Chapter 7
People with HIV/AIDS

Staggeringly large numbers of people are afflicted with HIV/AIDS in the United States. An increasing proportion of the population lives with HIV infection. By the early 2000s more Americans than ever before were likely to know someone affected by HIV or AIDS. Even people who live in remote geographic areas and do not believe they are personally at risk of acquiring HIV are aware of the epidemic from ongoing public health education campaigns, reports in the media, school health programs, and health and social service agencies dedicated to improving community awareness of HIV/AIDS.

PUBLIC FIGURES WITH HIV/AIDS

Perhaps one of the most famous HIV-infected people in the world is Earvin "Magic" Johnson, an internationally known former basketball player for the Los Angeles Lakers. When Johnson announced his HIV infection in September 1991, the world was shocked. He had no idea he was infected until he received the results of a routine physical examination for life insurance. Johnson freely admitted that prior to his marriage he had unprotected, and, in retrospect, unsafe, sexual contact with numerous women. He has no idea who transmitted the virus to him. The possibility exists that, however unknowingly, he passed the virus on to a subsequent sexual partner, who passed it on to someone else, and so on.

To many, Johnson became a hero for his courage and his immediate public acknowledgment of his HIV status. He became an HIV/AIDS spokesperson and began working in prevention programs. In 1991 Johnson started the Magic Johnson Foundation, which seeks to find funding and establish community-based education and social and health programs (including HIV/AIDS awareness) in inner-city communities and has given millions of dollars in grants to these causes. He was even named to the President's Commission on AIDS, from which he eventually resigned, frustrated with the lack of progress in HIV/AIDS efforts by the administration of then-President George H. W. Bush.

Despite his active, well-publicized efforts to increase awareness and prevention of HIV/AIDS, some people considered him anything but a hero because his highly visible, promiscuous lifestyle sent the wrong message to the millions of young people who admired him.

In September 1992, one year after Johnson announced his retirement from professional basketball, he indicated that he was returning to basketball on a limited basis. He played on the U.S. "Dream Team" in the 1992 Olympics, assisting the team in its successful bid for the Gold Medal. Johnson benched himself at the start of the 1993–1994 season when he cut himself in a preseason game, terrifying some of his fellow players. While some players feared infection, others worried that they should not play against Johnson with full force; after all, he was a man with a fatal disease. Johnson came back again for the 1995–1996 season, helping his team reach the play-offs, and continues to play basketball with the Magic Johnson All-Stars Team. He shows others, as one observer notes, that HIV infection is not something you die of; it is something you live with.

In 1992 former tennis star Arthur Ashe announced that he had become infected with HIV from a blood transfusion in the mid-1980s during a heart bypass operation. His was not a voluntary announcement, but one made necessary when the news media discovered his HIV infection and threatened to announce it before he did. Ashe was reluctant to make his condition public, fearing the effect on his five-year-old daughter. He maintained that because he did not have a public responsibility, he should have been allowed to maintain his privacy. He died in 1994.

Greg Louganis, another athlete, was diagnosed with HIV infection in 1988. The Olympic gold medalist diver announced his HIV status after the 1992 Olympics, when he hit his head on the diving board during competition. Though his injury was not serious, it did result in an open wound. Today, Louganis is a television and movie actor, the published author of two books, and an advocate of safe sexual practices, since he attributes his HIV infection to unsafe sexual behavior.

Mary Fisher, a heterosexual and nondrug user who contracted HIV from her husband, stood before her peers at the 1992 Republican Convention and announced that she was infected with HIV. A former television producer and assistant to President Gerald R. Ford, she said she considered her announcement part of her contribution to the fight against HIV/AIDS. The wealthy, attractive, and well-educated Fisher was among the first women to publicly dispel the image that, unfortunately, still comes to mind when many people think of HIV/AIDS: homosexual, poor, drug-addicted, and lacking access to support systems or adequate medical care and housing.

Puerto Rican-born Esteban De Jesus became the world lightweight boxing champion in 1976 by beating Itshimatsu Suzuki of Japan. Five years prior to this fight, De Jesus had gained world attention by beating the legendary Roberto Duran, the then newly crowned lightweight champion, in a non-title bout. He retired from boxing with a stellar record of fifty-seven wins (thirty-two by knockout) and five losses. Following his retirement, De Jesus was convicted of murder in the death of a man allegedly in a drug-related dispute. While in prison, he was diagnosed with AIDS. In a humanitarian gesture, Puerto Rican governor Rafael Hernández Colón pardoned De Jesus in 1990. He died one month later.

Another sports celebrity who succumbed to AIDS was NASCAR race car driver Tim Richmond. Born on July 7, 1955, Richmond died of AIDS-related complications on August 13, 1989, at age thirty-four. During his heyday on the NASCAR race circuit in the 1980s, Richmond became one of the circuit's premier drivers. Richmond was well known for his expensive tastes in food and drink and for his "playboy" lifestyle. Whether his lifestyle contributed to his illness is conjecture. Nonetheless, by the end of the 1986 racing season, Richmond had become noticeably ill. He was diagnosed with AIDS that same year. He was able to race again in 1987, but soon thereafter his health deteriorated precipitously. During another attempted comeback in 1988, when his illness was still unpublicized, Richmond faced the hostility and innuendo of his fellow drivers, who, guessing the nature of the illness, speculated about his sexual orientation and the possibility of drug abuse. In response, Richmond filed a defamation of character lawsuit against NASCAR. He subsequently withdrew the lawsuit to avoid making his condition public. Richmond ultimately retired from competitive racing and lived in seclusion with his mother until his death. After his death, as news of his affliction and the treatment he received from his fellow drivers and NASCAR became public, many people were outraged at the NASCAR organization, which has yet to apologize.

Actress Amanda Blake, best known for her nineteen-year role as Long Branch Saloon owner/operator Kitty Russell on the popular television series Gunsmoke, died in 1989 from throat cancer complicated by a type of AIDS-related viral hepatitis. Long a passionate supporter of animal rights, she was seminal in the founding of the Performing Animal Welfare Society (PAWS). Indeed, it is thought that she was infected with HIV during a PAWS-related trip to Africa.

Actor Brad Davis was another victim of AIDS. He was best known for his role in the 1978 movie Midnight Express, for which he received a Golden Globe award. He died of AIDS in 1991, after allegedly contracting the infection as a result of his cocaine abuse a decade earlier. His widow, Susan Bluestein, has continued to campaign for AIDS causes.

Actor Anthony Perkins, who is best known for his role as Norman Bates in the classic Alfred Hitchcock film Psycho, also died of AIDS. Forever typecast by that performance, Perkins was in fact an accomplished film and stage actor. He was bisexual and had relationships with a number of men including dancer Rudolf Nureyev (who also died of AIDS). Shortly before his death in 1992, Perkins commented in a press release about a National Enquirer article that revealed his AIDS-positive status by saying, "I have learned more about love, selflessness and human understanding from the people I have met in this great adventure in the world of AIDS than I ever did in the cutthroat, competitive world in which I spent my life." Perkin's widow, Berry Berenson, was one of the passengers on American Airlines Flight 11, which was hijacked and crashed into the World Trade Center North Tower on September 11, 2001.

Another movie star who succumbed to AIDS was Rock Hudson. Indeed, Hudson was the first major U.S. celebrity known to have died from AIDS. His death was especially noteworthy, given his status in the 1950s as the quintessential rugged, all-American male. Despite his many movie roles as a straight man, Hudson was homosexual, a fact that was covered up by movie studios. His 1955 marriage to studio employee Phyllis Gates (which ended in divorce in 1958) is thought to have been a studio-orchestrated attempt to cover up his sexual orientation. Hudson died in 1985 at the age of fifty-nine.

African-American rap star Eric Wright, whose moniker was Eazy-E, rose to fame as one of the members of the Compton, California-based group N.W.A. (Niggaz with Attitude). Using the money from illegal drug sales, Eazy-E had founded Ruthless Records. Soon after, he recruited Ice Cube, Dr. Dre, MC Ren, DJ Yella, and Arabian Prince to form N.W.A. The group's second album, Straight Outta Compton, which was released in 1988, became hugely popular. Following the dissolution of N.W.A., Eazy-E went on to have a successful solo career. In 1995 he entered the hospital for treatment of what he thought was asthma. But he was diagnosed with AIDS, which he did not hesitate in confirming. He died soon after. Eazy-E is now regarded as being one of the influential founders of the style of music known as gangsta rap. Every year, the city of Compton celebrates his life by observing Eazy-E Day.

Another music icon who died of AIDS was Freddie Mercury, the lead vocalist of the British rock band Queen. His more than three-octave vocal range and operatic compositional approach to rock resulted in classic hits such as "Bohemian Rhapsody," "Somebody to Love," and "We Are the Champions." The video that was made for the 1975 release of "Bohemian Rhapsody" is considered by some music insiders to be one of the seminal influences that spurred the popularity of music videos. Mercury was well known for his bisexuality, which for some years was promiscuous, and the extravagance and hedonism of his lifestyle. His diagnosis and deteriorating physical condition were kept private. Indeed, his eventual announcement that he had AIDS was made only one day before his death in 1991.

Elizabeth Glaser, wife of Paul Michael Glaser (one of the stars of the 1970s television series Starsky and Hutch ), was galvanized to cofound the Pediatric AIDS Foundation in 1988 (now called the Elizabeth Glaser Pediatric AIDS Foundation) following the discovery that she and her and Paul Michael's children, Ariel and Jake, were all infected with HIV. She originally contracted the virus from contaminated blood administered during pregnancy, but she was unaware of her illness until much later, already having unwittingly passed it to her children. In the ensuing years she became a vocal AIDS activist. The foundation that is her legacy contributes more than one million dollars annually to pediatric AIDS research. Elizabeth Glaser died in 1994. Her daughter Ariel died before Elizabeth, at age seven; her son Jake still lives with the disease; and her husband continues to raise money and AIDS awareness through her foundation.

Finally, in a list of examples that is by no means complete, prolific and influential science fiction author Isaac Asimov contracted HIV from infected blood given to him in a transfusion during heart bypass surgery in 1983. He died on April 6, 1992, of heart and renal failure that were complications of AIDS.

OLDER PEOPLE WITH HIV/AIDS

In "AIDS among Persons Aged 50 Years and Over—United States, 1991–1996" (Morbidity and Mortality Weekly Report, vol. 47, no. 2, 1998), the Centers for Disease Control and Prevention (CDC) reports that most older people infected with HIV early in the epidemic were typically infected through contaminated blood or blood products. Through 1989 only 1% of HIV/AIDS cases of people ages thirteen to forty-nine was due to contaminated blood. But in that same period 6% of cases of people fifty to fifty-nine, 28% of cases of people sixty to sixty-nine, and 64% of cases of those seventy and older resulted from contaminated blood or blood products.

In 1985 changes introduced to improve the safety of the nation's blood supply, including routine screening of blood donations for HIV, sharply reduced the risk of contracting the virus from contaminated blood or blood products. Subsequently, the proportion of people age fifty and over who acquired HIV from other types of exposure increased. Although male to male sexual contact and intravenous drug use remain the primary means by which HIV is transmitted among all age groups in the United States, heterosexual transmission of HIV is steadily increasing in people more than fifty years old.

HIV/AIDS Cases among People Age Forty-Five and Over

Approximately 11 to 15% of AIDS cases reported in the United States occur in people over age fifty, according to the CDC. This proportion did not vary much between 1991 and 1999. But it is expected to increase as HIV-infected people of all ages live longer as a result of effective drug therapy and other advances in medical treatment.

To December 2003, 150,063 cases of AIDS in people over age forty-five have been reported to the CDC. Among these reported cases, more than 80% were men, approximately 16% were women, almost 40% were African-American men and women, and approximately 17% were Hispanic men and women. More than three-quarters of AIDS cases reported in people over age sixty-five were from large metropolitan areas.

HIV Testing for Those over Age Fifty

Many older adults do not seek routine screening for HIV infection because they do not believe they are at risk of acquiring HIV. Among women older than fifty, the absence of the risk of pregnancy may lead to a false sense of security and the mistaken belief that they are at less risk for sexually transmitted diseases, including HIV. HIV-infected people age fifty and over may not be tested promptly for HIV infection. As a result, opportunities to start these patients on therapies quickly in order to slow the progression of the disease are often lost. The failure to test or the late testing of older patients may be because:

• Physicians are less apt to look for HIV in people of this age group.
• Some opportunistic AIDS illnesses that occur in older people, such as encephalopathy and wasting disease, have similar symptoms to other diseases associated with aging, such as Alzheimer's disease, depression, and malignancies.

It is vitally important to overcome older adults' reluctance to seek testing and other delays to diagnosis because recent research shows that age speeds the progression of HIV to AIDS and blunts CD4 response to highly active antiretroviral therapy. Equally important is continuing research to improve treatment of HIV-infected older adults and development of effective education programs to prevent infection in this population.

LIVING WITH HIV/AIDS

In order to gain a more complete view of the impact of HIV/AIDS, it is important to understand the psychosocial and emotional consequences of diagnosis with a potentially fatal disease.

A Frightening Diagnosis

In his introduction to When Someone Close Has AIDS (Washington, DC: National Institute of Mental Health, 1989), National Institute of Mental Health director Lewis L. Judd writes about the meaning of the diagnosis of AIDS. It means not only a shortened life, but also one that is "marred by chronic fatigue, loss of appetite and weight, frequent hospitalizations, AIDS dementia, and debilitating bouts of illness from unusual infections." The person diagnosed with HIV/AIDS also feels anger, confusion, depression, isolation, and hopelessness, which can also affect those around him or her who are often unprepared for the suffering they witness.

Judd advises that people diagnosed with HIV/AIDS need reassurance from friends and relatives that they will not be abandoned or isolated. He also recommends that those around HIV/AIDS patients encourage them to pursue hobbies, work as long as they can, and engage in social activities. He warns that caring for someone with AIDS is physically and emotionally exhausting and calls for inner strength, as well as the caregivers' coming to terms with their own feelings about the illness.

Coping with Discrimination

Unlike people diagnosed with other terminal or catastrophic illnesses such as cancer or multiple sclerosis, people with HIV/AIDS often confront the social isolation and discrimination that accompany a stigmatized status. Many people think of HIV/AIDS as a disease of homosexual men and drug users and believe that these people brought HIV/AIDS on themselves. Some still believe that AIDS is divine retribution for an "immoral lifestyle." Fear of unfavorable judgment keeps many infected individuals from disclosing their HIV infection to others, even friends and loved ones. Others simply do not want the pity that is often extended to people with fatal conditions. Still others worry that friends and family, fearing infection, will abandon them.

Under the Americans with Disabilities Act (ADA) of 1990, people infected with HIV and those diagnosed with AIDS are considered disabled and as such are subject to the antidiscrimination provisions of this landmark legislation. As a result, employers generally may not ask job applicants if they are HIV infected or have AIDS, nor can they require an HIV test of prospective employees. The only exceptions to this provision are those employers who can demonstrate that such questions or testing are job related and absolutely necessary for the employer to conduct business.

More importantly, the ADA requires employers to make "reasonable accommodations" for disabled employees. Reasonable accommodation is an adjustment to a job or modification of the responsibilities or work environment that will enable the worker with a disability to gain equal employment opportunity. Examples include flexible work schedules to allow for medical appointments, treatments, and counseling and the provision of additional unpaid leave.

THE STIGMA OF AIDS

In 1995 the Department of Sociology and Social Work at Fort Hays State University, Kansas, conducted a survey to find how knowledge and mode of transmission affected opinions of people with AIDS. In "The Stigma of AIDS: Persons with AIDS and Social Distance" (Deviant Behavior, October-December 1995), J. J. Leiker, D. E. Taub, and J. Gast write that as HIV/AIDS knowledge increases, people tend to attach less stigma to the disease.

According to the survey, respondents attached the least stigma to those infected by blood transfusions. The greatest stigma was attached to exposures from male to male sexual behavior and intravenous drug use. Survey participants who considered themselves homophobic (having a fear of or aversion to homosexuality) attached more of a stigma to people with AIDS than those who did not feel they were homophobic. People who labeled themselves "religious" attached less stigma to those infected through blood transfusions.

More than two decades after the first diagnoses of AIDS and widespread public health and community education efforts to inform people about HIV infection and prevent the spread of HIV, ignorance and misunderstanding of HIV/AIDS persist. Health educators and HIV/AIDS activists stress the importance of intensified, ongoing education to destigmatize people affected by HIV/AIDS and prevent discrimination. Reducing the stigma associated with HIV/AIDS may also encourage individuals to get tested and, for those who are infected, begin treatment as soon as possible.

In "Will Focus on Terrorism Overshadow the Fight against AIDS?" (Journal of the American Medical Association, November 7, 2001), Rebecca Voelker observes that after more than two decades the stigma associated with AIDS should have dropped to very low, barely detectable levels. Unfortunately, it has not diminished as expected. Researcher Lisanne Francis Brown of the Tulane University School of Public Health feels it is important to identify strategies to reduce stigma since it "undermines efforts to combat the epidemic at every level."

Dealing with Emotions

Not unexpectedly, anger and depression are natural and common reactions to discovering that one has an HIV infection. While experts stress the importance of recognizing and expressing anger and depression, if these feelings become all-consuming, they can prevent health- and life-improving actions. Many people with HIV/AIDS admit that sharing feelings with friends and family members and participating in support groups ease anguish and help generate more positive attitudes and actions.

Many HIV/AIDS sufferers report that the most difficult thing they had to do after being diagnosed with HIV was to inform people in their present or recent past whom they might have exposed to the virus. If the patient is unable to do this, a physician or public health official can notify present or former sexual partners without revealing the infected person's name.

Early Medication Improves Outlook

The earlier a person learns of his or her infection, the earlier he or she can begin medical treatment to suppress the virus's destructive growth, delay the onset of AIDS symptoms, and extend life. Along with antiretroviral drugs there are medications that fight the life-threatening opportunistic infections that eventually afflict most people who are HIV infected. Although these drugs cannot cure HIV infection, they have been shown to keep HIV/AIDS patients healthy and symptom-free for increasingly longer periods.

Practicing Good Health Habits

Experts advise HIV-infected people to exercise and maintain a balanced diet with sufficient lean protein. Not only does exercise improve overall fitness and generate a sense of well-being, it also releases endorphins, which are natural substances produced by the brain that boost immunity, reduce stress, and elevate mood. People with HIV/AIDS are advised to avoid smoking, excessive alcohol consumption, and using illegal drugs, all of which can act to depress the immune system.

Stress Not a Factor?

In addition to new health concerns, people with HIV/AIDS must confront an altered identity. Those diagnosed with HIV infection must immediately reevaluate their life goals. For example, saving money for retirement or a new car may no longer seem important. HIV-infected individuals often lose their health insurance coverage and must consider saving money for future health care needs and/or meeting eligibility requirements for health care coverage from Medicaid, the government entitlement program. They also must confront fears and uncertainty about the future such as how to care and provide for children or other loved ones.

Interestingly, a study conducted by Ronald C. Kessler, a research scientist at the University of Michigan's Institute for Social Research, indicates that stressful life events do not appear to trigger the development of AIDS symptoms in HIV-positive men who are feeling healthy. The findings, released in 1992, still warrant discussion in 2005. The findings are based on a correlation between the health and psychological status of 980 gay men in Chicago who participated in two studies from 1984 to 1987 ("The National Multicenter AIDS Cohort Study" and "The Coping and Change Study," both funded by the National Institute of Mental Health). The results of these landmark studies are considered to refute conclusively the hypothesis that stress plays a pivotal role in triggering the development of AIDS among people with HIV infection.

The data, collected twice each year, included the incidence and nature of stressful life events and the development of three HIV symptoms: fevers lasting longer than two weeks, bacterial infections of the throat and mouth (oral thrush), and declines of 25% or more in the number of T cells. One aim of the study was to investigate the findings of an earlier unpublished study that had found that HIV-positive men who were close to others with AIDS or people dying from AIDS often experienced a sudden onset of symptoms themselves.

The University of Michigan study measured the impact of twenty-four other serious stresses on health, such as job loss, death of a parent, and mortgage foreclosure, and found no consistent relationship between stressful events and the onset of HIV symptoms. Kessler does find that men who were grieving for deceased loved ones were more likely to suffer a decline in T cells and develop other symptoms, but he does not believe that this was an effect of a stressful event. Instead, it is more likely that those who had an onset of symptoms after friends died from AIDS were probably in the same group who were infected early in the epidemic.

HOUSING PROBLEMS

The difficulty in finding affordable and appropriate housing can be an acute crisis for people living with HIV/AIDS. HIV-infected people need more than just a safe shelter that provides protection and comfort; they may also require a base from which to receive services, care, and support. While adherence to complicated medical regimens is challenging for many HIV-infected people, for some homeless people it is nearly impossible.

While some individuals are homeless when they acquire HIV infection, others lose their homes when they are no longer able to hold jobs or cannot afford to pay for health care and housing costs. The National AIDS Housing Coalition reports that, by 2006, 50% of the estimated 886,575 people who will be living with HIV/AIDS will require some form of housing assistance.

The Department of Veterans Affairs reports that as many as one-third to one-half of all people with HIV/AIDS are either homeless or at great risk of becoming homeless due to their illness, a lack of income or other resources, and a weak support network. Several studies indicate that approximately 30% of all people with HIV in acute care hospitals (at a cost of more than $1,000 per day) are hospitalized not because they require the medical services available in the hospital, but simply because no community-based residential program will take them. According to the National Coalition for the Homeless, 1999 data show that more than 30% of HIV-infected people had become homeless since learning they were infected.

In 1990 the Department of Housing and Urban Development established a federal program specifically intended to meet the housing needs of people with HIV/AIDS. Congress established the program because the housing resources available at that time were not meeting the needs of people with AIDS, who, due to discrimination, had difficulties obtaining suitable housing and the supportive services that they required. The program Housing Opportunities for Persons with AIDS (HOPWA) was established under the National Affordable Housing Act of 1990 (PL 101-625). HOPWA began in 1992, and between that fiscal year (FY) and FY 2001, Congress allotted more than $1.5 billion for the program. In FY 2002 an additional $277 million was allocated, an increase of $19 million over the preceding year. FY 2003 funding was $290.1 million, about $13 million more than in 2002.

SUICIDE

Depression is a common psychiatric problem among patients who are seriously ill with HIV/AIDS. While this is a normal grief response, the combination of alienation, hopelessness, guilt, and lack of self-esteem can lead some to contemplate and plan for suicide in search of lost dignity and control. Others counter that the real dignity is in seeing the disease to the end. Those who encourage people with HIV/AIDS to "stick it out" often see the disease as becoming increasingly manageable with drugs and improved treatment techniques.

Several factors make HIV/AIDS patients more likely to commit suicide: they know they are certain to die sooner than they expected and chances are it will be emotionally and physically painful; they may lose their jobs, their insurance, or their homes; and they may be ostracized from society. Researchers find that factors that have a considerable impact on the quality of life include security, family, love, pleasurable activity, and freedom from pain and suffering and from debilitating disease. AIDS patients may lose all of these. For some, suicide seems like a reasonable alternative; it offers an end to pain and suffering, insecurity, self-pity, dependency, and hopelessness.

Euthanasia in the Netherlands

Euthanasia (ending the lives—for reasons of mercy—of those who are hopelessly ill or injured) and physician-assisted suicide are other unnatural deaths that are often requested by patients themselves. Euthanasia is illegal in the United States (although Oregon's controversial "Death with Dignity Act" allows physicians to help severely ill patients commit suicide if they meet certain criteria). In the Netherlands, however, euthanasia was officially legalized in 2001. While technically illegal prior to this, euthanasia had in fact been tolerated and studied in that country for many years. A 1995 study sponsored by Amsterdam's Municipal Health Service found that 22% of the 131 men with AIDS studied died from requested euthanasia or physician-assisted suicide. Among the 22%, physicians reported that 72% would have died within one month. The survey also found that the likelihood of euthanasia/physician-assisted suicide increased with the duration of survival after AIDS diagnosis and among those over the age of forty.

The authors of the Amsterdam study note that because AIDS patients usually know for many years that they are infected with HIV, they have time to discuss their condition and the possibility of euthanasia. Many of these people, explains a counselor of AIDS patients, choose euthanasia because it gives them the opportunity to die on their own terms.

The Physician's Role

In 1994–95 Lee R. Slome et al. ("Physician-Assisted Suicide and Patients with Human Immunodeficiency Virus Disease," New England Journal of Medicine, vol. 336, no. 6, 1997) surveyed all 228 physicians in the Community Consortium in the San Francisco Bay area of California. The researchers wanted to find out whether physicians were participating—or would be willing to participate to
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any extent—in physician-assisted suicide, which was defined as providing a patient with a sufficient dose of narcotics to kill him- or herself.

The physicians who treated HIV patients were told in the anonymous, self-administered survey that the fictitious patient, Tom, was a severely ill, mentally incompetent thirty-year-old man facing imminent death. A similar survey had been conducted in 1990. Compared to the 1990 respondents, the 118 physicians who responded to the 1995 survey were more racially diverse, more likely to be heterosexual, and more apt to have a large number of AIDS patients. (See Table 7.1.)

Of the 1995 respondents, 48% said they would be likely or very likely to grant Tom's initial request for physician-assisted suicide, compared with 28% of the 1990 respondents. When asked what they would do if Tom was insistent about his request, 51% of the 1995 respondents said they would grant it, compared with 35%
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of the 1990 respondents. The 1995 physicians (11%) were also less likely than the 1990 physicians (23%) to try to talk the patient out of his request. (See Table 7.2.)

Slome et al. also asked the physician respondents to estimate the number of times they had helped an AIDS patient commit suicide. Of the 117 who responded, about half (53%) indicated that they had prescribed a fatal dose of medication at least once to an AIDS patient. (Figure 7.1 shows the distribution of the number of patients assisted in suicide.) The researchers note that this number was surprisingly high, given the possible legal and ethical consequences of such an action.

The researchers concluded that:

• The survey suggests an increasing acceptance among physicians of assisted suicide.
• A physician's sexual orientation (homosexual or bisexual) is positively related to his or her willingness to assist in suicide, although sexual orientation is only one of four factors affecting the doctors' decision. (See Table 7.1 for other factors or characteristics of respondents.)
• Some doctors consider their assistance to be psychological intervention rather than a means of facilitating death; that is, the medication allows patients to regain some of the control AIDS has taken away.

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During the 1990s there were heated debates, voter initiatives, and court decisions about the legalization of physician-assisted suicide. Only one U.S. state—Oregon—has legalized physician-assisted suicide; Oregon voters determined that the right to end one's own life is intensely personal and should not be for-bidden by law. (Though attempts and acts of suicide are no longer subject to criminal prosecution in the United States, aiding a suicide is considered a criminal offense.)

Both the public and physicians themselves are divided about the issue of physician-assisted suicide. People who support the practice believe that doctors should make their skills available to patients to end anguish and suffering. Those who oppose physician-assisted suicide argue that better end-of-life care—effective pain management, emotional and spiritual support, and widespread education to reduce anxiety about dying—may reduce the frequency of requests for physician-assisted suicide. Opponents also fear that the legal right to assist suicide has the potential to be misused or abused and that such abuses might victimize already vulnerable populations.