Physicians' Contemporary Obligations

AIDS does not raise new issues about physicians' responsibility to treat patients. Even before the AIDS epidemic caused some physicians to reexamine their obligations, a few critics were uneasy about the subtle and less than subtle ways in which physicians sometimes denied their services to patients. Such issues have a long history that is perceived more clearly against the background of previous centuries than in the context of twentieth-century optimism about the progress of medicine. It is a history of professional accommodation to civic obligation rather than simply of adherence to ethical precepts. Accommodation has been based on a sense of collective professional responsibility: Most medical communities have been intolerant of assertions that each physician could make his or her own decision about how to behave in an epidemic. Instead, civic and professional leaders have jointly chosen or recruited plague doctors. Moreover, a similar pattern has been followed for identifying physicians to treat such endemic infectious diseases as leprosy, syphilis, and tuberculosis.

The question of what should be done when contemporary physicians hesitate or refuse to treat patients whose conditions may harm them may not be resolved much differently than in the past. If the resolution is similar, however, it will result from political circumstances, not historical inevitability. A considerable number of physicians are refusing to treat persons with AIDS or HIV infection, or threatening to refuse. Leaders of the medical profession have recently joined with civic authority, both formally and informally, in setting policy. In New York, for example, where medical school faculty members treat most persons with AIDS in public and voluntary hospitals, the members of the Asso-

ciated Medical Schools threatened to censure faculty members who withhold treatment. However, the civic and medical authorities who negotiate with physicians to treat persons with AIDS are more likely to offer them incentives than disincentives. In the past, many physicians' incomes improved during epidemics. Plague doctors performed the most dangerous tasks, but they were amply rewarded in cash and, if they survived, in the more important coin of social and professional status. A new cadre of plague doctors now serve in dedicated AIDS units or treat most of the persons with AIDS in particular hospitals. Their rewards are often access to research funds or academic status rather than income alone.

The new problem of our time is the potential risk to physicians who perform invasive procedures on patients potentially infected with HIV. In the past, most physicians who were uneasy about treating patients with infectious diseases did not run the risk of working inside their bodies. Moreover, physicians cannot identify HIV infections in asymptomatic patients and therefore cannot refuse to treat them without first testing. A negotiated solution to these problems may involve more widespread testing of patients upon admission to hospitals or more rigorous adherence of physicians to universal infection-control procedures.

There is—and no professional historian would say this judgmentally—continuity between the physician in Chaucer's Canterbury Tales who delighted in the "gold he kept from pestilence"^[20] and the well-known academic physician who said in my presence two years ago that "AIDS has been good to me."^[21] This continuity may be the result of a broader truth about civic behavior in Western society, at least since the late Middle Ages: It is not that every person has a price, but that, within any group, enough people's prices can be paid to achieve most goals of policy.