CMA rescinds controversial policy

CMAJ 2000;163(5):594

Physicians and other health care workers are familiar with the anguish that results from percutaneous and mucocutaneous exposure to blood and at-risk biologic substances. (In 1996, almost 1 million health care workers in the US faced such exposure, with nurses being at particular risk.) The risk of HIV transmission following a needlestick injury from an HIV-positive person is about 3 per 1000 (Moloughney BW. Bloodborne pathogen source testing: a review of the evidence. Ottawa: Canadian Medical Association; 2000). This risk can be reduced to less than 1 per 1000 with postexposure treatment, but such prophylactic efforts entail frequent side effects; some of these, such as pancytopenia, are rare, but they can be life threatening. To lessen anxiety and to make rational decisions about continuation of prophylaxis and sexual relationships, health care workers want to know whether the patient involved in the exposure is HIV positive.

Most patients readily agree to HIV testing in these cases and most health care providers discontinue prophylaxis when the result is negative. However, about 5 patients per 1000 either refuse to be tested or are incapable of consenting. It was precisely this situation that was targeted last year by General Council, which passed a resolution that such patients "be required to sign a waiver that would allow [HIV testing]." The policy was criticized as uninformed and impractical in a CMAJ article (Tyndall MW, Schechter MT. HIV testing of patients: Let's waive the waiver.

Implementation of this resolution caused considerable grief for the CMA Board of Directors because it violated several sections and many of the values of the CMA Code of Ethics; the code itself would have had to be revised to accommodate the new policy. As well, mandatory testing of nonconsenting patients was a direct and nontrivial violation of an individual's rights to "security of person" and to "protection from unreasonable search or seizure," both of which are guaranteed under the Canadian Charter of Rights and Freedoms.

Legal counsel was sought on 2 occasions as the board struggled with the resolution. In the end, the board split over the issue and decided to refer the motion back to General Council. And again this year there was passionate debate, but when the votes were tallied delegates approved a resolution to rescind the original 1999 motion. Thus, the CMA no longer supports mandatory HIV testing of nonconsenting patients and returns to its original and widely supported policies on the virus. — John Hoey, CMAJ

© 2000 Canadian Medical Association or its licensors