An ethical analysis of physical therapists' duty to treat persons who have AIDS: homosexual patients as a test case.

Professional health care traditionally has been characterized as an objective, scientific, and value-free enterprise. Many commentators, however, have shown that it has within it an inseparable moral component. [1,2] This component is revealed in a variety of ways. Conceptually, it is seen in the way that health is deemed to be a "good" state of affairs and, by extension, illness an undesirable, "bad" phenomenon. [3] In addition, health professionals commonly generalize their technical expertise to make moral pronouncements on issues in the social and political spheres, even though this expertise does not qualify them to speak knowledgeably in those arenas. [4] Meanwhile, in the context of everyday health care, professionals are subject to value judgments concerning their patients. Some patients enjoy a "halo" effect. [5] At the same time, certain others are "unpopular," [6] "undesirable," [7] "hateful," [8] or regarded as a "problem." [9,10] This diverse group of commentators, taken together, generally agree on three main reasons why a negative judgment is made:

1. A patient exhibits a condition that is "inappropriate" to the interests, expertise, or career aspirations of the professional.

2. The patient causes problems with regard to management, through poor response to available therapeutic options or through various forms of "noncompliance."

3. The patient's lifestyle elicits disapproval or a similar from of negative moral evaluation on the part of the professional.

Those who have the acquired immunodeficiency syndrome (AIDS), or who test positive for the human immunodeficiency virus (HIV), may fit into all three of these categories. The consequence for the patient of such disparagement is frequently avoidance or an inferior standard of treatment.

In this article, we focus the reader's attention on the physical therapy challenge of providing high-quality care to patients who have AIDS. We examine in some detail the phenomenon and consequences of the negative moral evaluation often made in respect to patients with AIDS. We conclude that physical therapists do have a duty to treat such patients, and we suggest mechanisms for a safe and supportive treatment environment. Although many societal groups are affected by the ravages of this disease, our focus is to explore the difficulties that arise around the treatment of homosexuals who have AIDS, because it is with this group of individuals that many of the relevant questions were first raised and are still discussed. The arguments with which we will deal tend to be proposed in relation to this category of patients with AIDS, and it is in this context that we will address them. Nonetheless, the key issues are (with certain changes of emphasis, which we will endeavor to identify) equally applicable to individuals with AIDS originating from the injection of drugs and, to a lesser extent, to other groups as well.

There is good reason for the focus of our concern. In terms of epidemiology, the number of people in the United States infected with HIV was estimated at between 1,000,000 and 1,500,000 in 1988. [11] The US Department of Health and Human Services' Centers for Disease Control has projected that between 52,000 and 57,000 cases of AIDS would be diagnosed during 1990 and that this rate of incidence will rise to between 61,000 and 98,000 cases in 1993 (on the assumption that 85% of diagnosed cases of AIDS are eventually reported). [12] On the basis of figures such as these, it has been argued that health care workers will increasingly come into contact with persons with AIDS. [13] The important contribution that physical therapy can make to the care and management of patients with AIDS--especially in the respiratory and neuromuscular areas of practice--has already been identified, [14,15] and it is therefore reasonable to assume that these patients will figure increasingly among the clinical caseloads of physical therapists.

Recent research has shed light on the beliefs and attitudes that surround this syndrome. It has been shown, for example, that AIDS and homosexuality may elicit negative and prejudicial responses from medical students. [16] An earlier questionnaire survey of nurses and physicians revealed that nearly 10% of the respondents believed that "homosexuals who contract AIDS are getting what they deserve." [17] Although in absolute terms this is a small percentage, and despite the lack of a concurrent control group from the lay public, the researchers considered it an alarming finding in a sample of health professionals. Royse and Birge, [18] using a sample that included allied health students, found that homophobia was associated with a lack of empathy with patients who have AIDS and with a fear of the disease; the investigators voice the concern that patients with AIDS may accordingly receive inferior care. Indeed, health professionals' overt "refusal to treat" has been noted by several commentators. [19-22] A form of "covert" refusal to treat may also occur, through strategies of delay, avoidance, or premature discharge. [22,23] Each of these refusals may arise from negative responses to such patients.

Although empirical evidence of prejudicial attitudes toward persons with AIDS on the part of physical therapists is lacking, Hansen [23] warns that it is unwise for members of any single profession to presume that they "know better." Therefore, whether there can be any justification for a refusal of treatment to patients with AIDS who are homosexual and how the variable of their sexual preference and practices (eg, what is perceived to be a "gay lifestyle," with numerous sexual encounters) figures in the moral judgment as to how such patients should be viewed or treated are pressing questions for the profession. In line with both the principle of beneficence and the principle of non-maleficence, [24] a responsibility on the part of health professionals to work in the best interests of their clients is generally assumed, and central to this responsibility is an obligation to treat each patient according to his or her health-related needs. Such thinking is reflected in the ethical codes of physical therapists. Principle 1 of the American Physical Therapy Association's (APTA's) Code of Ethics [25] enjoins physical therapists to "respect the rights and dignity of all individuals," and the codes adopted by the Australian Physiotherapy Association [26] and the United Kingdom's Chartered Society of Physiotherapy [27] make virtually identical statements. In the APTA's Code of Ethics, this principle is elaborated upon as follows:

Physical therapists are to be guided at all times by concern for the physical, psychological, and socioeconomic welfare of those individuals entrusted to their care. [25]

The obligation to treat is not absolute and may be overridden if more powerful moral reasons exist for doing so. Consequently, if the obligation to treat is to be abrogated in respect to certain groups of patients and their practices, very convincing arguments must be put forward to support such a course of action. In the case of patients with AIDS who practice homosexuality, attempts to propose such arguments might take one of the following forms:

1. Patients with AIDS are less deserving of treatment because they contracted the disease through immoral conduct (ie, "acted immorally").

2. Patients with AIDS have brought their condition upon themselves (ie, "acted irresponsibly").

3. Patients with AIDS pose unacceptable hazards to others (ie, "are dangerous").

We examine these possible justifications in turn, highlighting some of their conceptual, logical, and ethical difficulties. We conclude with a proposal for future strategies that physical therapists individually and collectively might adopt to deal with this difficult area.

The Argument from Morality 

The argument that homosexual individuals infected with HIV have less claim on the physical therapist's professional skills because the pathology was incurred through immoral conduct implies that immoral acts have the effect of placing such individuals beyond the pale of normal obligations; that is, they have disqualified themselves from the rights to which they normally would be entitled. This position is illustrated in the comment of an Illinois family practitioner, as cited by Arras:

I would not knowingly treat a homosexual patient with AIDS, but I would treat patients who got the disease by blood transfusion, and I would treat children with AIDS, [21(p20)]

Central to such a thesis is the argument that homosexuality is self-evidently immoral. Because physical therapists may believe this argument to be true or may be explosed to other professionals who believe this argument to be true, it is efficacious to review the major philosophical grounds on which such a proposition may be based. First, it might be claimed that homosexuality is immoral because it is unnatural; a type of traditional "natural-law" reasoning is applied to this practice. One version of this type of reasoning relies on determining what is natural by observing what the vast majority of the population chooses to do. In other words, what is common necessarily is natural. One decides what ought to be from what is. Natural-law reasoning often is applied to sexual practices, and here two additional types of argument are usually presented; one relates to natural "ends" of sexual activity, the other to unnatural "desires." [28] In the first argument, homosexual activity, being a form of sexual behavior that makes no contribution to the process of propagation of the human species, is judged unnatural. In the second argument, heterosexual desire is presumed to be the only natural type of desire; therefore, homosexuality is unnatural insofar as it pursues the fulfillment of "unnatural" desires. Each of these positions, in different ways, ties immorality to homosexuality on the basis that homosexual behavior is "unnatural." The wide diversity of natural-law theories, however, points to the implausibility of basing a health profession's practice regarding homosexual patients on the question of the naturalness of homosexuality.

An alternative line of thinking is to premise the immorality of homosexuality on its contravention of some form of divine law. [28] To this end, passages from holy scriptures may be cited to demonstrate divine disfavor. A logical difficulty lies in attempting to transpose a general scriptural pronouncement beyond the particular framework of religious belief and the historical context in which it appears. This line of reasoning requires the assumption that a religious injunction of one group is an appropriate basis for the care of patients, regardless of the beliefs of either the providers or the recipients of care. One premise of policy is that, in a pluralistic society such as ours, practice will conform to a consensus level that includes many diverse views.

There are other philosophical modes of reasoning that can be brought to bear on the question of whether homosexual conduct is immoral, but these are the two most frequently heard premises. The key question for physical therapists regarding the appropriate moral stance is this: Even if it could be established that homosexuality were immoral, would immoral behavior be an appropriate ground for a professional's deliberation about whether to treat? Some have cited the "conscience clause" or notion of moral repugnance that allows health professionals to decline to take part in procedures they deem immoral, such as abortion. This is not a germane comparison, because moral repugnance applies to a procedure, not to the patient as a person. For example, one may object to performing a suction abortion or to inserting a needle intravenously for the purpose of euthanizing a patient. [29] Procedures required for patients with AIDS are all usual and customary techniques also applied to persons with symptoms similar to those arising from HIV infection.

The Argument from

Responsibility

An alternative strategy that may be utilized to limit the obligation to treat is to claim that individuals with AIDS contracted through homosexual practices (or via drug abuse or prostitution) are less deserving of care because they have brought their condition upon themselves and have endangered others as well. Such a view was expressed in regard to homosexual practices quite early in the history of the disease in a letter by a British nurse:

. . . frankly, I have no sympathy with homosexuals who contract the disease. . . . [W]hile nurses have a duty to care for the sick, we must also recognize that it is "self-inflicted" in the truest sense of the term, and need not have arisen in the first place. What makes AIDS more horrific is that a stranger's perverse sexual actions can harm totally unknown innocents. [30]

An argument such as that put forth in the letter views HIV infection primarily as a result of reckless or irresponsible conduct, though a bias relating to the "perversity" of the conduct is also apparent.

The suggested response to this allegedly irresponsible behavior is to make the errant patient pay the consequences, that is, to punish the patient. There are, however, no such explicit exceptions made to usual obligations of care for persons who are acting irresponsibly through criminal activity, overeating, consuming alcohol, or overworking or in other ways threatening their own well-being and that of others. On the contrary, codes of ethics, including that of the APTA, diligently counteract such an approach by emphasizing the dignity inherent in each individual as a human being. The focus on human dignity tends to remove the authority of any argument based on what a person "deserves."

Almost all physical therapists would agree that treatment should be allocated on the basis of a need requirement, rather than on the basis of desert. One's prime concern is with the patient's current clinical needs, and time and effort are apportioned accordingly, regardless of the perceived morality or immorality of the patient's past conduct. Indeed, this idea of need-oriented treatment is implicit in the clinical decision-making process adopted by therapists. Data are gathered in a systematic manner, and, by a rational, inductive process, a series of problems are identified. These problems represent various clinical "needs" of the patient, which presumably are within the purview of the therapist to attempt to solve. Although the ethical consequences of various interventions are highly relevant in such matters as the formulation of treatment priorities, speculation as to the moral origins of the patient's condition sits uneasily within an approach to care that responds to need rather than to a subjectively held notion of what the patient deserves.

The Argument from Danger

to Others

The proposition has been advanced that the hazards associated with the care of patients who have AIDS serve to decrease or annul a duty to treat. In other words, under such circumstances, treating these patients is supererogatory, or "beyond the call of duty." This argument is less often specifically applied to the treatment of patients who have AIDS and are homosexual and more often to all patients with AIDS, including those who contracted the syndrome in a way free from any possible imputation of immorality (eg, via blood transfusions). In the case of homosexual patients, however, this third line of argument takes its strongest form, by being added to the allegations of immoral or irresponsible conduct to support abrogation of the duty to treat.

Caring for those with HIV infection entails a risk. there is little doubt that the consequences of contracting AIDS are very grave, and it is understandable that health care workers, physical therapists among them, may experience intense anxiety and fear. In this regard, physical therapists are amiss if they do not take serious steps to help co-workers address these fears and anxieties in a supportive and informed context. It is essential that any assessment of actual hazards of contamination is conducted rationally and grounded in an informed grasp of the relevant evidence. Potential consequences must be considered independently of the likelihood of infection. Many commentators have emphasized that the likelihood of HIV infection is low for health care workers, particularly when prudence is added to basic safeguards, such as the Universal Precautions implemented in the United States. [31-33] Even exposure to HIV via needlestick injury carries a low risk of infection. [34]

Although the risks of HIV infection may be high for some health professionals, for most they are negligible. Almost all physical therapists come under the latter category; those few activities, such as wound care, that may bring the therapist into contact with the patient's blood are well covered by the Universal Precautions, and those factors associated with the highest risk, such as needlestick injuries, are not part of the everyday practice of physical therapy.

Additionally, it should be borne in mind that shunning contact with known HIV-positive patients is no guarantee of avoiding the virus itself. Other groups of possible HIV carriers include asymptomatically infected individuals who are yet to be tested; those with "false-negative" test results; persons who, following infection, are in the latent period during which no antibodies are present in the blood; and even those patients with long-standing infection who have lost their antibodies. [33] Physical therapists should regard all patients as potentially infected. [14] A refusal to treat HIV-positive patients can at best minimize, but not eliminate, the risk of infection. The occasional therapist who does not want to take the risk of encountering the virus should probably not continue to work in the clinical setting.

Identifying objectively the level of risk of transmission in a therapeutic context does not settle the question as to its acceptability to a given physical therapist. Determining what constitutes an acceptable level of risk ideally should be a collective task for therapists in an open dialogue with other professionals and the patients they serve. If the degree of acceptability is decided on an ad hoc, individual basis, away from public scrutiny, the patient entering a therapeutic relationship will have no reliable means of knowing how he or she will be received. By way of contrast, if the greater emphasis is placed on objectively known levels of risk, in preference to subjectively held notions of acceptability, it is likely that the patient will receive care consistent with the traditional approaches based on need discussed earlier.

It may be felt that one can rightfully decline to treat a patient who is perceived as potentially hazardous in order not to render oneself unfit to treat others (ie, by contracting the disease). Even if it were shown that a substantial danger exists, however, this argument entails the paradoxical conclusion that the identified patient should go untreated. Although this may seem to be an argument in favor of the general good, it tends to resolve itself into an argument that is relevant to the individual patient already affected.

In summary, the evidence is that the known risks to physical therapists of HIV infection are extremely low, provided that routine precautions are followed. Moreover, even if the dangers were greater than they are, physical therapists would not necessarily judge them unacceptable, particularly if the consequence of doing so would mean that seriously ill patients are left untreated. An element of risk is integral to many roles in society, including that of the health professional. Indeed, Silver [35] has demonstrated the weakness of the risk-free position by transforming it into a generalized principle such as "only help others when such help poses no possible serious threat to oneself," or "health care providers should treat illness only when it can be done without any possible danger to the provider." Surely these are maxims that few physical therapists would wish to espouse.

A Look Ahead

Three meain lines of reasoning--the arguments from morality, from responsibility, and from danger to others--have been applied to the issue of the health professional's duty to treat homosexual patients who have AIDS. We have highlighted each of these positions from the logic of the standpoint itself, the difficulty of establishing empirical evidence to substantiate an abrogated duty, and the necessity of brining practice into compliance with long-held values of the professional ethic of care.

Hardly anybody has postulated an absolute duty to provide treatment to anyone under all circumstances. One writer [36] likens the health professional's duty to treat patients who have AIDS to the fire fighter's obligation to respond to an alarm. We would agree there is such a duty. At the same time, we would grant that the fire fighter's actualy duty would stop short of rushing into a collapsing building. This construction of how duty operates allows prudence to be a guide.

Because a decision to abrogate the well-being of certain patients has serious negative consequences for the quality of health care, and for certain deep-stead values of health professionals, constructive steps must be taken to providsafe and supportive environment for all involved. Among the resources available are

1. The development of support systems within institutions for addressing ignorance, prejudice, legitimate fear, and other detriments to good patient care.

2. The growing commitment of the larger society to help find effective preventive and treatment measures in the fight against AIDS.

3. The opportunity for continued participation in the effort to arrive at humane policies.

The first of these spheres of activity is consistent with Principle 1 of the APTA's Code of Ethics, which requires physical therapists to be "responsive to and mutually supportive of colleagues and associates." [25] It is important to establish an ongoing dialogue within a multidisciplinary settling, in which misconceptions can be dispelled and emotionally charged issues can be sensitively and compassionately explored. Given that totally "value-free" health care is a chimera, health professionals must together decide which personal values should be permitted to determine standards of care and which should not. Again, Principle 1 of the APTA's Code of Ethics gives valuable guidance:

Physical therapists are to recognize that each individual is different from all other individuals and to be tolerant of and responsive to those differences. [25]

The second of these resources highlights the vital role of the physical therapist as an agent for health promotion. Working both within health care facilities and in the wider community, the therapist can seek to raise levels of knowledge among the populace and to dismantle irrational fears and anxieties. The benefits of such health education will extend beyond immediate medical concerns (such as the prevention of infection) to those that embrace a wider notion of health, such as the creation of a more rational and humane climate in which those affected by AIDS can be cared for. In this respect, the professional conduct of health care workers sets an example to society as a whole. As Silver points out:

If doctors will not operate on HIV-positive patients and nurses will not care for them, it becomes difficult to convince the public to work, eat or play with them. [35](p156)

The role of the physical therapist is broadened still further in the third area of involvement. Working either as individuals or through professional associations, therapists can serve the interests of their patients by seeking to influence policies established to deal with the social problems posed by AIDS and HIV infection, whether at the institutional, neighborhood, state, or federal level. In the same way that misunderstandings or irrational fears can be dispelled at the level of the clinic, the physical therapist can ensure that policies determined in the public sphere are well-informed and free from the prejudice that largely stems from ignorance. This area of involvement may entail reassessment of the therapist's role and a realization that activities outside the direct patient care arena can be as beneficial to patients as those pursued within the immediate clinical context. Watts articulated this view clearly:

We should expand our thinking to recognize that our professional practice cannot be conducted in isolation from society and from societal issues that have a profound bearing on the health of mankind. [37](p1808)

The ethical dilemmas posed by AIDS are an area in which physical therapists can meet this challenge.

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J Sim, MSc, PT, is Lecturer, Department of Health Sciences, Coventry Polytechnic, Priority St, Coventry CVI 5FB, England.

RB Purtilo, PhD, PT, FAPTA, was Program Director, Ethicist-in-Residence, and Henry Knox Sherrill Professor of Medical Ethics, Program in Ethics, MGH Institute of Health Professions, 15 River St, Boston, MA 02108-3402, at the same time this article was submitted. She is currently Professor of Clinical Ethics, Creighton University Center for Health Policy and Ethics, Omaha, NE 68178. Address all correspondence to Dr Purtilo at 3429 Hawthorne Ave, Omaha, NE 68131 (USA).