The Lancet Student

Latest blog post:Old Virus, Same Stigma

This blog was submitted by Ohad Oren on 19th February 2015.
Tagged with HIV, discrimination, Medical ethics, dental care

An HIV-infected patient seeks dental care but is denied treatment. He is told by multiple care providers that they do not take care of individuals with HIV. He keeps being referred from one clinic to the next. The man eventually files a lawsuit alleging discrimination based on disability. He then files another, then another. He wins three, loses two. It is no longer clear if teeth maintenance is his real desire. Or is he just abusing the system?

Isaac (not his real name) is at the heart of a charged controversy in Israel these days. The HIV carrier has prosecuted countless dentists, surgeons and cosmeticians for discrimination based on his viral condition. American Laser, the Smile Clinic, and Clalit healthcare services are among those brought to trial. Isaac accuses them of negligent practice and demands monetary compensation.

The defendant health care providers depict a different story. They say Isaac was not honest with them: that he concealed his HIV diagnosis until the second visit, recorded all communications without their knowledge, and was not even interested in getting dental care.

Money-driven and fraudulent or a poor victim of an HIV-stigmatising society? The court had to decide.

After much deliberation, the Magistrate Court judge presented the verdict: patient was not morally wronged. Rather, it was a professional disagreement about therapeutic options that prevented the patient from getting the service. “The physician did not decline to provide medical care but believed in an alternative treatment plan”, the judge wrote. Isaac was not innocent, the court determined: he obscured the medical history by hiding his HIV diagnosis, was repeatedly involved in court proceedings of questionable nature, and mis-used the legal platform.

I can understand the court’s decision, faced with a sequence of arguably-dubious claims. But here is a more global analysis that I would suggest.

This case represents a challenging conundrum with three overlapping questions: medical, ethical and societal. The medical one regards the effectiveness and safety of dental care in HIV patients. The scientific literature tells us that, following teeth interventions, HIV patients actually have comparable rates of complications to those who are HIV-free. Studies show that the likelihood of unfavourable results (after implanting teeth) is influenced by the type and site of the tooth extracted, the number of intervened teeth, the age of the patient, smoking status, and the experience of the surgeon. HIV infection in itself is not a contraindication to a procedure, and the approach should be individualised based on his or her condition. According to formal society guidelines, dentists are obliged to perform dental extractions and other procedures (in patients with HIV) based on the same criteria used for other patients. Ignorance, fear, or stereotypes are never an excuse.

The ethical and legal perspective should also be considered. HIV equals disability. That means that discrimination against patients with HIV/AIDS is illegal (according to the ‘Equal Rights of Persons with Disabilities Law’, 1998, Israel). Physicians may not refuse to treat individuals with HIV, the same way they cannot decline to provide care to a patient with obesity or a neurodegenerative condition. In addition, physicians and dentists do not have the right to require disclosure of HIV test results from any patient. They are obliged to take care of every patient, HIV positive or negative, and always to take proper precautions as if the patient had an HIV infection.

The societal angle is a also critical one to understand. I do agree that, at the theoretical level, Isaac might have attempted to gain economic revenues when making appointments with clinicians (who would then refer him to another provider). But this in itself is not a misdemeanour and it provides us with a much-needed reflective mirror of our culture and systems. It reminds me of Edward Snowden’s WikiLeaks saga, malicious in the eye of the American government but priceless for the values of greater democracy. Isaac’s repetitive suits may be an harassment at the juridical level, but they attest to our country’s lack of sensitivity towards HIV patients. Care providers who systematically avoid treating patients with disability are doing us a disservice.

I look at my country’s health care system with grave concern. Israel is, on the one hand, home to a flourishing network of scientific facilities. Its public hospitals allow outstanding medical treatment for the masses. Local investigators deliver cutting-edge discoveries to their physician counterparts, improving the lives of individuals and communities. And yet, a stigmatising virus bends our ethical sense in ways not thought imaginable.

Isaac was times and again portrayed as a merciless villain. The newspapers, the televised media, even the court, described him as a swindler guided solely by the manipulation impulse. His up-scale theatrical abilities, it has been argued, served nothing but his mushrooming bank account. But regardless of whether proper dental hygiene was his prime motive or not, it is shameful to hear his story.

For this is a tragic tale of prejudice and alienation. An HIV patient was prematurely labelled by the public, repeatedly rejected by clinicians, and unjustly treated by pundits and decision-makers. His job opportunities might also have been compromised and he lost all source of income. The high costs of HIV treatment and excessive specialist waiting times probably added fuel to the fire. No other choice was left. Isaac had to pursue a drastic measure just to survive.

We, as a society, have failed Isaac. We regarded him as a ‘contagious’ threat, deprived his freedom and basic human rights, and then closed our ears to his desperate pleas.

Isaac is only the tip of the iceberg. Which is why his story must resonate with all Israelis and more. We must remember that individuals with chronic disease already endure immense suffering. Many of them are trapped within a disease landscape that includes aggravating symptoms, increasing debility and the uncertainty of the future. Stigma is the last thing they need. We must do everything we can to relate to them with compassion and empathy and ensure their access to high-quality care.