THERE is now, for the first time, hard clinical evidence of an effect that AIDS doctors have suspected for years: If you are H.I.V.-positive, being on antiretroviral drugs will probably save not only your life, but also the lives of your sexual partners.This month, a randomized clinical trial — the gold standard in medical research — showed that the drugs lowered the chances of infecting a partner by 96 percent.This is good news for the infected and their lovers. But it is a moral dilemma for doctors whose infected patients do not want to start taking drugs immediately, usually because they do not yet feel sick and have heard exaggerated rumors about side effects.What does a responsible doctor do with a patient who is sexually active and teeming with a fatal and incurable virus? Advise him to use condoms and trust him to act decently? Beg?Behind each doctor — whose primary duty is to one patient — there is a government public health bureaucracy, whose duty is to protect the whole country. The epidemic has been killing Americans for 30 years now.Whose rights should be paramount? Those of the patient? Or those of his healthy spouse — or boyfriend, or date, or hookup, or client, or rape victim, or incest target?This debate has been going on since AIDS began, and has always been inextricably mixed with the circumstances of its birth: it was a sexually transmitted disease that emerged among gay men in the middle of the sexual revolution and the new gay rights movement. AIDS still carries a huge stigma and provokes hatred wildly out of proportion with the fact that it is simply a new virus. (Neither SARS nor H1N1 were called “God’s wrath.”)But the fact that there is a new form of prophylaxis reopens old questions.Several AIDS clinicians interviewed for this article said the idea of forcing treatment onto a patient was repulsive to them.“It was unthinkable when we had this debate in the early 1980s, and it’s unthinkable in 2011,” said Dr. Myron S. Cohen of the University of North Carolina, who led the study that found the 96 percent protection rate. During a long discussion, he called the idea “medieval” and “a violation of civil rights.”Recalcitrant patients “ultimately do come around,” argued Dr. Wafaa El-Sadr, who has treated AIDS patients in Harlem and Africa for decades. “You talk to them, you talk to them, you talk to them. Forcing them would make them run away.”Ronald Bayer, who teaches ethics at Columbia University’s Mailman School of Public Health, agreed, even as he reflected that he is “rarely in the position where I’m the one urging restraint — they used to call me ‘Dr. Coercion’ because I’m often on the side of public health trumping individual rights.”Hypothetically, he said, if there were a single pill that could render a patient noninfectious for a year, forced treatment might be imaginable.But there is not, and the practical barriers to forcing someone onto daily pills for life are enormous. Dr. Bayer compared it to Jeremy Bentham’s notion of a Panopticon — a late 18th century jail where every prisoner knows he can be watched at all times.Furthermore, several doctors said, it would be unethical to expend effort on forcing a tiny minority of selfish and self-destructive patients into treatment when so many others lack it, when 8,000 Americans are on waiting lists for the drugs, and millions of others, mostly in Africa, have little hope of getting them.And yet in many legal circumstances, people can be forced into treatment to protect others. In New York’s outbreak of drug-resistant tuberculosis in the 1990s, uncooperative patients were locked into Bellevue Hospital. Mental patients can be involuntarily medicated if a judge or medical panel rules them dangerous; “Kendra’s Law” permitting just that in New York State was named for a young woman killed by one.Women with hepatitis B can be forced to immunize their babies within 12 hours of birth. Children must have shots before they enter school not just for their own sake but also to protect their classmates who are allergic to vaccines or have compromised immune systems.And most of the quarantine laws written a century ago, when cholera, typhus and plague were around, are still on the books. “Typhoid Mary” was not imprisoned for 25 years for treatment. She was never sick, didn’t believe in germs although she carried them, and attacked a public health official with a fork when he demanded a stool sample. She was imprisoned because she kept taking jobs as a cook, sometimes under false names, infecting 51 people.Dr. Thomas R. Frieden has been on both sides of the dilemma. As head of the Centers for Disease Control and Prevention, he is a leader in the national response to AIDS. As health commissioner of New York City during the tuberculosis outbreak, he had to imprison some patients.“I see a bright line between tuberculosis, which can be passed standing next to someone in an elevator, and H.I.V., which usually requires consensual sexual activity,” he said in an interview.But, it was argued to him, even consensual sex isn’t truly consensual when someone is lied to, or drunk, or in a dozen other situations that would negate the ideal of “informed consent” if, say, a contract were being signed.“I know,” he said, describing interviews he had done with infected men early in the epidemic. “The stories were heartbreaking — young men, moving to New York to finally come out as gay, and they’d say, ‘I know who did it. I just can’t believe they’d have lied to me about something like this.’ ”Nonetheless, he said, he still would never force a patient into treatment.“It’s a small subset of people who pass on the virus by lying,” he said, “and people have a right to refuse treatment.”Dr. Howard Markel, a medical historian at the University of Michigan, said that, even after 30 years, there is still a sense of what he called “AIDS exceptionalism” — the belief that this illness is like no other, despite historical precedents. (The obvious one is syphilis, which until antibiotics became widespread in the 1940s was the exemplar of a slow-progressing fatal disease. To stop it, mandatory testing was adopted; many states would not issue a marriage license without a negative result. AIDS tests are not only not mandatory, but also it is often legally difficult to add them to routine blood work.)“Is it time for AIDS exceptionalism to become a historical relic?” Dr. Markel asked. “That’s an interesting question. It may be time for it to just blend in with the others. But that might not happen until some other attention-getting disease comes along.”
Source:NewYork Times
No comments:
Post a Comment