Ethical Imperatives and the New Physician: V. Responding to the Patient with AIDS
Commencement Address by C. Everett Koop, MD, ScD
Surgeon General of the U.S. Public Health Service
U.S. Department of Health and Human Services
Presented at Class Day Exercises
Harvard Medical School
June 9, 1988
Harvard, like many other schools has a class day for certain graduate schools and then on commencement day, usually the day
afterward, all of the schools graduate together at one big commencement. This address was delivered to Harvard Medical School's
Class Day audience, Class of 1988.
I started with extending my thanks for the invitation, which came not from the faculty, among whom I count many friends, but
from the graduating class, which means that young physicians know me and the Office of the Surgeon General and that bodes
well for the future, because we in the Public Health Service are interested not only in the present, but those things that
lie beyond the horizon. I gave examples of the here and now problems, as well as some that exist now and will continue beyond
the foreseeable future. Then, I said I wanted to spend the few moments we had together to talk about AIDS and that I wished
to approach it not from the usual health and social issues, but from the viewpoint of the several ethical issues that AIDS
has raised for medicine and indeed for all of society.
They were then informed about the cycle of six commencement addresses - a copy of all would be in the mail to them during
Then, I reminded them that ethics was the "in" subject, because it was on everyone's mind these days for lawyers,
educators, government officials, business managers, and physicians. I also reminded them that two of the biggest box office
hits from Hollywood in the past year were Wall Street and Broadcast News, both of them very tough-minded stories about personal
ethics that went sour. From my point of view as Surgeon General there seems to have been an important ethical dimension to
every medical and health problem that was placed on my agenda since I first took office back in 1981. The ethical subject
I wanted to discuss on this occasion might be entitled, "The Reluctant Physician". I then went through the litany
of the things they should know about AIDS, incidence, fatality, absence of a vaccine, our only weapon being education, etc,
etc. That meant that AIDS had all the elements of a major human tragedy: fear, prejudice, rejection, and hopelessness.
I had written an editorial in the Journal of the American Medical Association the previous year asking physicians to take
the lead in the fight against AIDS. I didn't understate the responsibilities, but in retrospect, perhaps I should have
spelled it out more fully. I then listed three examples of things physicians are being asked to do that they really don't
like to do. In addition to that, we were asking physicians to take a sexual and drug use history of appropriate patients -
and in many practice areas that means all patients. Dr. Neil Schram of Los Angeles said, "Most physicians have had too
little training for this, so a great deal of new information and a great many new skills must be learned and applied."
My addition to that would be that the learning and application must be right now.
Should physicians be concerned about themselves, as well as the general public? Of course, they should! However, it is not
an overwhelming task; the Public Health Service has published a set of common-sense safety guidelines for all health personnel,
including physicians. Other guidelines, such as those of the American Hospital Association were particularly applicable to
hospital workers. The result was that fewer than a dozen people out of the nearly 7 million people, who were exposed to the
danger of HIV in health settings, had become accidentally infected with the HIV virus while providing patient care. In almost
every case, that accident could have been prevented.
At the time of this lecture, we heard almost every day, of instances in which a physician, dentist, nurse, or other health
professional had refused to treat persons with AIDS. Such conduct had never been condoned and almost 2,400 years ago the Hippocratic
oath covered the situation quite well.
The refusal to treat AIDS patients is unacceptable professional behavior say the American Medical Association, the American
College of Physicians, the American Nurses Association, the American Dental Association, and many others. And I have said
it from dozens of platforms in the years prior to this, plus in the media, including newspapers, radio, and television. But
the ethical conduct of the majority - which is perfectly acceptable - should not shield the unprofessional and unethical conduct
of a fearful and irrational minority. If we permit this with regards to AIDS, what will be the next expected condition . .
. or class of patient?
That led to the question of testing, which I thought was unnecessary and presented a great burden to institutions, out of
all proportion to the occasional AIDS patient that came under their care. There are certain circumstances, which should alert
hospital personnel to do testing, such as evidence of intravenous drug addiction, or a homosexual patient with a history of
sexual promiscuity or sexually transmitted disease in a heterosexual patient, especially one with a multiple sex partners.
I don't think this is an infringement on personal rights; I think people who cannot control their own high-risk behavior
should not expect -- nor should they get - a "free-ride" from the health care system. Penalties for high-risk behavior
include the possibility of dying from AIDS, but also being tested for AIDS as a prior condition to receiving medical care.
I'm always concerned in a situation like this that the longer the health profession delays establishing ethical procedures
covering its own people with AIDS, the sooner will the public lose patience and turn to the courts for relief. That means
someone tells medicine what to do.
I then turned to economics and raised the question of American taxpayers willingly supporting a great many programs in health,
which include programs for alcoholics, drug addicts, and persons with syphilis. The difference with AIDS is the virtual 100
per cent mortality and in a relatively short period of time. This led to talking about the average cost of health care per
patient and the anticipated logging in of 74,000 new AIDS patients in 1991. I then asked a number of questions having to do
with reimbursement, the public's asking for relief, the cutting of comers, and the possibility of "second-class care".
At this point, I turned to the thought of asking the audience to begin thinking of their own response to these ethical issues,
because they would surely arise, and perhaps in some highly publicized way. I didn't have any hard and fast answers to
the questions I raised, but we all should be deeply concerned about the answers, as well as be deeply engaged in the process.
I closed with a plea asking each of the graduates to keep probing, keep climbing, and keep their vision as clear as can be
throughout their careers in medicine.