ORIGINAL

HEATON ORI ECTURE
By
C, Everett Koop, M.D., Sc.D.
SURGEON GENERAL
OF THE
U.S, PuBLic HEALTH SERVICE
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

CV OD

PRESENTED AT WALTER REED ARMY MEDICAL CENTER
WASHINGTON, D.C,
Marcu 30, 1988
1
(GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.)

IT’S A DISTINCT HONOR TO BE CHOSEN AS THE PERSON TO DELIVER
THIS YEAR’S HEATON MEMORIAL LECTURE. AND OF COURSE IT’S A GREAT
PERSONAL PLEASURE TO BE AMONG COLLEAGUES IN SURGERY,

FOR NEARLY 40 YEARS OF MY LIFE I LABORED IN PEDIATRIC
SURGERY AND I STILL RECALL THOSE YEARS WITH GREAT FEELINGS OF
PRIDE AND A SENSE OF PERSONAL FULFILLMENT,

TODAY I AM YOUR SURGEON GENERAL. BUT, AS YOU KNOW, IN THIS
PARTICULAR POSITION I'M NOT ALLOWED TO PERFORM SURGERY. AND --
ALAS! -- NEITHER AM I A “GENERAL.” IN FACT, I HOLD THE RANK OF
VICE ADMIRAL.
2
T THOUGHT THIS LITTLE CONFESSION WAS IN ORDER, SINCE I WOULD

NOT WANT TO PARADE BEFORE YOU WITH ANY FALSE FLAGS. I ADDRESS
YOU THIS AFTERNOON AS A NON-SURGEON NON-GENERAL ... AND THERE'S
NOTHING I CAN DO ABOUT THAT.

BUT T DON’T INTEND TO SPEAK DIRECTLY TO THE SPECIALTY OF
SURGERY IN ANY CASE. RATHER, I WANT TO EXPLORE A MORE FAR-
REACHING ISSUE, ONE IN WHICH SURGEONS -- AND INDEED ALL HEALTH
PROFESSIONALS -- NEVERTHELESS HAVE A KEEN INTEREST.

I’M SURE YOU KNOW BY NOW THAT I’M TALKING ABOUT AIDS.
3
I‘M NOT GOING TO DWELL ON THE PARTICULARS OF THE DISEASE,

THE DAILY PRESS -- AND OUR PROFESSIONAL JOURNALS -- DO A VERY
GOOD JOB OF THAT.

INSTEAD, I WOULD LIKE TO SHARE WITH YOU MY PERCEPTION OF
WHAT EFFECT THE EPIDEMIC OF AIDS IS HAVING UPON THE WAY AMERICANS
THINK ABOUT DISEASE ... ABOUT EACH OTHER ... AND ABOUT RESPONSI-
BILITY: PROFESSIONAL, SOCIAL, AND PERSONAL RESPONSIBILITY,

MAKE NO MISTAKE ABOUT IT. AIDS IS NOT JUST A DISEASE
AFFECTING THE BODIES AND MINDS OF A FEW THOUSAND PEOPLE.

THIS DISEASE ALSO THREATENS OUR COUNTRY’S SOCIAL COHESION
AND NATIONAL PURPOSE.
4
WHY IS THIS SO? WHAT MAKES AIDS SO THREATENING?

AS A BEGINNING, WE NEED TO ISOLATE THOSE THREE ASPECTS OF
THE AIDS EPIDEMIC THAT COLOR EVERYTHING DONE AND SAID ABOUT IT,

FIRST, AIDS IS STILL A MYSTERY.

THAT MAY COME AS A SURPRISE TO MANY OF YOU WHO SEE AIDS
ARTICLES POPPING UP IN EVERY CONCEIVABLE MEDICAL PUBLICATION.
AND IT’S TRUE THAT WE KNOW QUITE A BIT ABOUT IT.

BUT UNFORTUNATELY WE DON’T YET KNOW ENOUGH TO PRODUCE A
VACCINE TO PREVENT ITS SPREAD OR A DRUG TO STOP IT IN ITS TRACKS,
5
I SHOULD ADD THAT THE WORLD'S MOST TALENTED VIROLOGISTS AND

IMMUNOLOGISTS HAVE BEEN WORKING ON THIS DISEASE FOR ONLY A HALF~
DOZEN YEARS AND THEY'VE MANAGED IN THAT SHORT A TIME TO PRODUCE
AN IMPRESSIVE BODY OF KNOWLEDGE.

OF COURSE, THE AVERAGE PERSON WANTS A CLEAR-CUT “YES” OR
“NO” TO THE MOST PRESSING PERSONAL QUESTIONS IN REGARD TO AIDS.
BUT, AS YOU WELL KNOW, SCIENTISTS SHY AWAY FROM CLEAR-CUT
ANSWERS.

BUT IN THE CASE OF AIDS, WE SHY AWAY ... BECAUSE THE CLEAR-
CUT ANSWERS SIMPLY AREN’T THERE.
6
AND, REMEMBER, WE’RE TRYING TO EXPLAIN THIS TO A GENERATION

OF AMERICANS WHO HAVE BEEN USED TO READING ABOUT THE CONQUESTS OF
BIOMEDICAL SCIENCE -- NOT ITS DEFEATS.

IT MAY TAKE A FEW MORE YEARS -- AT THE LEAST -~-BEFORE WE
UNRAVEL ALL THE RIDDLES OF THIS VIRUS. BUT WE WILL.

T HAVE ABSOLUTELY FAITH IN THE PERSISTENT GENIUS OF OUR
BIOMEDICAL RESEARCH COMMUNITY.
/
AFTER ALL, OUR SCIENTISTS ARE CONQUERING BALDNESS ...

OBVIOUSLY THEY‘LL CONQUER AIDS.

IT'S NOT “WHETHER” -- IT'S “WHEN.” BUT WE DON’T KNOW WHEN.
AND THAT’S WHAT IS SO UNNERVING FOR THE AMERICAN PEOPLE,

) SO, AIDS IS A MYSTERY. BUT IT HAS A SECOND AND EVEN MORE
TERRIFYING ATTRIBUTE: AIDS IS ALSO FATAL.

IN FACT, AIDS SEEMS TO HAVE ONE OF THE HIGHEST FATALITY
RATES OF ANY INFECTIOUS DISEASE WE’VE EVER COME ACROSS,
8
WHEN YOU LOOK AT ALL THE REPORTED CASES OF AIDS SINCE 1981

-- AND THE REPORTED DEATHS AS WELL -- THE MORTALITY RATE IS ABOUT
56 PERCENT ... WHICH IS BAD ENOUGH,

BUT WHEN YOU RETURN JUST TO THOSE PERSONS WHO HAD AIDS IN
1981, YOU DISCOVER THAT 93 PERCENT OF THEM HAVE SINCE DIED OF THE
DISEASE.

AND IN MY BOOK, A MORTALITY RATE OF 93 PERCENT IS AS BAD A
RATE AS 100 PERCENT.
9
SO, THE DISEASE IS A MYSTERY ... IT’S FATAL ... AND, THREE,

THE AIDS VIRUS IS TRANSMITTED BY THE KIND OF BEHAVIOR THAT MOST
PEOPLE DON’T ENGAGE IN -- OR APPROVE OF.

AS I'M SURE YOU KNOW BY NOW, THE HIGHEST CONCENTRATIONS OF
THE AIDS VIRUS ARE FOUND IN BLOOD, SEMEN, AND -- LESS FREQUENTLY
-- IN VAGINAL SECRETIONS,

HENCE, THE SPECIFIC PERSONAL BEHAVIORS THAT PRODUCE THE
HIGHEST RISK OF TRANSMISSION ARE UNPROTECTED ANAL INTERCOURSE --
PARTICULARLY AS PRACTICED BY HOMOSEXUALS AND BISEXUAL MALES --
THE SHARING OF NEEDLES BY INTRAVENOUS DRUG ABUSERS, AND TO A
LIMITED DEGREE VAGINAL INTERCOURSE AS WELL.
10
UNFORTUNATELY, THERE’S A GREAT DEAL OF UNINFORMED AND WRONG-

HEADED TALK ABOUT OTHER MODES OF TRANSMISSION: TEARS AND
MOSQUITOS AND WATER GLASSES AND TOILET SEATS AND SO ON.

IF ANY OF THESE REALLY DID PERMIT THE TRANSMISSION OF THE
AIDS VIRUS, THE EPIDEMIC OF AIDS WOULD BY NOW HAVE WIPED OUT MANY
MILLIONS OF AMERICANS -- AND TENS OF MILLIONS OF PEOPLE AROUND
THE GLOBE.

BUT IT HASN’T,. AND THE REASON IS SIMPLY THAT THE VIRUS
THRIVES BEST IN TWO BODY FLUIDS -- BLOOD AND SEMEN -- AND LESS
FREQUENTLY IN VAGINAL FLUIDS AS WELL. OBVIOUSLY IT TAKES MORE
THAN A CASUAL ACT TO PASS THOSE FLUIDS FROM ONE PERSON TO
ANOTHER,
11
BUT THE OVERWHELMING MAJORITY OF AMERICANS OF ALL COLORS AND

PERSUASIONS DO NOT ENGAGE IN ANAL SEX AND I.V. DRUG ABUSE, YOU
DON’T HAVE TO BE A BOARD-CERTIFIED PROCTOLOGIST TO KNOW THAT THIS
TS TRUE.

AND THIS IS THE RESULT OF CONSCIOUS CHOICE. THE AMERICAN
PEOPLE -- BY AND LARGE -- DON’T LIKE AND DON’T APPROVE OF THESE
TWO BEHAVIORS ... THE TWO THAT ACCOUNT FOR THE OVERWHELMING
MAJORITY OF AIDS CASES THUS FAR.
12
THESE THREE KEY ASPECTS OF THE DISEASE MAKE THE AMERICAN

PEOPLE VERY EDGY ABOUT AIDS -- AND FRANKLY, WHO CAN BLAME THEM?
I THINK WE WOULD BE EVEN MORE UPSET IF PEOPLE WERE NOT CONCERNED
ABOUT THE THREAT OF A DISEASE WITH THESE THREE DISTURBING
CHARACTERISTICS,

YES, THE AMERICAN PEOPLE HAVE EVERY REASON TO BE EDGY ABOUT
AIDS. BUT THEY HAVE NO REASON TO BECOME PARALYZED BY IT.
13
YET, SOME AMERICANS ARE PARALYZED. AND I’M SORRY TO REPORT

THAT THE WORST EXAMPLES ARE OF PROFESSIONAL PEOPLE WHOSE
JUDGMENT IS OBSCURED BY IRRATIONAL FEARS:

* SCHOOL OFFICIALS, FOR EXAMPLE, WHO BAR CHILDREN WITH
AIDS FROM PUBLIC CLASSROOMS, THAT KIND OF ACTION STIGMATIZES A
CHILD AND SETS HIM OR HER APART FROM THE COMMUNITY -- AND FOR NO
GOOD REASON. IT IS TRAGIC FOR THE CHILD ... AND A DISGRACE FOR
THAT SCHOOL AND COMMUNITY,
14
* AN EMPLOYER WHO SUMMARILY DISMISSES A WORKER WITH AIDS

TS PLAIN WRONG. I HAVE TOLD MANY AUDIENCES OF BUSINESS PEOPLE
THAT THE ONLY REASON THEY HAVE FOR DISMISSING SOMEONE WITH AIDS
IS IF THE ROUTINE WORK OF THEIR COMPANIES INVOLVE ANAL
INTERCOURSE OR “SHOOTING” DRUGS.

IF THAT’S THE CASE, THEN BY ALL MEANS, THEY SHOULD DISMISS
THE OFFENDING EMPLOYEE. BUT THEY OUGHT TO TAKE A LOOK AT THE
REST OF THE PLACE, TOO, BECAUSE THEY’VE GOT MUCH MORE TROUBLE
THAN JUST AIDS.
15
* AND PHYSICIANS AND HOSPITAL ADMINISTRATORS WHO TURN

AWAY AIDS PATIENTS ARE ALSO WORTHY OF OUR CONTEMPT AND
CONDEMNATION.

FOR THREE MILLENNIA, THE HEALING ARTS AND SCIENCES HAVE
REACHED OUT TO ALL WHO HAVE NEEDED ATTENTION. THIS IS HARDLY THE
TIME -- AND AIDS IS HARDLY THE REASON -- FOR ANYONE TO REVERSE
THE COURSE OF THIS NOBLE HISTORY.
16
ARE THERE, THEN, NO RISKS AT ALL FOR HEALTH PERSONNEL?

YES, OF COURSE THERE ARE. AS EARLY AS 1982, THE PUBLIC HEALTH
SERVICE RECOGNIZED THE POTENTIAL FOR TRAGEDY INVOLVING HEALTH
PERSONNEL AND WE RELEASED THE FIRST SET OF PRACTICAL GUIDELINES.

SINCE THEN THERE HAVE BEEN A FEW MINOR REVISIONS, BUT THE
GUIDELINES ARE ESSENTIALLY THE SAME AND ARE ROOTED IN COMMON
SENSE AND A KNOWLEDGE OF ASEPTIC PRACTICES ALREADY FAMILIAR TO
MOST HEALTH PERSONNEL.
17
IF THEY ARE FOLLOWED, THESE GUIDELINES WILL PROTECT ANY

HEALTH WORKER FROM BECOMING CONTAMINATED OR INFECTED WITH THE
AIDS VIRUS.

I HOPE YOU AND YOUR PERSONNEL ARE COMPLETELY FAMILIAR WITH
THOSE C.D.C. GUIDELINES. FRANKLY, I°D HAVE TO ASSUME THAT MOST
OF YOU WERE, BECAUSE, OUT OF A TOTAL HEALTH WORKFORCE OF NEARLY 7
MILLION PERSONS, FEWER THAN A DOZEN HAVE SO FAR BECOME INFECTED
WITH THE AIDS VIRUS BECAUSE OF SOME MISADVENTURE ON THE JOB,

AND IN EACH OF THOSE CASES, THERE WAS A MOMENT WHEN THE
PERSON’S VIGILANCE WAS RELAXED AND THE VIRUS FOUND A WAY IN,
18
UNFORTUNATELY, DESPITE THIS EXTRAORDINARY RECORD OF SAFETY,

WE STILL HEAR OF STORIES INVOLVING HEALTH PROFESSIONALS -- OR
GROUPS OF PROFESSIONALS -- WHO REFUSE TO TREAT SOMEONE WITH AIDS
»e+ OR REFUSE TO TREAT SOMEONE WHOM THEY SUSPECT OF HAVING AIDS,

 

THIS [TS NOT CHARACTERISTIC OF THE OVERWHELMING MAJORITY OF
QUR COLLEAGUES, T MUST SAY. THOSE MEN AND WOMEN CONTINUE TO
PROVIDE QUALITY, COMPASSIONATE CARE TO EVERY PATIENT -- INCLUDING
PERSONS DYING OF AIDS.
19
IN THIS CONNECTION, I SHOULD LIKE TO RECOGNIZE THREE LEADING

NATIONAL ORGANIZATIONS OF HEALTH PROFESSIONALS FOR THE STRONG
STAND THEY HAVE TAKEN TO REINFORCE THE ETHICAL CONDUCT OF THEIR
MEMBERS.

JUST THIS PAST DECEMBER THE AMERICAN MEDICAL ASSOCIATION
ADOPTED A POLICY THAT STATES UNEQUIVOCALLY...

"A PHYSICIAN MAY NOT ETHICALLY REFUSE TO TREAT A
PATIENT WHOSE CONDITION IS WITHIN THE PHYSICIAN’S
CURRENT REALM OF COMPETENCE SOLELY BECAUSE THE PATIENT
IS SEROPOSITIVE, PERSONS WHO ARE SEROPOSITIVE SHOULD
NOT BE SUBJECTED TO DISCRIMINATION BASED ON FEAR OR
PREJUDICE.”
20
THE POLICY STATEMENT ALSO DEALS WITH THE POSSIBILITY THAT

THE PHYSICIAN ~- NOT THE PATIENT -- MAY BE SEROPOSITIVE FOR AIDS.
IN THAT CASE, SAYS THE A.M.A, POLICY PAPER...

“A PHYSICIAN WHO KNOWS THAT HE OR SHE IS SEROPOSITIVE SHOULD
NOT ENGAGE IN ANY ACTIVITY THAT CREATES A RISK OF TRANSMIS-
SION OF THE DISEASE TO OTHERS,” BUT “SHOULD CONSULT
COLLEAGUES AS TO WHICH ACTIVITIES (TO) PURSUE WITHOUT
CREATING A RISK TO PATIENTS,”
21
SIMILARLY THE AMERICAN COLLEGE OF PHYSICIANS AND THE

INFECTIOUS DISEASES SOCIETY OF AMERICA ADOPTED A JOINT “POSITION
PAPER” ON AIDS THIS PAST JANUARY. ITS FIRST “POSITION” SAYS
THAT...

“aa sPHYSICIANS, OTHER HEALTH CARE PROFESSIONALS, AND
HOSPITALS ARE OBLIGATED TO PROVIDE COMPETENT AND HUMANE CARE
TO ALL PATIENTS, INCLUDING PATIENTS WITH AIDS AND AIDS-
RELATED CONDITIONS, AS WELL AS HIV-INFECTED PATIENTS WITH
UNRELATED MEDICAL PROBLEMS. THE DENIAL OF APPROPRIATE CARE
TO PATIENTS FOR ANY REASON IS UNETHICAL.”
22
FURTHER ALONG IN THE DOCUMENT, SUCH BEHAVIOR BY A PHYSICIAN

IS CALLED “MORALLY AND ETHICALLY INDEFENSIBLE. “

AND FINALLY, THE AMERICAN NURSES’ ASSOCIATION LAST JUNE
REAFFIRMED ITS ...

—",,. COMMITMENT TO PROTECTING THE CIVIL AND HUMAN RIGHTS OF
PERSONS AFFECTED WITH AIDS AS WELL AS THOSE OF THE
CAREGIVERS.” IN THE SAME CONTEXT, THE A.N.A. HOUSE OF
DELEGATES ALSO REAFFIRMED “THE COMMITMENT OF THE NURSING
PROFESSION TO ALL PEOPLE IN NEED OF NURSING SERVICES,
REGARDLESS OF THE ILLNESS OR THE SEVERITY OF THAT ILLNESS.”
23
T BELIEVE THE RESPONSIBLE LEADERS IN MEDICINE AND NURSING

HAVE CORRECTLY GAUGED THE NEED TO REASSERT THE PRIMACY OF
ETHICAL CONDUCT IN HEALTH CARE. AND THEY HAVE DONE SO.

I THINK MOST PEOPLE WANT TO DO THE RIGHT THING. AND SUCH
STATEMENTS AS THESE MAKE IT POSSIBLE FOR INDIVIDUAL HEALTH
PROFESSIONALS TO DO THE RIGHT THING AND TO FEEL THE STRENGTH OF
NUMBERS AS THEY DO SO.

I AM PERSUADED THAT THE OVERWHELMING MAJORITY OF AMERICAN
HEALTH PROFESSIONALS ARE LIVING UP TO THE HIGHEST IDEALS OF THEIR
CALLING. AND, THEREFORE, I BELIEVE THAT MOST PATIENTS WITH AIDS
WILL GET THE HEALTH AND MEDICAL CARE THEY NEED.
24
BUT THIS IS HARDLY THE END OF THE MATTER ... PARTICULARLY

FOR SURGEONS. MANY OF THEM ARE SPEAKING AND WRITING ABOUT THE
HEIGHTENED DANGER OF AIDS TRANSMISSION IN THE OPERATING ROOM,
WHERE THERE’S NEVER ANY SHORTAGE OF BLOOD AND SHARP INSTRUMENTS,

LIKE ALMOST EVERYTHING ELSE IN THIS EPIDEMIC, WE HAVE NO
SIMPLE ANSWER TO THIS PROBLEM EITHER,

WHAT I WOULD ADVISE, HOWEVER, IS ESSENTIALLY THE SAME
ADVICE I HAVE CONVEYED TO THOUSANDS OF OTHER HEALTH PROFESSIONALS
OVER THE PAST TWO YEARS:
25
FIRST, YOU HAVE A PROFESSIONAL OBLIGATION TO TREAT YOUR

PATIENTS. AND HERE SUCH STATEMENTS AS THOSE OF THE A.M.A., THE
AMERICAN COLLEGE OF PHYSICIANS, AND THE AMERICAN NURSES’
ASSOCIATION, AND OTHERS ARE ALL GERMANE,

 

IN OTHER WORDS, WE MUST BEGIN FROM THE PREMISE OF WHAT WE*RE
GOING TO DO AND NOT FROM A PREMISE OF WHAT WE WILL NOT DO,

SECOND, IF YOU BELIEVE THAT IT IS IN YOUR PATIENTS’
INTERESTS -- AS WELL AS YOUR OWN -- THAT YOU DETERMINE THEIR
SEROPOSITIVITY FOR AIDS, THEN DO SO.

 
26
BUT THIS IS NO IDLE DECISION. IT OUGHT TO BE BASED, FOR

EXAMPLE, ON SOME KNOWLEDGE OF THE LEVEL OF AIDS PREVALENCE IN
YOUR AREA. CLEARLY A SURGEON IN NEW YORK ~- WHICH ADDED 4200
MORE CASES OF AIDS TO THE ROLLS OVER THE PAST 12 MONTHS -- HAS
REASON TO BE CONCERNED. BUT A SURGEON, SAY, IN NEBRASKA, WHICH
REPORTED ONLY 34 NEW CASES DURING THAT SAME PERIOD, MAY NOT.

BUT THERE ARE OTHER CONSIDERATIONS, TOO: THE NATURE OF THE
ILLNESS THAT BRINGS THE PATIENT TO YOUR ATTENTION, HIS OR HER
PERSONAL HISTORY OF HIGH-RISK BEHAVIOR, AND SO ON,
2/
BUT IF YOU DO HAVE A GOOD REASON TO DO A BLOOD TEST FOR

AIDS, THEN YOU OUGHT TO DO IT INA MANNER CONSISTENT WITH THE
CONDUCT OF OTHER TESTS: IN OTHER WORDS, WITH THE INFORMED
CONSENT OF THE PATIENT OR -- AS THE CIRCUMSTANCES MAY DICTATE --
WITH THE CONSENT OF A GUARDIAN OR OTHER RESPONSIBLE PARTY,

“THERE ARE, OF COURSE, SITUATIONS IN MEDICINE WHICH PREVENT
THE OBSERVATION OF GOOD PROTOCOL: THERE’S NO TIME ... NO ONE’S
AROUND TO GIVE CONSENT ... OR THERE’S NO PROCESS OR SYSTEM TO
HANDLE THE INFORMATION. THEREFORE, THERE MAY BE NO TESTS TO
DETERMINE SEROPOSITIVITY EITHER,
28
IN THOSE SITUATIONS, SURGEONS AND THE ENTIRE O.R. TEAM MUST

EXERCISE GREAT CAUTION, THE BEST PROTECTIVE CLOTHING AND
EQUIPMENT SHOULD BE AVAILABLE AND ALL GUIDELINES SHOULD BE
CLEARLY UNDERSTOOD AND RIGOROUSLY FOLLOWED BY EVERYONE,

THIRD, BEFORE A TEST IS GIVEN AND THE RESULTS RETURNED TO
YOU, YOU OUGHT TO KNOW WELL IN ADVANCE JUST HOW YOU’RE GOING TO
HANDLE THAT INFORMATION. THAT IN ITSELF IS NO SMALL MATTER.

YOU NEED ANSWERS TO SERIOUS QUESTIONS REGARDING CONFIDENTIALITY
«s+ AND YOU NEED THOSE ANSWERS BEFORE THE TESTS ARE CARRIED OUT.
29
FOR EXAMPLE, SHOULD THE PATIENT BE FULLY INFORMED? I WOULD

SAY “YES” TO THAT.

BUT WHAT IF YOUR PATIENT CONSENTS TO THE TEST --- BUT DOES
NOT WANT TO KNOW THE RESULTS? WHAT SHOULD YOU DO THEN?

WE'VE ALL KNOWN PATIENTS WHO, WHILE WAITING FOR A BIOPSY
REPORT, WILL SUDDENLY SAY, “I'D RATHER NOT KNOW WHAT IT IS. I
WANT TO LIVE MY LIFE JUST AS I’VE ALWAYS LIVED IT.” AND SO ON,
30
BUT AIDS IS OBVIOUSLY DIFFERENT. IF “LIVING YOUR LIFE”

COULD MEAN HAVING SEX WITH A SPOUSE -- OR ANYONE ELSE, FOR THAT
MATTER -- THEN THE CHOICE OF BEING IGNORANT IS -- IN MY BOOK --
AN IMMORAL CHOICE AND, IF THE PHYSICIAN AGREES, THAT IS -- AGAIN,
IN MY BOOK -- AN UNETHICAL ACT OF COMPLICITY.

AND WHAT ABOUT OTHERS INVOLVED IN THE SURGICAL PROCEDURE
AND IN POST-OPERATIVE CARE -- NURSES, ANESTHESIOLOGISTS, INTERNS,
AND SO ON? HOW MANY OF THEM -- ALONG WITH THE SURGEON OR
SURGEONS -- HAVE A NEED TO KNOW AND A RIGHT TO KNOW THE RESULTS
OF AN AIDS BLOOD TEST?
31
WHOM WOULD YOU TELL? AND WHOM WOULD YOU NOT TELL? AND

WHY?

AND EQURTH, WHAT ARE YOUR RESPONSIBILITIES TOWARD A PERSON
WHO LEARNS -- FROM A ROUTINE PRE-OP BLOOD TEST -- THAT HE OR SHE
TS SEROPOSITIVE?

I THINK THE ETHICAL FOUNDATIONS OF OUR PROFESSION DICTATE
THAT WE FOCUS ON THAT NEW INFORMATION AS WE WOULD ANY OTHER NEW
AND TROUBLING INFORMATION: THE DISCOVERY OF DIABETES, FOR
EXAMPLE, OR THE PRESENCE OF A MALIGNANCY, OR BLOOD OR LYMPHATIC
DYSCRASIA, AND SO ON,
32
WITH OTHER CONDITIONS, WE GENERALLY KNOW WHAT TO DO, WHAT TO

SAY, AND WHERE TO GO NEXT FOR HELP.

BUT AIDS IS STILL RELATIVELY NEW AND REFERRAL INFORMATION IS
NOT COMMONLY KNOWN,

NEVERTHELESS, I BELIEVE THAT THE PHYSICIAN WHO HAS GONE
THIS FAR MUST GO A STEP OR TWO FARTHER AND MAKE THE APPROPRIATE
REFERRALS AND RECOMMENDATIONS FOR COUNSELING AND TREATMENT.

I DON’T THINK THERE’S AN ALTERNATIVE TO THAT KIND OF
RESPONSIBLE ACTION,
33
IT’S POSSIBLE THAT A SURGEON WOULD RECOMMEND THAT A PATIENT

BE TESTED AND, ONCE HAVING SECURED ALL THE PERMISSIONS, GO AHEAD
AND HAVE THE TEST DONE.

AND IT'S POSSIBLE THAT THE SURGEON'S UNDERLYING REASON FOR
THE TEST IS TO ALLAY HIS OR HER OWN FEARS AND THE FEARS OF O.R,
COLLEAGUES ... WITH THE PATIENT’S INTERESTS SECONDARY,

I CAN’T DENY THAT SUCH A THING CAN HAPPEN, EVEN THOUGH I
DON’T LIKE IT. BUT EVEN IN THIS KIND OF CIRCUMSTANCE, IF THE
OUTCOME IS SEROPOSITIVE, THE FOCUS OF ATTENTION ABSOLUTELY MUST
THEN SHIFT TO THE PATIENT.
34
YOUR QUESTIONS MAY HAVE BEEN ANSWERED ... BUT THE PATIENT’S

QUESTIONS ARE JUST BEGINNING TO FORM.

I'M SURE TO MANY OF YOU THIS IS NOT NEW INFORMATION. BUT
I’M SORRY TO SAY THAT WITH A GREAT MANY OF OUR COLLEAGUES, THESE
KINDS OF QUESTIONS ARE STILL BEING SHUNTED ASIDE TO BE FACED

~ LATER ... IN SOME FAR-DISTANT “TOMORROW, ”

BUT THAT’S NOT GOOD ENOUGH,
35
PHYSICIANS AND INSTITUTIONS MUST BEGIN NOW TO WORK TOWARD AN

OPTIMUM SURGICAL ENVIRONMENT IN THIS “AGE OF AIDS," SO THAT ALL
HEALTH PERSONNEL MAY FOLLOW THE DICTATES OF THEIR MEDICAL ETHICS
WITH AS LITTLE RISK TO THEIR OWN PERSONS AS POSSIBLE ... AND WITH
MAXIMUM BENEFIT FOR THEIR PATIENTS.

BUT I’M NOT NAIVE. AND NEITHER ARE YOU. EVEN IF ALL THE
KINDS OF ACTIONS I’VE DISCUSSED SUDDENLY BECAME ROUTINE IN THIS
COUNTRY, THERE WOULD STILL BE A GREAT DEAL OF UNEASINESS ABROAD
IN THE LAND AND IN THE HEALTH CARE PROFESSIONS THEMSELVES.
36
AND YOU CAN TRACE THOSE FEELINGS BACK TO THOSE THREE ASPECTS

OF THE DISEASE I MENTIONED EARLIER: ITS MYSTERY, ITS HIGH
MORTALITY RATE, AND THE PARTICULAR WAYS IN WHICH THE DISEASE IS

TRANSMITTED.

 

AS A FINAL WORD, LET ME RETURN FOR A MOMENT TO THAT THIRD
ASPECT OF THE DISEASE, THE WAYS IN WHICH IT IS TRANSMITTED ...
AND THE PEOPLE WHO DO THOSE THINGS,

* 1,.V, DRUG ABUSERS COMPRISE ONE MAJOR GROUP ... A FOURTH
OF ALL AIDS VICTIMS SO FAR. AND IT APPEARS THAT THIS GROUP IS
GROWING THE FASTEST.
37
DRUG ADDICTS HAVE NEVER BEEN WITHIN EASY REACH OF THE HEALTH

CARE SYSTEM. AND INDEED ONLY A FEW HAVE COME FORWARD TO SHAKE
THEIR HABIT AND ESCAPE THE RISK OF AIDS.

ON THE OTHER HAND, THE HEALTH SYSTEM ITSELF HAS NOT BEEN
ESPECIALLY INNOVATIVE IN REACHING OUT TO FIND THEM. WE MAY ALSO
HAVE FAR TOO FEW DRUG TREATMENT CENTERS, RELATIVE TO THE NEED --
A SITUATION CAUSED AS MUCH BY NEIGHBORHOOD OPPOSITION TO SUCH
CENTERS AS BY ANY LACK OF FUNDS..

FOR DRUG ABUSERS, THEN, THE STATEMENTS OF ETHICAL CONDUCT I
READ EARLIER -- EXCELLENT STATEMENTS THOUGH THEY MAY BE -- MAY
BE IRRELEVANT.
38
HENCE, I AM DEEPLY CONCERNED THAT THE PEOPLE NOW BURIED

ALIVE IN THE WORLD OF AIDS AND DRUG ADDICTION, ON THE ONE HAND --
AND THE AMERICAN SYSTEM OF HEALTH CARE ON THE OTHER -- WILL FAIL
TO CONNECT IN THE FUTURE, AS THEY HAVE FAILED TO CONNECT IN THE
PAST.

AND WITH TRAGIC CONSEQUENCES FOR THEMSELVES ... AND FOR
SOCIETY.

* THE SECOND MAJOR HIGH-RISK POPULATION IS COMPRISED OF
THOSE HOMOSEXUALS AND BISEXUAL MALES WHO ARE NOT MONOGAMOUS AND
WHO ENGAGE IN UNPROTECTED ANAL INTERCOURSE. THEY ACCOUNT FOR
TWO-THIRDS OF ALL AIDS CASES SO FAR.
39
SEVERAL YEARS AGO, IN THE EARLY STAGES OF THE AIDS EPIDEMIC,

IT WAS CLEAR THAT A GREAT MANY MEN IN THIS GROUP USED A VARIETY
OF “ALTERNATIVE” HEALTH SERVICES -- CLINICS AND HEALTH PROVIDERS
WHO WERE MORE KNOWLEDGEABLE AND MORE TOLERANT OF THE HOMOSEXUAL
LIFESTYLE BUT WHO WERE, NEVERTHELESS, OUTSIDE THE MAINSTREAM OF
AMERICAN HEALTH CARE ... AND, AS A RESULT, OUTSIDE THE MAIN
SOURCES OF THERAPY, INFORMATION, AND MONEY.

AND I’M INCLINED TO BELIEVE THAT OUR TRADITIONAL COMMUNITY
MEDICAL SERVICES PREFERRED TO KEEP THINGS THAT WAY.

IT WAS A MUTUAL STAND-OFF AND I BELIEVE IT HURT BOTH SIDES,
40
IT HURT THE MEN WHO HAD BECOME INFECTED WITH THE AIDS VIRUS

AND WHO NEEDED ACCESS TO THE BEST CARE AVAILABLE ... AND IT HURT
THE HEALTH CARE SYSTEM ITSELF, BECAUSE THE DIFFICULT CHALLENGE OF
UNDERSTANDING THE AIDS EPIDEMIC THUS BECAME EVEN MORE DIFFICULT.

* AND THEN THERE'S A THIRD GROUP ... ABOUT A THOUSAND
WOMEN -- MOSTLY BUT NOT EXCLUSIVELY PROSTITUTES ... WHO HAVE
BECOME INFECTED BY BEING THE SEXUAL PARTNERS OF DRUG ABUSERS OR
BISEXUAL MEN WITH AIDS.

THESE WOMEN KNOW -- AND ARE KNOWN BY -- HOSPITAL EMERGENCY
ROOM PERSONNEL AND THE NEAREST V.D. CLINIC. BUT THE REST OF THE
HEALTH CARE SYSTEM IS, FOR MANY OF THEM, ALIEN TERRITORY.
41
HERE AGAIN, AMERICAN MEDICINE IS CHALLENGED TO PROVIDE GOOD

MEDICAL AND HEALTH CARE -- WHILE ASSUME SOME MEASURE OF PERSONAL |
RISK -- ON BEHALF OF PEOPLE WHO BEHAVE IN WAYS THAT MOST OF US
FIND REPREHENSIBLE.

* AND FINALLY, AT OUR LAST COUNT THERE WERE SOME 700
BABIES WHO WERE GIVEN NOT ONLY THE GIFT OF LIFE -- BUT ALSO OF
AIDS -- FROM THEIR VIRUS-INFECTED MOTHERS.

A GREAT MANY OF THESE NEONATES HAVE BEEN ABANDONED BY THEIR
MOTHERS AND HAVE BECOME BOTH PATIENTS AND WARDS OF THE NURSING
STAFFS IN THE HOSPITALS WHERE THEY WERE BORN. THIS IS AN
UNFAMILIAR AND INTOLERABLE BURDEN FOR THOSE INSTITUTIONS, AS YOU
CAN WELL IMAGINE.
42
* AND FINALLY, YOUNG BLACK AND HISPANIC AMERICANS APPEAR

AMONG THE AIDS CASE REPORTS TWICE AS OFTEN AS THEY APPEAR IN THE
POPULATION GENERALLY. THE MINORITIES WITH AIDS TEND TO BE POOR,
UNINSURED OR UNDERINSURED, AND URBAN, LIVING IN THOSE SAME MAJOR
METROPOLITAN AREAS WHERE THE HEALTH DELIVERY SYSTEMS ARE ALREADY
STRAINED TO THE LIMIT.

WE SEE THEM AS PERSONS WITH AIDS. BUT THEY SEE THEMSELVES
AS PERSONS MIRED IN ECONOMIC, SOCIAL, ENVIRONMENTAL, AND MEDICAL
CHAOS. HERE AGAIN, I THINK MEDICINE -- AND THE COMMUNITY IT
SERVES -- ARE STILL TALKING PAST EACH OTHER. AND I’D HAVE TO SAY
THAT BODES POORLY FOR THE EVENTUAL CONTROL OF THIS EPIDEMIC.
43
THIS, THEN, HAS BEEN A QUICK BUT, I HOPE, ACCURATE SKETCH OF

THE AIDS CASELOAD, THEY ARE CITIZENS WHO ARE PREYED UPON BY THE
AIDS VIRUS AND WHO BECOME THE QUARRY OF ONE OR MORE AIDS-RELATED
CONDITIONS.

THEY TEND TO BE ON THE PERIMETER OF OUR COUNTRY’S MAINSTREAM
HEALTH DELIVERY SYSTEM.

CAN WE REACH THEM? CAN WE BRING THEM IN?

I QUOTED FROM THREE STATEMENTS OF ETHICAL CONDUCT A FEW
MOMENTS AGO. AND THEY ARE GOOD STATEMENTS, BELIEVE ME,
Ay
BUT THEY’RE NOT ENOUGH.

SUCH STATEMENTS MUST BE ACCOMPANIED BY THE WILL TO PUT THEM
TO WORK,

IT'S DIFFICULT FOR MANY INSTITUTIONS AND MANY PRACTITIONERS
TO DO THAT, SINCE MOST PEOPLE CARRYING THE VIRUS DO NOT KNOW THE
HEALTH SYSTEM VERY WELL ... NOR DOES THE HEALTH SYSTEM KNOW
THEM,

IT’S A SITUATION THAT NEEDS MAJOR CORRECTION. AND WE IN THE
HEALTH SYSTEM MUST TAKE THE INITIATIVE ... AND DO IT.
45
THESE, THEN, ARE SOME OF THE QUESTIONS THAT CONFRONT

MEDICINE AND HEALTH CARE IN A FREE SOCIETY SUCH AS OURS ... A
SOCIETY THREATENED BY THE EPIDEMIC OF AIDS.

BUT THROUGHOUT OUR OFTEN TURBULENT DOMESTIC HISTORY, WE
AMERICANS HAVE MANAGED TO MAINTAIN A NATIONAL TEMPERAMENT OF
CHARITY AND TOLERANCE ... OF RESPONSIVENESS ... AND OF
AFFIRMATION,

WE'VE BEEN GENEROUS TO EACH OTHER IN EVERY TIME OF NEED.

AND THIS IS SURELY ONE OF THOSE TIMES,
46
OUR SOCIETY IS BEING TESTED, THERE’S NO QUESTION ABOUT THAT.

THE EPIDEMIC OF AIDS IS PROVIDING ONE OF THE MOST SERIOUS TESTS
OF SOCIAL AND POLITICAL WILL THAT WE’VE EVER EXPERIENCED.

YET, I TRULY BELIEVE WE WILL COME THROUGH THIS TEST WITH
OUR IDEALS AND OUR INSTITUTIONS INTACT.

THE NEXT FEW YEARS WILL NOT BE EASY. BUT WE’LL MAKE IT ...
AND WE‘LL MAKE IT TOGETHER.

THANK YOU,
HHH # #