Transcript Balancing the Precepts of Public Health and Medical

Balancing the Precepts of
Public Health and
Medical Professionalism
Sheila M. Rothman, Ph.D.
Professor of Public Health
Columbia University
Peking University health science center
October 21, 2008
Medical Professionalism and Public Health
Sources of conflicts between physicians and
public health in the United States:

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Physicians committed to patient confidentiality
Fear that violations of privacy will lead patients to give
misinformation or avoid care
Physicians, therefore, object to mandatory disclosure of
patient name and contagious disease to public health
officials.
Sheila M. Rothman
Balancing the Precepts of Public Health and
Medical Professionalism
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Public Health Officials and Confidentiality
Public health officials


Fear a dedication to confidentiality will fuel epidemics
Regard mandatory reporting as a powerful tool to reduce
transmission
These conflicts have increased because


The boundaries of what is considered public health has
expanded
The authority of public health has enlarged
Sheila M. Rothman
Balancing the Precepts of Public Health and
Medical Professionalism
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The Origins of Public Health Reporting,
1890-1920
Koch identifies the tubercle bacillus as the cause
of tuberculosis (1882)

Tuberculosis is spread person to person

Reducing contacts between sick and healthy can prevent
disease transmission
Sheila M. Rothman
Balancing the Precepts of Public Health and
Medical Professionalism
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New Public Health Reporting Policies
The findings led public health officials to enact new
policies to reduce transmission

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Mandatory reporting by physicians of those diagnosed
with tuberculosis
Ongoing surveillance of persons with tuberculosis by
sanitary inspectors
Confinement of the newly diagnosed patients to
sanatoriums
Sheila M. Rothman
Balancing the Precepts of Public Health and
Medical Professionalism
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Physicians’ Objections

The policies violate a key principle of medical
professionalism: doctor-patient confidentiality

Surveillance leads to social discrimination

Surveillance leads to economic discrimination
(loss of employment, housing)
Sheila M. Rothman
Balancing the Precepts of Public Health and
Medical Professionalism
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Public Health Officials Recognize Danger but
insist on Reporting
Herman Biggs, New York City Commissioner of Health, 1898
“The government of the United States is democratic, but the sanitary
measures adopted are sometimes autocratic and the functions
performed by sanitary authorities paternal in character.”
BUT:
“We are prepared, when necessary, to introduce and enforce, and the
people are ready to accept, measures which seem radical and
arbitrary, if they were not plainly designed for the public good and
evidently beneficent in their effect….Friends of patients often
declare that they prefer to expose themselves to the chance of
infection rather than have their dear ones banished…but this is
sheer nonsense.”
Sheila M. Rothman
Balancing the Precepts of Public Health and
Medical Professionalism
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A New Public Health Consensus, 1920-1985

Physicians more willing identify persons
with contagious diseases

The Polio Epidemics of the 1930-1950’s

Scientific discoveries reduce the number
and scope of epidemics
Sheila M. Rothman
Balancing the Precepts of Public Health and
Medical Professionalism
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The Challenge of AIDS
Public Health officials see AIDS as a Plague
“For every case of reported AIDS in the United
States there are about 100 or more
carriers…Once infected, infected for life…We
see a wave of devastating disease
approaching.”
Sheila M. Rothman
Balancing the Precepts of Public Health and
Medical Professionalism
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The Challenge of AIDS, continued
To reduce transmission, public health officials
propose:
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Compulsory testing of high risk groups
Reporting by name of every person diagnosed with
AIDS
Closing down public bathhouses
Sheila M. Rothman
Balancing the Precepts of Public Health and
Medical Professionalism
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AIDS Advocates Respond
Public Health is discriminating against a
stigmatized group
They resist:
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
Reporting their names to the Department of Health
(make testing anonymous)
Mandatory testing for HIV
Sheila M. Rothman
Balancing the Precepts of Public Health and
Medical Professionalism
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Physicians Divide on the Issue
Some are sympathetic to the AIDS
community demands
More want to protect themselves and the
public
Sheila M. Rothman
Balancing the Precepts of Public Health and
Medical Professionalism
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First Resolution: AIDS Exceptionalism
At first, AIDS community wins:

Persons with HIV must consent to HIV testing

In most states, physicians did not report AIDS
patients by name
Sheila M. Rothman
Balancing the Precepts of Public Health and
Medical Professionalism
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Current Situation
AIDS loses its Exceptional Standing:
Why?
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Changing Demography of the Epidemic
New cases of HIV more often minorities
The availability of effective treatment
Sheila M. Rothman
Balancing the Precepts of Public Health and
Medical Professionalism
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New Policies

Testing now part of routine health care- written
informed consent no longer necessary

Mandatory testing for some populations
(pregnant women, prisoners, military)
Sheila M. Rothman
Balancing the Precepts of Public Health and
Medical Professionalism
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The New Public Health Threats

Multidrug resistance Tuberculosis

Bioterrorism

Emerging infectious global diseases (West Nile
Virus, Avian Flu)
Sheila M. Rothman
Balancing the Precepts of Public Health and
Medical Professionalism
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Medical Responses to the Threats

Respect for patient confidentiality remains a strong
value
But in situations of epidemics, support public health
mandates
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Will report individual patients
Will test without patient consent
Sheila M. Rothman
Balancing the Precepts of Public Health and
Medical Professionalism
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Physicians Recognize the Value of Privacy
but Elevate Public Health

If the outbreak of an epidemic is hidden, it will
spread more quickly and be more devastating

Elevate public health over own convenience

Elevate public health over objections from their
institutions
Sheila M. Rothman
Balancing the Precepts of Public Health and
Medical Professionalism
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Implications for Professionalism
Physicians should respect the wishes of their
patients and others who might want to restrict
their freedom to report contagious diseases
But:
A physician’s commitment to health not only for
their patients but for their community must take
precedence.
Sheila M. Rothman
Balancing the Precepts of Public Health and
Medical Professionalism
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