Hepatitis B and medical students
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* Robert Colistro

Because of hepatitis B virus (HBV) infection and other infectious diseases, several Canadian medical schools have created controversial admissions policies that have led to ethical debates about the rights of students and their future patients.

One prevention strategy requires students to provide evidence of vaccination before clerkship or face training and career restrictions, thus making successful immunization a condition of employment. To minimize high-risk encounters, most schools steer HBV-positive students into community medicine, administration, laboratory medicine, psychiatry and research. Only one school permits students to enter family medicine or certain subspecialties, with the understanding that they are not to perform any elective obstetric or invasive procedures. To allow students to make informed decisions regarding career goals and preferred training locations, all Canadian medical schools should be reading off the same song sheet.

Given the perception of exposure risk, public disclosure of (future) physicians' serologic status would have devastating effects on their livelihood and invade their right to privacy. A delicate balance must be struck between a patient's right to informed decision-making and the potential harm caused by disclosure. Physicians and ethicists must make a "best-interest judgement" and determine the risk that a reasonable person in the patient's position would be willing to take. Unlike medical students, who agreed to a certain level of risk upon entering medicine, it may not be right to assume that patients also agree.

The principles of biomedical ethics do not point to a clear course of action but provide conflicting guidance. In the meantime, schools must inform (prospective) students of the risk of training-related disability, offer appropriate counselling services and provide options for income security through meaningful work or retraining.

The debate over the suitability of potentially infectious students raises legal, ethical and individual issues. Voluntary testing, coupled with an intensive public health initiative to vaccinate the entire population, may be the most respectful of solutions. Nevertheless, patients must come first. Students performing "exposure-prone" procedures have a moral and ethical obligation to know their HBV status. However, students should be free from unwarranted immunologic discrimination based on remote risks that are generally tolerated within society, such as those seen in noninvasive medical procedures. But how much risk is acceptable?