Dr. Thomas has presented an interesting UNAIDS document from 1996 that
presents ethical principles surrounding HIV/AIDS. In re-visiting
the UNAIDS document, I was again struck with the strong political and social
slant that some follow, and the near absence of a biological reality that
by necessity must guide our thinking in public health.
the most important concept to keep in mind is that every AIDS patient or
HIV-positive person was infected by another individual, often during intimate
moments or private activities that are not easily discussed at the personal
level, or openly addressed at the community level. Thus to control
the epidemic, societies must figure out ways to stop HIV-positive persons
from infecting susceptible persons. In this regard, if public health
efforts are successful, the epidemic will decline. If not, the epidemic
will increase, first silently as HIV infections build, and then loudly
with ever increasing AIDS cases and deaths. With that notion
in mind, let's revisit the UNAIDS points, as presented by the ever-thoughtful
"Compassion: Compassion requires that people respond to the suffering
of others, including those with HIV/AIDS, with sympathy, mercy and a willingness
I fully agree with this.
"Solidarity: Solidarity requires that people come together to respond
to the suffering, as well as the injustice, caused by HIV/AIDS,"
I agree that we should respond to suffering, but am not sure about the
injustice component. Perhaps it could be modified to read, "...as
well as the injustice caused by someone infecting another with HIV."
“Responsibility: Responsibility means that every individual, community,
institution and nation must act responsibly towards HIV/AIDS to prevent
its spread and to care for those infected and otherwise affected."
As a broad statement of principle, this is certainly worth supporting.
"Tolerance: Tolerance requires respect for the equal worth, dignity
and autonomy of people affected by HIV/AIDS, including those with different
beliefs, opinions, and life styles."
I agree with this, but not to the degree that I support keeping HIV
hidden from loved ones who otherwise would likely become infected.
"Information: All individuals and communities should have available
to them the information necessary to make good and necessary decisions
about their health, including how to avoid HIV infection with HIV/AIDS
and how to cope with its consequences."
I agree with this. By "information necessary to make good and
necessary decisions about their health," I gather that testing and informing
both the tested person and the spouse is covered by this statement.
"Empowerment: All people should have the ability to protect themselves
from infection by being able to refuse unsafe sex and to cope with HIV/AIDS
if they or someone in their family is infected."
This statement should be modified to include, ..."to refuse unsafe sex,
be told of their sexual partner's infection, and to cope with HIV/AIDS..."
Otherwise, it seems fine.
"Well-being/Beneficence: HIV/AIDS policies should be designed for the
general good, and the benefits of the proposed policy should be weighed
against the harms. There should be no infliction of harm on people, including
those living with HIV/AIDS or suspected of it."
This statement should be modified to reflect public health concerns.
I would change the second sentence to include "There should be no intentional
infection of susceptible people and no infliction of harm on those living
with HIV/AIDS or suspected of it, other than what is necessary to prevent
further transmission." We have many documented cases in the
United States and elsewhere of persons who knowingly and willfully infected
others. Typically in economically developed nations, this small group
is dealt with by the criminal justice system. Less clear is
the man who becomes infected, is told of his infection and learns
all about the virus in a counseling session, and then knowingly goes home
and continues to have unprotected sexual intercourse with his unsuspecting
wife. While such people are generally not considered criminals, their
existence certainly cannot be ignored by officials entrusted to protect
the public's health.
Justice: The burdens and benefits of HIV/AIDS
policy should be distributed equitably among the population. No groups
or individuals should be discriminated against in the context of HIV/AIDS.
All people and groups should be treated fairly and equally and have equal
access to available information, prevention methods, treatment and research
In general I agree with the spirit of this statement. Yet with
continued public education on transmission modes, it becomes clear to most
people that some willingly continue to place themselves and others at high
risk. When this occurs, the "burdens and benefits of HIV/AIDS policy"
are not distributed equitably. Similar issues occur in public health
when people who should know better continue to smoke until they develop
lung problems, or refuse to wear motorcycle helmets until head injuries
have left them incapacitated, or refuse to have their children vaccinated
until a harmful communicable disease takes its toll. In each instance,
the actions of the few who ignore public health knowledge become a burden
to the many, who must pay for the consequences of such actions.
Persons: Individuals have the capacity and right to make
choices and decisions about their bodies. personal integrity, and actions
as long as do not diminish rights of others. aid should be free from unjustified
interference by others. including in the context of HIV/AIDS. People of
diminished autonomy who are dependent or vulnerable should be protected
against harm or abuse."
This section is rather difficult to read, but I understand the general
intent. I would add that "respect for persons" means that those who
are infected are expected to inform others before engaging in high-risk
behavior. If the spouse or long-term lover does not understand HIV,
then both persons should discuss the matter with a physician or HIV counselor
to fully appreciate and understand the danger that comes with certain
"Confidentiality: People have a right to keep confidential any information
which is highly personal and the divulgence of which could be detrimental
for them, including information about their HIV/AIDS status. Professional
ethics requires that professionals (lawyers, health care workers, insurance,
social workers) maintain strict confidentiality concerning all personal
information obtained from clients in the context of their professional
The concept of confidentiality is often viewed differently by medical
and public health people. A physician who serves patients would be
expected to maintain the confidentiality of an HIV infected person.
Conversely, a public health professional who serves the larger community,
might find that such confidentiality places others at risk. By not informing susceptible persons who are in harms way, public health
officials serve poorly the very people they are expected to protect.
"Obligation to treat (or offer services
?): Medical ethics requires
that health professionals must treat, to the best of their ability, all
persons seeking their medical attention without discrimination and without
prejudice based on the origin or nature of the patient's illness, including
I strongly support this.
Consent: Respect for the integrity and autonomy of the individual
means that informed consent should be obtained before the administration
of medical tests, drugs, treatment or participation in research, including
those that are related to HIV/AIDS."
I certainly agree with informed consent for participation in research,
the role of consent in "administration of medical tests, drugs, treatment"
is less clear. There has been much written about consent (or lack
thereof) for groups such as children, prisoners, and the mentally
incapacitated. In general the notion of informed consent is
challenged when the persons in question are wards in one way or another
of family or government. I do agree, however, that in a society
the principles of informed consent which apply to other diseases or health
conditions should apply equally to HIV/AIDS.
HIV/AIDS has become much more than an infectious disease, due to a large
extent to the fear and loathing associated with the condition. Nevertheless
those with a public health orientation must keep in mind that the disease
is caused by a deadly microbe, and such microbes have little regard for
ethical or moral concepts or principles.
Documents from international
organizations such as UNAIDS can be used to guide social and political
thinking. Public health officials in high-prevalence HIV nations,
however, must be careful to not follow social principles at the expense
of biological reasoning. Otherwise their society will pay a very