WASHINGTON — Washington. - It's hard to argue that patients don't have the right to know if their doctor has AIDS. The interesting question is why they have such a passionate wish to know. Of all the risks you face in your life, the chance of catching AIDS from your doctor is farcically small.
Yet the country is riveted by it. The Senate recently voted 82-19 to send any doctor to jail for 10 years who operates on a patient without revealing if he is HIV-positive.
Americans' irrationality when it comes to assessing risks -- especially very small risks of very bad outcomes -- is one of my favorite subjects. So I got very excited by a suggestion in Newsweek a few weeks back that your chance of catching AIDS from an infected surgeon was about the same as your chance of dying in a car crash on the way to and from the hospital. That would mean that a nearby doctor with AIDS was a safer bet than an uninfected colleague a few miles further away.
It turns out that's not quite right. The study in question equates the risk of dying on the way to and from the hospital with the risk of getting AIDS from all surgeons, not just from surgeons who are HIV-positive. Still, the fact remains that nobody contemplating an operation thinks twice about the risk of dying in transit while everyone seems obsessed with fear of catching this fatal disease from the doctor.
There is only one known case of a health-care worker transmitting AIDS to his patients. That is the notorious dentist Dr. Acer in Florida, who seems to have infected five patients. How one dentist could infect five people with this hard-to-transmit virus has been a puzzle. The odds against it happening in the normal course of a practice are stratospheric. And evidence is emerging that Dr. Acer was criminally irresponsible about sanitary precautions.
Sloppy sanitation is more deadly, and more common, in health care than AIDS. If you had to choose between a doctor with bad sanitary practices but no AIDS and a doctor with AIDS but good sanitary practices, you'd be crazy to choose the doctor without AIDS. Yet the Senate isn't concerning itself with doctors who don't properly sterilize their equipment.
The best study of the risk of AIDS transmission in a health-care setting -- necessarily theoretical, since no actual case is known except Dr. Acer -- came from the Centers for Disease Control earlier this year.
It estimated that the risk of transmission of the HIV virus from a surgeon to a patient was somewhere between one in 41,000 and one in 416,000. The risk of transmission from a dentist to a patient was between one in 263,000 and one in 2.6 million. The center estimates that 10 to 100 people may have contracted AIDS from dentists since 1981, and 3 to 28 from surgeons.
Using the same methodology, the institution calculates that the risk of contracting Hepatitis B from an infected surgeon is 100 hTC times greater than the risk of contracting AIDS. And it calculates that 5 to 85 people have actually died from hepatitis passed on by a surgeon since 1981. In other words, surgeons who give you fatal hepatitis ought to be a bigger worry than surgeons who give you AIDS. But they aren't. The level of concern among senators and other lay people about catching hepatitis in surgery is just what it ought to be: approximately zero.
To really guarantee patients their "right to know" would require AIDS testing of health-care personnel. And testing is costly. According to a study of the economics of AIDS testing recently reported in Science magazine, a standard two-level AIDS-testing program (where a second test is administered to those who test positive the first time) costs $35 per person, if the blood must be drawn for the AIDS test alone.
To be done right, the testing would have to be done regularly -- every few months at least. You're talking hundreds of millions of dollars to save a few speculative lives. How many more lives could be saved if the same money were spent on AIDS research or education -- or on measles vaccines for poor kids, to note but one health-care measure on which the United States now lags the civilized world?
There are other costs as well. The Centers for Disease Control estimates that an AIDS-infected surgeon has an 8 percent chance of infecting a patient in the course of his entire career (sadly figured at seven years). That's one in 12. Does a good surgeon not have at least a one-in-12 chance of saving at least one additional life by continuing his career?
"A single death is a tragedy," goes the aphorism attributed to Stalin, "a million deaths is a statistic." Stalin's point was slightly different than mine, but the insight into public psychology is still applicable. The story of Kimberly Bergalis is a genuine tragedy, but it is not a sensible basis for either public policy or personal decision-making.
Yes, catching AIDS from your surgeon or dentist is a risk you can do something about, unlike (say) the risk of dying from anesthesia on the operating table -- which the CDC estimates is four to 40 times greater. But if you're really interested in cutting back on one-in-41,000 risks, you're going to have to spend your ** whole life at it. In fact, you won't have much of a life left.
TRB is a column of the New Republic, written by Michael Kinsley.