The hospital-based attorney as patient advocate

HIV/AIDS, with all the overwhelming and vexing issues surrounding the disease, may, as a positive outcome, have the potential of developing valuable models in the management of illness. Not unlike the space program, which did not seem to promise any relevant outcome to daily life but gave us, at the most basic level, velcro and teflon, the AIDS epidemic forces us to rethink the definition of a medical "standard of care." In the broader context of urban health, this is an era where disease has not only medical implications but social and legal ones as well. These sociolegal issues do not wait outside the doctor's office or the hospital's entrance. Rather, these issues permeate the atmosphere surrounding the patient and frequently frustrate efforts of medical providers to treat the illness. This paper describes one nonmedical intervention--provision of legal services to HIV-infected patients--that demonstrates that medical treatment may need to include consideration of the nonmedical concerns of patients. A hospital-based legal services program for HIV-infected parents may be a radical departure from accepted notions of medical treatment, but as the experience of developing such a model has demonstrated, an attorney can be a useful and welcome member of a comprehensive medical care team. Providing legal services within an institutional framework does, however, raise some perplexing legal and ethical issues. What is the significance of providing legal services within the clinical context? Should an attorney be included in confidential case conferences; Who is the client? Does bringing an attorney to the bedside or the clinic "medicalize" law or "legalize" medicine? What role does the attorney play if the patient dies or severs all connection with the medical providers? Is it fair to limit such free legal services to one type of patient, such as an HIV-infected parent? In a larger sense, these questions raise important issues concerning legal and medical professional obligations in the delivery of health care, and perhaps are cause to reconsider the definition of professional responsibilities in the purview of AIDS treatment delivery. The history of one particular legal services program provides some of the context in which these questions arose. The project, which began at the Division of Bioethics at Montefiore Medical Center, initially had a modest goal. As attorneys and ethicists, we sought to make advance medical directives available to persons hospitalized with AIDS and to train the medical practitioners in how to introduce these documents. To implement the project, we joined the hospital AIDS team and instituted weekly bed rounds. As we became known to patients and staff, requests for legal assistance with housing, insurance claims, discrimination allegations, and credit problems surfaced. However, the issue raised most frequently by female patients, overriding all other concerns, was the future custody and guardianship of their children. We quickly realized that issues of custody and guardianship required immediate attention, particularly since women constituted more than 25 percent of the patient population and their life expectancy after diagnosis tended to be tragically brief. The project goals thus evolved to include legal representation to secure future child guardianship, to offer assistance with advance directives and other urgent legal matters such as housing, insurance, and credit claims for all HIV-infected Montefiore patients, and to develop a model program to be replicated in other hospitals. We became aware through contacts with community-based legal service providers that HIV-infected women usually were too sick to seek out whatever services did exist in the community and that often such services simply did not exist. The program, therefore, would have broad applicability, and if properly structured, could be easily adapted for other facilities. Devising the method by which legal assistance would become a regularized part of comprehensive AIDS services at first presented some difficulties. …