October 1999 Bulletin

HCV-positive surgeons face dilemma

Should they practice? Should they inform patients, partners?

As with other infectious diseases that have rapidly evolved such as Hepatitis B and HIV, there are diverse issues and ethical dilemmas facing a hepatitis C virus (HCV)-infected orthopaedic surgeon today.

One concern: Should an HCV positive orthopaedic surgeon be allowed to practice and perform noninvasive and invasive surgery?

It's a complex question because there are no recommendations to restrict a healthcare worker who has HCV from practicing, according to the U.S. Center for Disease Control and Prevention (CDC).

"HCV is a major health issue for doctors and patients alike," explains Herbert Rakatansky, MD, chairman of the American Medical Association's (AMA) Council on Ethical and Judicial Affairs. "There are no 'yes' or 'no' recommendations as to whether a health care worker with HCV can practice," he says.

Once a little known virus before 1988 when it was first identified, HCV is the leading cause of cirrhosis and liver cancer. It causes between 8,000 and 10,000 deaths from chronic liver disease and is now the leading reason for 1,000 liver transplantations in the U.S., according to the CDC.

By the CDC's estimates, 3.9 million people in the U.S. and 200 million people worldwide may carry the potentially deadly virus and many persons with HCV are asymptomatic.

According to the CDC, "The risk of transmission from an infected healthcare worker to a patient appears to be very low. . . . As recommended for all healthcare workers, those who are HCV positive should follow strict aseptic technique and standard precautions, including appropriate use of hand washing, protective barriers, and care in the use and disposal of needles and other sharp instruments."

Dr. Rakatansky observes that "the science of HCV is in flux." The answer as to whether or not a physician should practice in their specialty, he says "would be up to an organization's ad hoc committee to determine recommendations. This decision would be made always thinking of the benefit of the patient and to avoid any risk to the patient, but then again, not to penalize the patient by denying him the expertise of the doctor if there is no significant risk." That's a paraphrase of the position stated in the AMA's Ethical Opinion on Physicians and Infectious Diseases.

The AAOS's Advisory Statement on Hepatitis C does not address this issue, except to note that health care workers' exposure to blood and sharp objects makes them vulnerable to HCV and that seroconversions after needlesticks have occurred. The Advisory Statement observes that "a serosurvey among orthopaedic surgeons attending the Academy's Annual Meeting in 1991 showed that 0.8 percent of surgeons without nonoccupational risk factors were positive for anti-HCV."

AAOS's Advisory Statement for the HIV-Infected Orthopaedic Surgeons recommends "that an HIV-infected orthopaedic surgeon should not perform invasive surgical procedures except in specific limited instances" outlined in the statement. The statement also recommends "that if a patient might be put at risk for HIV transmission because of invasive surgery by an HIV-infected orthopaedic surgeon, the HIV-infected physician has an obligation to inform the patient of his or her HIV status and of the relative risks involved prior to performing the invasive procedure."

Since the virus is asymptomatic for years, many physicians may not be aware that they are infected.

Take Dr. X, (a pseudonym for an AAOS member), who discovered in 1993 that he had HCV. "I had no symptoms but it [HCV] was picked up when I was trying to donate blood," says Dr. X, who is married and has children. "My liver enzymes were elevated. I kept on working, never stopped the 80-hour schedule and did perform surgeries. Disclosing that I had hepatitis C would be the end of my practice as a surgeon."

Dr. X underwent Interferon alpha treatments that worked for awhile. "While I was on Interferon, my viral levels were not detected, so I was pretty safe-the safest in terms of operating," he says.

But soon, he was classified as a 'relapser.' In August 1998, Dr. X received the combination of Interferon alpha treatment with Ribavirin. The U.S. Department of Health and Human Services says "prolonged therapy and the combination [Interferon alpha and Ribavirin] may reduce long-term remission in disease for 40 percent of patients."

"But the combination treatment of Interferon and Ribavirin was experimental," explains Dr. X. "It turned out that I was in the placebo group. Once again, I was classified as a 'relapser.'"

Since Dr. X relapsed, he limits office hours and performs no surgical procedures.

He's also been "skirting" a lot of credentialing questions from insurers. Dr. X has not disclosed his HCV status to any insurance health plan that the group is affiliated with. "Since I'm not operating or putting anybody at risk, I'm not going to give him or her that information," he says.

Should his viral levels of HCV respond to treatment in the near future, Dr. X would like to operate again. "My dilemma now is if I return to surgery, I think I should disclose my status," he says. "But I think that would be the end of my practice, too. I'd have to limit surgeries to less invasive procedures to continue operating."

So, is there a definitive answer as to whether or not an orthopaedic surgeon can practice?

"I don't think a blanket 'yes' or 'no' is the right answer to this question," stresses Lainie Friedman Ross, MD, PhD, assistant director of the MacLean Center for Clinical Medical Ethics at the University of Chicago and assistant professor in the department of pediatrics. "If a physician is willing to limit his or her practice to procedures in which there's minimal blood exposure, I don't think there's any reason for informing patients about their hepatitis C status. However, if they want to perform invasive surgery, that information is relevant just like the hepatitis C status of a patient is relevant. It doesn't mean a complete ban is necessary. It just needs to be part of the informed consent process."

"If you pose a risk [to the patient], the physician should disclose it," says Arthur Caplan, director, Center for Bioethics and trustee professor of Bioethics, University of Pennsylvania. "Nothing will happen until we create a strong safety net. So far, it hasn't happened. This isn't so hard [a question] ethically. We know what the right thing is: it's just you're asking people to sacrifice too much to do the right thing."

Although Dr. X has not disclosed his viral status to his patients, his colleagues are well aware of his plight. "I have always shared all of my knowledge about the risks of the disease with my colleagues who've afforded me time for treatment, all the while protecting my confidentiality which is not an easy undertaking in either a clinic, hospital setting or among curious colleagues."

Nevertheless, Dr. X's partners are concerned over the potential risks to the corporation should any charges of malpractice occur.

"My malpractice carrier has stated that should a transmission to a patient occur under my existing policy, the carrier would defend me," Dr. X says.

And other malpractice carriers will, too, says Richard E. Anderson, MD, chairman of the board of the Doctor's Company in Napa, Calif. "The reason we'd defend him or her is several fold," he explains. "First of all, a successful malpractice suit requires a number of things. One is a breach in the standard of care. Now, at this moment in time, there is really no established medical standard that I'm aware of that says surgeons with HCV should be prohibited from practicing."

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