AIDS, judges, and the right to medical care.

AIDS, Judges, and the Right to Medical Care The AIDS epidemic continues to bring to public attention major problems in our medical care system. One central question is whether there is a "right to medical care," and if so, what it means for AIDS patients. This issue is at the core of a suit by the Dallas Gay Alliance (DGA) against Parkland Hospital in Dallas, Texas. Parkland is one of the premier public hospitals in the U.S., and the only Dallas County hospital that treats indigent AIDS patients. It cares for about 55 percent (230) of the county's AIDS patients. The DGA had been negotiating with Parkland for months over issues relating to the care of indigent AIDS patients. The DGA had three major concerns: * AZT availability: Primarily because of a shortage of physicians in the AIDS clinic to monitor patients on AZT, there was a long waiting list of AIDS patients who met the medical criteria for the drug and wanted it, but could not obtain it. * Aerosol pentamidine availability: Parkland allegedly has a rule that no drug not approved by the Food and Drug Administration (FDA) for a specific use could be prescribed for that use for a Parkland patient, except as part of an IRB-approved clinical trial. Aerosolized pentamidine has not been approved by the FDA for use to prevent pneumocystis carini pneumonia. * Rationing beds for AIDS patients: It was alleged that Parkland had set aside a limited number of beds for AIDS patients, and would not admit any more than this number of AIDS patients to the hospital. The hospital was not totally unresponsive: It denied there was any formal bed rationing and said consistently that the medical staff would like to meet the other demands. The problems were manpower (sufficient physicians to staff the AIDS clinic) and money (particularly reimbursement for pentamidine, as AZT was fully paid for by the Texas Medicaid program). In a press release dated April 7, 1988, the hospital administrator promised to try to eliminate the AZT waiting list, then composed of some sixty patients, within thirty days; to increase the number of physicians serving the AIDS clinic; and to develop a clinical trial of pentamidine to begin July 1. The waiting list was almost immediately reduced to twenty patients (seven had died, and eleven no longer wanted the treatment or no longer met the medical criterial for it). Physician staffing was seen as a more intractable problem; the AIDS clinic allegedly remained the only one of more than 100 clinics at the hospital that medical students and residents did not routinely rotate through. Nonetheless, on May 19, 1988, the DGA filed suit against Parkland Hospital asking for an immediate temporary restraining order to compel the hospital to: (1) dispense AZT to all patients who qualified for and needed it; (2) deliver aerosolized pentamidine inhalation treatment to all patients who qualified for and needed it; and (3) abolish all bed controls for HIV-positive patients, and allocate hospital beds to AIDS and ARC patients on the basis of need. Judge John M. Marshall, of the Dallas County District Court, ruled on the request for a temporary restraining order after a brief hearing on the day it was filed. He essentially gave the DGA all they requested, ordering the immediate elimination of the AZT waiting list; the immediate dispensing of AZT "to qualified patients upon each patient's proper proof of indigence" and a physician's prescription; the immediate delivery of "aerosolized pentamidine inhalation treatment" to all qualified patients upon prescription; and the immediate abolition of all bed controls for HIV-positive patients. The judge read a brief statement explaining his decision: This case presents the paradigm of AIDS cases that we will undoubtedly see in the future if a cure should not be found, that is, an AIDS victim, as the disease progresses, will descend the economic ladder into indigency so that, at the moment of greatest need, the victim has the fewest resources to meet it. …