Keeping the disease under wraps
Would you be prepared to undergo open-heart surgery with the leading light of the operating room - who has HIV? The Health Ministry doesn't think you should have a problem with that. But many doctors and hospital department managers would rather you didn't.
The question isn't a theoretical one. In May of this year, a Health Ministry committee decided that a top surgeon at Sourasky Medical Center (Ichilov Hospital) in Tel Aviv was entitled to return to the OR, despite having been infected with HIV, the virus that causes the acquired immune deficiency syndrome, or AIDS. Nor does he have to advise his patients of his condition, the committee ruled.
Since then the doctor, whose case has stunned Israel's medical establishment, has operated on dozens of patients. In keeping with the Health Ministry ruling, none of the patients were advised of the - admittedly very remote - risks involved in undergoing surgery conducted by someone who is HIV-positive.
At Israeli hospitals, the norm is for one of the junior medical staff to explain the risks of surgery to the patient and obtain his signature on an informed-consent form. At Ichilov, the management told the cardiac surgery team that there was no need to inform the patients about the doctor's condition.
Meaning, the fact that he has HIV is concealed from his patients. (His name has not been published in the media based on his right to privacy as a patient.)
The surgeon is back at work, full time, following the decisions at the Health Ministry and Ichilov, and after a check found that among the patients he'd operated on in recent years - about 544 out of 800 were tested for HIV and not one had contracted it. He is receiving the usual drug therapy for HIV, which has improved his physical condition. He is required to wear two pairs of gloves and to accept monitoring - medical and laboratory - of his condition. The results of the tests are reported to Ichilov management.
The decision to conceal his condition from patients has aroused fiery controversy in the medical community, and plenty of biting criticism from many doctors.
Some believe the decision violates medical law and ethics, with respect to doctors and hospitals alike. Senior doctors, including cardiac surgeons and cardiologists, told Haaretz this week that they'd never accept the risk, however small, of a doctor with HIV operating on them.
The main concern is that somehow, the doctor's blood would come into contact with the patient's circulatory system. That could happen if the doctor nicks himself with one of the surgical instruments or is stabbed by a needle. These things happen in operating rooms.
In May, a panel consisting of three experts submitted its recommendations to Dr. Boaz Lev, the deputy director general at the Health Ministry. They recommended restoring the surgeon to his job, and not requiring him to divulge his condition to his patients. The Health Ministry steadfastly refuses to disclose the name of the experts, on the grounds that there's "no material need to do so."
According to the panel's report, which is presented here for the first time, based on medical literature - the probability of a doctor with HIV infecting a patient is extremely low, at most 5 cases per 100,000 events of invasive treatment. The probability is much lower than that of being infected with hepatitis by a doctor, according to literature on the subject.
Only seven cases of doctors infecting patients with HIV have been reported worldwide, the panel says. One was a dentist who infected five patients in the United States. One patient got the disease from an orthopedist in France and one from a gynecologist (see box). But the panel found dozens of reported cases of doctors infecting hundreds of patients with viral hepatitis.
In most Western nations, including the U.S., doctors with HIV are not barred from working, the panel added. Nor in most cases are doctors required to inform patients of their status as carriers. Britain is one of the few exceptions in the West: It bans HIV carriers from performing surgery.
The panel recommended that the Health Ministry allow the surgeon to resume work in cardiac surgery, contingent on stringent medical monitoring and after he'd been taught the requisite rules of caution. Ichilov stated this week that it would allow patients to refuse to undergo surgery with that doctor. "As of now, none of the patients have asked for that," the hospital added.
One critic of the policy of concealment is a department manager at Ichilov. "It should be mandatory to inform patients of the disease," he says: It is every person's right to know of the risks before surgery, and to make an informed decision. "The risk in this case may be small, but it isn't zero, and it comes on top of the usual risks in cardiac surgery. The doctors cannot be allowed to make the decision instead of the patient. The hospital's dilemma is a tough one, but ultimately I would have expected it to decide in favor of the patient's welfare."
If he had to undergo heart surgery, the fact that his surgeon has HIV would frighten him, he says. He'd prefer another doctor, despite the remoteness of the risk.
Dr. Shimon Scharf, general manager of Barzilai Hospital in Ashkelon, agrees with the Health Ministry decision to reinstate the surgeon. But he also feels that it is the doctor's duty to inform patients of his condition. "The general good prevails over the private good and the need to preserve the doctor's medical confidentiality," Scharf says. His view is also based on the Patients Rights act, he adds.
Scharf, who also participates in Health Ministry disciplinary tribunals, said he would be perfectly happy to undergo surgery with an HIV-positive doctor, but he'd like to know in advance.
A top Health Ministry official buttresses Scharf's position: "Even if, scientifically speaking, the probability of the doctor infecting his patients with HIV is miniscule, the patient is entitled to that information. The Health Ministry and Ichilov must not make the decision to conceal crucial information from patients," he says. "It violates the basic rights of the patients and weakens the public's faith in the system."
It is the Health Ministry's duty to protect the public, the official added, and this case makes it seem that instead of primarily protecting the public interest, it's protecting the commercial and professional interests of the hospital and the doctor.
Cardiologist Victor Guetta, director of cardiac catheterization services at the invasive cardiology unit of Sheba Hospital at Tel Hashomer, also thinks it is the ethical duty of any doctor with HIV to tell his patients. He himself would not hesitate to be operated on by a carrier, he says: "The chance of my infection in the department is close to zero. But as a patient I'd like to know about the disease and would make up my own mind."
A top doctor in cardiology told Haaretz that frankly, if heaven forfend he were in the unhappy doctor's position, he'd forgo his job. "I wouldn't continue to operate. I wouldn't want to expose patients, and also, it isn't fair to keep on going as though nothing had happened," he says. If he had to undergo surgery he'd want another doctor, he says.
Shay Feuring is a doctor and lawyer, and an expert on medical negligence. In recent weeks he's conducted an informal survey, asking dozens of doctors, including cardiac surgeons and gynecologists, some department managers at major hospitals, whether they'd be prepared to undergo surgery by a doctor carrying HIV. The absolute majority said no, he says.
"That shows that the tiny or miniscule risk of infecting the patient may still be the deciding factor when deciding whether to undergo surgery, even among people who know the actual chances of infection," Feuring says. "It also shows that the Health Ministry would have been wise to run a campaign explaining its decision to the public, not to hide the information about the doctor from his patients."
The knowledge that his doctor has HIV won't change the patient's attitude about the surgery itself: At worst he'll seek another doctor, Feuring says. "Therefore, the decision was designed to protect the doctor's livelihood, or freedom of occupation." He feels that the Health Ministry and Ichilov could have found other ways to protect the doctor's pocket and rights while still allowing him to use his professional skills.
Prof. Eran Dolev used to head the Ethics bureau at the Israel Medical Association. He also runs the Internal Medicine departments at Wolfson Hospital in Holon and at Ichilov. "Based on medical ethics, the right thing to do would be for the doctor to present himself, limitations and all, to patients and reveal his condition to the patient before surgery," Dolev says.
He does suspect that disclosure would mean patients would balk at undergoing surgery with this doctor, despite the negligible danger of infection. "Our society still has a problem with the connotation of the disease," Dolev say. "I myself, as an educational act, would have undergone surgery with him, if I needed it. I would not view his status as carrier as a limitation, and it would not be a consideration when choosing a surgeon."
Prof. Avinoam Reches, current head of the IMA's Ethics bureau, concurs: "The good of the patient demands disclosure of the doctor's medical condition, but in the case of HIV, the actual danger is so low that there is no real danger to the patient," he says. "It is all but certain that if the doctor discloses his condition, most patients would refuse to undergo surgery with him, on populist grounds, not scientific ones. That would injure his livelihood, his privacy and his dignity."
Reches believes it is in the interest of the medical establishment and the public to encourage medical workers to report their disease to their superiors, and doctors would have the confidence that their privacy would be preserved.
Dr. Gideon Hirsch, director of the Israel AIDS Task Force, has been HIV-positive for 19 years. He studied medicine at Tel Aviv University after he was infected. In 1998, he relates, as a student at Ichilov, he was barred from participating in surgical procedures. At the time the prohibition made sense to him but today he feels it would be unjustified.
Hirsch agrees that a doctor shouldn't be forced to divulge his condition to patients. "The public's ignorance, including among doctors, is terrible," he says. "Therefore, disclosing the disease would not help fight the stigma that drives the wheels of the disease around the world."
The first court verdict regarding a doctor who infected patients with a contagious disease was handed down in July, at the Be'er Sheva District Court. Judge Nathan Zlotchover convicted Dr. Sergei Pontus of deliberately infecting 25 patients with Hepatitis C when working between 2001 and 2003 as an anesthesiologist at Soroka University Medical Center in Be'er Sheva. Pontus was addicted to an anesthetic and used the same needles on patients that he had used to inject himself with the drug.
Judge Zlotchover said that the patients Pontus infected might suffer terrible conditions that could even kill them.
The judge raised issues that had never before been discussed in the Israeli courts: "It is a difficult question, with legal, moral, medical, ethical and other ramifications, whether a hospital may employ a doctor, especially in the operating room, when the hospital knows that the doctor has contracted an infectious, dangerous disease, and whether any distinction should be made in that respect between, for instance, a surgeon and an anesthetist," Zlotchover wrote.
"Even if the decision is that a doctor with a dangerous disease be allowed to work in the operating rooms, for instance distinguishing between a surgeon and an anesthesiologist, that decision might be and should be contingent on conditions that reduce the potential damage to patients.
"Also, it should be asked whether, even at the price of injuring the doctor's privacy, the doctor's direct superiors should be advised of the disease and what level of superiors should be advised.
"Another question is to what degree the public of patients should be advised, if at all, regarding the risk arising from treatment by that doctor, and if the public of patients has the right to know, and what the extent of that right is, given the ill doctor's right to privacy."