Professionalism And Risks

Persons choosing their life's work must make choices that reflect their own deeply embedded values and personality. In choosing their life's work, they assume certain known risks: firemen may get burned, policemen shot, and health professionals infected. Risks, however, are also, to some extent at least, imponderable and may appear during the course of a life's work: fire-fighting equipment and the nature of blazes change, criminals adopt new methods and weapons, and the nature of a given infection evolves. Every occupation has its advantages and drawbacks, its risks and benefits. Medicine is no exception.

Physicians and other health professionals are exposed to risks throughout their professional lives. These risks are rarely explicitly spelled out; nor can they be. Members of social structures, when first coming together, have established communities with far differing notions of what communities are all about (see also Chapter 3). No matter what our notions of the specifics of this contract may be, its existence cannot be much in doubt. The alternative, no social contract and no understanding or agreement of mutual obligation, cannot be called a community. Community is not merely a collection of individuals held together only by explicit undertakings. Such explicit compacts, such affirmations of mutual responsibility, cannot come about without the tacit undertakings and expectations that enabled them in the very beginning.31

Historically, health professionals, when confronted with infectious disease, have had to fear contagion. Fear (here defined as a sensation or feeling of anxiety caused by the realization, perception, or expectation of impotency in the face of perceived or expected danger or evil) subsumes qualities of dread and awe and further has other emotive and aesthetic elements.32 Counterpoised against such fears are the presumed duties of the profession: not only the obligations assumed by moral agents in recognition of the moral law as distilled through the vision of specific social contract by particular societies, but likewise the more specific obligations inherent in being a professional of a particular type. Courage (the "disposition to voluntarily act, perhaps fearfully, in dangerous circumstances," its essence being the "mastery of fear for the preservation of a perceived good against dangers") gives the edge to doing what one perceives to be the right thing despite one's fears.33 What health professionals perceive to be "the right thing," however, derives from their understanding of social contract applied, in this instance, to the way in which the implicit covenant with the community is envisioned. And such a vision is historically grounded.

Health professionals throughout history have assumed obligations to treat patients despite personal risks. Presuming that health professionals were aware of the possibility of contagion (and that therefore they were quite mindful that they could contract the disease in epidemics), epidemic disease can serve as a paradigm for such an examination. Although the knowledge of what causes infection was still far in the future, there is sound evidence that it was soon clear that some disease could be spread by personal contact. Thucydides, in describing the plague of Athens (5th century BCE), mentions the disproportionate number of physicians who died there, and Hippocrates carefully instructed physicians in methods of avoiding infection. By the time of the Justinian Plague (540-590 CE), there is no question that knowledge of contagion (albeit hardly of its mechanisms) was firmly entrenched. Laypersons as well as professionals were obviously quite aware of the risks.

Many factors enter into our clinical or personal decisions to take, or not to take, risks. Some of these factors are technical: "What kind of risk am I taking?" "How much risk is there?"—to name but two. The answers here are crucial to our ethical deliberations. If undertaking a given course would result in certain death, a different set of considerations pertains than if the risk is moderate or small. Even in the first instance, there is a critical difference between the heroism that gives a life to save another and an action that gives a life with no hope of saving another. Giving one's life to save another may, under most circumstances, be a supererogatory act; doing so with no hope of saving a life in turn for one's own may surely be even more problematic. Under most circumstances, neither can be simply viewed as a clear-cut and absolute moral obligation that must, under all circumstances, be discharged.

For physicians and other health professionals, there is, furthermore, a consideration at least as important as the saving of life. There is a great deal of difference whether, beyond saving a life, significant comfort can be given. The obligation of health professionals clearly does not end with the saving of life. Historically the obligation to give comfort is far more enduring than is the obligation to save life, and this ancient obligation is presumed today. Health professionals must consider both the saving of life and the amelioration of suffering. When a disease is hopeless, ameliorating suffering moves into the foreground of professional obligation. As long as patients have not irretrievably lost consciousness, health professionals are obligated to provide what comforts they can. Such an obligation is grounded in the shared historical vision of the patient-physician relationship.

Both physicians and communities have historically profited from their vision of the social contract. Health professionals gain a tremendous amount from their side of the bargain. Physicians, and to a lesser extent other health care professionals, have been blessed with immense privilege, prerogatives, and power as well as with considerable material reward; communities have profited from their healer's skill and from the security entailed in the knowledge that the contract will be honored in times of need. Like all contracts, social contract implies mutuality and bilateral agreement.

What about the HIV-infected physician or other health care professional? Do such persons have an obligation to inform others about their condition, or is seeking such information a violation of that person's privacy? Is mandatory testing for health care professionals a reasonable incursion on their private liberty, or is it not? As with all problems, one must start one's inquiry by gathering "facts"—at least the best facts that are available. At this writing, no single case of physician-to-patient transmission has occurred. One dentist who in the course of his work appears to have infected several patients apparently did so under particularly peculiar circumstances that make it likely that he, whether deliberately or not, failed to sterilize his instruments properly.

Although laypersons seem very concerned about possible HIV infection in their physicians, such concern does not appear to be based on factual evidence but on rumor, fear, and hysteria. Although some feel that physicians, especially those who do invasive procedures, have an obligation to inform their patients of their status, a persuasive argument in the face of overwhelming data that such transmission rarely if ever occurs is difficult to make. Laypersons who are afraid of such transmission are, it seems, laboring under a false assumption: since data will not substantiate this belief, it is a form of prejudice and one that can be ruinous for the person against whom this prejudice is directed. Rumors, fear, hysteria, and prejudice are not properly addressed by restricting another's freedom of action, but are properly addressed by the education of those who are misinformed. Furthermore, even though a theoretical risk can certainly be argued, patients are not ordinarily informed about many aspects of their physician's private lives that may constitute a risk to them. If a surgeon sleeps badly the night before surgery or if he or she is overworked, worried, or otherwise troubled, the risk to the patient is a very actual one. And yet we do not think about forcing surgeons to reveal their lack of sleep, the fact that they had been to a party, or their domestic or financial worries to their patients.

If physicians were forced to reveal their HIV status to their institutions, licensing boards, or patients, their ability to have a successful and satisfying practice would be severely limited. The minimal risk their patients might face (and all of us every day assume small risks when we go about our business) is out of balance with the destruction such information would cause to their lives.

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