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Last Updated

11 Feb 2003

Source: New York Times, February 11, 2003


In Times of Turmoil, Clarion Call for Doctors Often Goes Unanswered


Smallpox vaccination is off to a slow start in the United States, as the argument among doctors over its pros and cons is escalating.

To some extent, this hubbub is simply the unhappy reaction of people accustomed to operating off carefully calculated risk-benefit ratios being forced into decisions in a time when such ratios cannot easily be calculated.

Doctors desperately want to know the true risk of weaponized smallpox, the health risks of vaccination for themselves, the risks for patients, and the risk of other consequences like litigation for untoward vaccine effects.

Without any of these numbers in sight, a chaos of gut reaction has ensued.

Predictably, the hubbub is also beginning to include a few distinctly trumpetlike noises clarion calls for doctors just to transcend their viscera and answer to a higher moral authority.

"Health professionals are familiar with risk," a Jan. 30 editorial in The New England Journal of Medicine said, urging physicians to accept smallpox vaccinations if necessary. "Doctors and nurses have responded during past crises to provide care for patients and help protect the public health, even when there has been significant personal susceptibility."

These trumpetlike tones last sounded in the early days of AIDS, when it became clear that exposure to infected blood commonplace for doctors and nurses could transmit the virus. No numbers to quantify risk were available then either.

A raging debate ensued over the behavior of doctors who declined to accept that risk whether by refusing to operate on H.I.V. patients or by refusing to allow them over the office threshold. Invariably, doctors were urged to recall the self-sacrificing traditions of their profession then, too.

But the full truth is often forgotten: while the medical profession does indeed have a tradition of selflessly accepting unquantifiable risks, it has an equally long tradition of the most self-protective, risk-averse behavior imaginable.

Doctors who declined to risk their skins for their profession include some of the famous physicians of history. Galen, the eminent Greek doctor, fled Rome in A.D. 166 at the onset of an epidemic that might have been smallpox.

Thomas Sydenham, the pre-eminent cardiologist of 17th century London, left town as soon as plague broke out there in 1665. When yellow fever struck Philadelphia in 1793, three of the best known doctors immediately headed for the Poconos (but the indomitable Benjamin Rush stayed behind).

These men were hardly the exceptions. Medieval records repeatedly bemoan the cowardice of doctors who left infected towns during the great bubonic plague epidemic of the 14th century (and also note the outrageous consultation fees demanded by those who stayed).

In an outbreak of plague in Venice, most of the doctors who did not actually leave the city locked themselves in their houses and refused to come out.

Ultimately many European cities resorted to hiring "plague doctors" usually young graduates paid generous salaries to treat plague patients and relieve other doctors of that duty.

But even plague doctors had their limits sometimes. "If you are asked to treat a patient with no chance of recovery," wrote the author of a late-14th-century medical textbook, "say that you will be leaving town shortly and cannot take the case."

Up through our era, the record of the medical profession when it comes to unknown professional risks is reliably spotty. In the 20th century, some doctors contracted tuberculosis, polio and AIDS from their patients. Others just said, No thanks, not me.

The American Medical Association's first Code of Ethics, adopted in 1847, called for doctors to care for infectious patients "even at the jeopardy of their own lives."

This clause disappeared in a 1957 revision and then reappeared in 1989, one of the trumpets summoning the profession to care for people with AIDS.

There is no evidence that the presence or absence of an official endorsement of selfless acceptance of risk made a whit of difference in how members of the profession behaved.

Now we seem to be heading for a similar watershed. Some doctors are prepared to accept the risk of severe side effects of vaccination (which range from persistent skin blisters to a severe smallpoxlike disease); others are agonizing over the possibility of infecting susceptible patients; others are just saying, No thanks, too risky for me.

If history is any indication, ringing editorials are unlikely to change this spectrum of behavior.

Every decade or so, it seems, we must relearn that medicine attracts a spectrum of individuals, with saints at one end and those determined to avoid sainthood at the other. In between stretches a long chain of relatively reasonable men and women, each of whom is prepared to create a personal compromise between professional obligation and personal risk.

At the moment, though, it is impossible to calculate either variable for smallpox vaccination. Everyone is simply watching and waiting. The trumpets are just warming up.