Surgeon General of the U.S. Public Health Services
U.S. Department of Health and Human Services
Presented to the Assembly of AMA Medical Student Section
December 5, 1987
It had been four days since I had last spoken publicly on the subject of AIDS.
Speaking to the Student section of the AMA was always a great pleasure for me because in my years before coming into government
and in the years that I was a delegate (as Surgeon General) to the House of Delegates of the AMA, I was impressed with the
astuteness, innovation, and perseverance of the Student Section. Many of the more important things that happened at the top
levels of the AMA, that therefore affected policy in this country, started in the Student Section. I'd like to see a study
done sometime on how the politically active medical students affected policy-making in days that followed. I imagine they
were as outstanding late, as they were early.
Some of the discussion at the meeting before I made my appearance had been on the relevance of the Hippocratic oath in modern
medicine. I made it clear that although the Hippocratic oath had been around for two thousand years, its power did not rest
in that fact, but that we hold the power when we repeat such an oath, believe it, and live by its tenets. That's when
the oath has power!
My questions to this audience were, are we talented enough . . . are we compassionate enough . . . are we honest enough .
. . to be physicians? The answers are even more difficult in the age of AIDS. I acknowledged upfront that there is cause for
physicians to be concerned, especially about their own health and exposure to patients with AIDS, but pointed out that such
is not new in medicine. However, what AIDS had done, that no other disease did before, was to becloud the situation with the
powerful elements of fear, rejection and hopelessness. Incidentally, I pointed out that the Hippocratic oath was written to
counter each of these elements in human failing, thereby providing the opportunity to give faith and hope were once there
may have been only despair.
That seemed to put the practicing physicians in the first line of defense for the human race against the scourge of AIDS.
The public health service had recognized this and published common sense guideline for health personnel. Evidently the guidelines
had worked; of the nearly seven million people involved in healthcare in this country only eight had become accidentally infected
with the virus while providing direct patient care. Incidentally, all of those accidents could easily have been prevented.
I then raised the philosophical question that comes to the mind of many people in treating a disease that is, at the moment,
a hundred percent fatal. Why do we spend all this time and effort when our patients are going to die anyway? That's blunter
than many people pose the question, but it's nevertheless, what they think. I hastened to say that this was not characteristic
of all health professionals because the overwhelming majority of our colleagues have provided and will continue to provide
quality, compassionate care to persons dieing of AIDS. I reminded them that, as physicians and as Americans, they should be
as proud, as I am, to be a part of a tradition of care that will not abandon the sick and disabled whomever they are. However,
that tradition is what is at stake today. In other words, the virus of AIDS can further weaken the ethics of medical practice
in the United Sates.
I then got into the economic implications that have been covered in previous lectures and raised the issue about how long,
in this fragile climate, we will continue to pour taxpayers money into the care of patients with AIDS. I predicted that in
1991 we would log in 74,000 new AIDS patients and that the cost of patient care that year would be between 8 and 16 billions.
Does that mean that comers will be cut and second-class care will be accepted for AIDS patients?
To all the questions I posed, I indicated that we had to most careful with the answers over the next three years because
on them depended the future of medicine in this country. I went back to the Hippocratic oath as the foundation of the uniqueness
of the doctor patient relationship, which led to a discussion of the community's tolerance in the argument to provide
the right of privacy for each individual while at the same time caring for the safety of the community. We have always used
the promise of full confidentiality in order to get as much sensitive health-related information as possible from individuals.
Without such a system we would never have succeeded in containing most other infectious disease. But I acknowledge that AIDS,
like no other previous disease, had a high mortality rate and was so resistant to therapy and prevention. That naturally led
to the "voluntary vs. compulsory" debate on testing and the question whether total confidentiality was ever possible.
I reported to the students that the secretary of HHS, Dr. Otis R. Bowen, had sent a letter to the governors of all fifty states
asking them to focus on three issues: 1. Confidentiality of patient records and protection from disclosures, 2. The issue
of protecting infected persons from discrimination whether on the job, in school, in housing or in healthcare itself, and
3. The issue of protecting the public from exposure to the disease of AIDS. I felt it necessary then to call attention to
the fact that medical care in the United States is a state-licensed and state-regulated profession and I, as a federal officer,
can discuss these issues, but actually have less direct effect on American professional life than if I were a state official.
When speaking to medical students I always encourage them to be politically active in the field of medicine. You can't
criticize it from the outside but you can change it from the inside. I closed my remarks to this group, in which I had so
much confidence saying that, that I wanted them to keep probing, keep climbing, and keep their vision as clear as possible
throughout their medical career.
Effect of AIDS on patient preference for hospitals
Effect of AIDS on residency selection
American tradition of "Care for all"
Baby Jane Doe
Challenges to medical students for the future
Involvement of Medical students in medical politics
Low incidence of Infection of health workers
Power of persuasion of the Hippocratic oath
Protecting the public from exposure to AIDS
Role of Confidentiality in public health
"Second-Class Care" for AIDS patients
Secretary Bowen's request to 50 governors
Statistical predictions on AIDS for 1991
Stresses on the Hippocratic Oath caused by AIDS
Taxpayers' support of AIDS care
Tension between the right to privacy and the protection of the community
The avoidance of discrimination against AIDS patients
The cost of AIDS per patient
The Risk of health workers exposed to AIDS patients
Threats to the ethical practice of medicine in the United States