his rural Midwestern town and he was shunned. His landlord asked him to move. Ten days after testing, the life he had known for the past ten years was permanently ruined and he left town. With the loss of his job came the loss of health insurance and insurability; he has been unable to obtain health or life insurance since then.
In this case, no purpose was served by obtaining the HIV-antibody test. The patient had been diagnosed with acquired immunodeficiency syndrome (AIDS)-related complex which has a 95 percent correlation with HIV infection six months earlier at Cook County Hospital. He was aware of his diagnosis and its implications. He had been following safe sex guidelines for the preceding 18 months and had never donated blood or semen.59
This passage makes clear the potential devastation of an HIV test. Let us look at the effects in some more detail. First, it is obvious that to be known as an HIV carrier is often to be stigmatized. Since many people are inordinately fearful of infection with HIV, their knowledge of one's status can lead to unreasonable reactions. The patient easily may become isolated from friends and face social exclusion. This can and does lead to depression and increased rates of suicide among individuals who are HIV seropositive.60
Second, the dissemination of the information can cause the loss of essential insurance policies. Most insurance companies want to reduce their expenses from AIDS-related claims. Therefore, they are unwilling to write health policies for individuals who are HIV seropositive. In addition, there are constraints on the availability of life insurance for people who are HIV seropositive.61 Thus an individual who tests positive through mandatory screening at a hospital may find that he loses both life and health insurance, as did the patient described by Sherzer. Those who are HIV seropositive may also face discrimination in their workplace. There have been many examples of people who have been harassed by coworkers, or even fired by employers, because their status as HIV carriers became common knowledge.62 Carriers may also face housing discrimination.
These problems tend to pale, however, compared to the threat of quarantine. There appears to be both public and academic support for coercive public health intervention for those who are HIV seropositive. Some have now recommended quarantine as a solution for "recalcitrant" individuals who carry HIV.63 While these proposals concern only those people who repeatedly endanger others through sexual contact or through sharing needles for intravenous drug abuse, there are no bright line definitions for the term "recalcitrant." Thus proposals regarding limited quarantine would soon lead to broader use.
Of course, quarantine, discrimination in housing and at the workplace, and even, to a certain extent, loss of availability of insurance are unacceptable burdens on the liberty interest of individuals who are HIV seropositive. In the liberal state, which values the concept of
pluralism and the ability, of each citizen to set his or her own agenda within the sphere of negative freedom, such encumbrances are intolerable. Indeed, in our country, we have a series of constitutional protections designed to prohibit such encumbrances.64 The Fourth Amendment of the United States Constitution explicitly protects citizens from unreasonable searches and seizures. This seems to include searches and seizures of one's body and thus, presumably, laboratory testing.65 In other words, our liberal Constitution prohibits mandatory testing against an individual's will. Given that just doctoring must conform with the public morality of the liberal state, it must be unethical for physicians to recommend mandatory testing. Even more important, since just doctoring involves an altruistic commitment to the patient's best interest, and since the individual's best interests may very well not be served by mandatory testing, there seems to be no basis within medical ethics for anything but opposition to mandatory testing of patients.
One may counter that the best interests of the patient might be met by early treatment of HIV infection, and that this early treatment can occur only if we know the patient's HIV status. Of course, the rational approach to accomplishing this goal is not mandatory testing. It is, rather, careful education of the patient about the options available for therapy. Once the physician explains the benefit of early treatment (and thus the benefit of testing) to the patient, and the patient refuses, then the liberal state is served only by respecting the patient's decision. In our discussion of informed consent, we concluded that the informed patient should be able to make decisions regarding medical therapy. An individual who wants therapy for an HIV infection and who is well educated about the benefits of this therapy can undergo voluntary HIV testing. Those who do not wish to know their HIV status because they are unconvinced of the efficacy of therapy, or because they fear the potential constraints on their freedom should others acquire knowledge of their HIV status, should be able to refuse testing. Medical ethics as just doctoring supports this notion and must therefore be opposed to mandatory testing.
One further argument in favor of mandatory testing is that many of the problems associated with testing can be obviated if rest results are kept strictly confidential. Thus no one loses insurance or faces discrimination if their test results are positive. The problem with this is that no one can be assured that results will be kept strictly confidential. Moreover, physicians must be concerned that even though they prom-
ise patients that the test results will be kept confidential, the state might decide otherwise. Indeed, it is conceivable that a majority might some day support the publication of such results in a liberal state. We must, as just doctors, be concerned for the welfare of the minority, especially when this minority consists of all individuals who are HIV seropositive. Therefore, we must be aware that even though confidentiality appears to be assured, there are no airtight guarantees. Confidentiality of results alone does not provide grounds for mandatory testing.
Many of these same arguments apply to converse testing proposals, that is, proposals that all physicians should be screened for HIV. While the chances of an HIV infected health care worker transmitting the virus appears to be low,66 one such case has been reported by the CDC.67 Given patients' informed consent rights discussed in the previous chapter, one could make an argument that the liberal state could require testing, especially of physicians involved in serious invasive procedures.68
Medical ethics as just doctoring does not create an ethical duty to mandate screening. For many of the same reasons cited above regarding testing of patients, mass screening of health care workers appears inappropriate. Physicians retain their liberty rights, and without clear and rather substantive benefit to the patient, these should not be forfeited. Individual physicians may choose to be tested, especially if they are at high risk, and are often involved in potential percutaneous transfer of blood products with patients. They may also choose to disclose the results to patients. But, until there is evidence that there is some measurable risk to patients, any form of screening of physicians and nurses is inappropriate. Of course, this does not mean there is symmetry in the justifications for patient versus health care worker screening. Indeed, the altruistic commitment of physicians to patients may mean that a certain level of risk would justify screening for physicians, but not for patients.
These are issues all health care workers must begin to debate, and for which they must help develop policies. Just doctoring requires public policy development by health care workers and the public. Medical ethics in the liberal state must consider and elaborate propositions on various issues that were previously considered matters for courts or for governments. Health policy, issues are an important part of medical ethics. Thus it is appropriate for physicians to consider the
effects of discrimination on their patients. They should understand that their concern for patient welfare must extend beyond the disease process and into social implications of disease. Moreover, medical care, especially under the conditions of an epidemic, butts up against public health issues. Here again medical ethics moves beyond the individual relationship between doctor and patient and addresses social and political issues. For instance, consider the question of whether the physician has a duty to warn individuals who may be put at risk by contact with the physician's HIV seropositive patient.