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If only AIDS were different!

In most Western European countries and North America, strategiees to contain the spread of AIDS have emphasized civil liberties. This may be due more to the epidemiology of the disease than to moral progress.

When the plague claimed its first victim in the Derby, shire village of Eyam on 7 September 1665 the villagers were faced with a terrible dilemma, one that presents itself to all those with a communicable disease. The dilemma, simply stated but often agonizingly difficult to resolve, is how those who have the disease or are at acute risk are to understand and discharge their responsibility to limit its spread.

Eyam presents one celebrated and terrible solution. As the infection spread, the rector, William Mompesson, and his nonconformist colleague, Thomas Stanley, persuaded the villagers to impose on themselves a voluntary quarantine. remaining in the village and so reducing the chances of the plague's spreading throughout Derbyshire. In accepting this responsibility the villagers must have known that they would probably contract the plague and so die. As the plague took hold, Mompesson arranged for supplies of food and other necessaries to be left at the boundary stone of the village; the payment was disinfected by placing the coins in running water or vinegar. All in all about 260 villagers were claimed by the plague, a heroic shouldering of civic and moral responsibility felt and acted upon in the absence of any social welfare provision or reciprocal care for the diseased. Nor was there compensation for those who took on the burdens and dangers of voluntary quarantine.

AIDS has not so far required (or even raised questions about) a comparably dramatic response. In most Western European countries and in North America the response to the AIDS epidemic has been characterized by a relatively liberal approach, thereby distinguishing it from the draconian measures often instituted in the past when an epidemic arose. We do not expel those infected with HIV from society, require them to wear special clothes, or demand that they ring a bell and shout "unclean" when they enter human habitations.[1] Nor for that matter have those infected with HIV imposed such restrictions on themselves. There have of course been departures from the liberal approach, but all in all, the Western European and North American countries have put a value on the individual liberty of citizens higher than that put on the interests of society in controlling the spread of the disease.

The liberal nature of the present response could be taken to indicate that our societies have progressed morally, leaving an old ethics of control, punishment, or self-denial behind and embracing a new morality of individual autonomy and freedom. There is undoubtedly some truth in this interpretation. We would, however, like to suggest that the difference in the response to the AIDS epidemic compared to previous epidemics is not only the result of a change in society's ethics.

Specifically we want to suggest that two crucial features in the natural history of HIV infection have allowed a more liberal response toward this epidemic than would be possible or even desirable toward other actual and possible epidemics with a deadly disease. These features are:

1. the low infection rate of the

human immunodeficiency virus,

which is a result of

2. the inability of the virus to be

transmitted by normal social contact

or even through ordinary

contact with, for example, excreta

from infected persons (see


If it is true that the liberal response to the AIDS epidemic is not primarily caused by a change in social ethics, but is predicated on features specific to the natural history of HIV infection, then this fact has major implications, not only for our understanding of how social ethics have evolved but perhaps more crucially for our use of the AIDS epidemic as a model for future policy.

If we consider possible alternative scenarios for the mode of transmission of lethal diseases we will be in a position to see a number of things more clearly. The first of these is what our response to future lethal epidemics of a different character might have to be. Equally important is how our response to AIDS will have to change if the virus mutates so that transmission of the disease takes a different form.

We would therefore like to consider the implications of three different scenarios in which the course of the HIV infection is held constant but the mode of infection is modeled after other existing infectious diseases. We have chosen to use existing infectious diseases as models because these existing diseases exemplify modes of transmission that are not only theoretically possible but actually occur in nature. Many strange modes of transmission are logically and probably physically possible, but by looking at models of real diseases we avoid basing our arguments on pure science fiction.

We know it is very likely that humans will encounter other "new" infectious diseases in the future, either because truly new diseases appear through genetic change in the causative organisms, or because changing modes of agriculture bring human populations into contact with animal populations in which pathogens that have never before been encountered by humans are endemic.[2] It is therefore of considerable practical interest to consider what policies should be chosen if a new epidemic is capable of spreading more quickly than the AIDS epidemic.

The Epidemiology of HIV

AIDS has an interesting epidemiology.[3] The human immunodeficiency virus, of which there are two distinct types (HIV and HIV II), has a very low infection rate, and transmission normally requires contact between excreta or blood from an HIV-infected person and the bloodstream of an uninfected person. There are no insect or other animal vectors carrying this virus. This means that HIV transmission between persons only occurs through certain sexual practices, through direct blood-to-blood contact (transfusions, needle-stick injuries, or needle sharing), and through vertical transmission between mother and fetus. It is known that certain sexual practices such as receptive anal intercourse carry a higher risk of transmission than others, presumably because the lining of the lower intestinal tract is more easily injured during intercourse than the vaginal lining.

The course of HIV infection is considerably protracted. Apart from a transient acute illness with skin rashes and enlarged lymph nodes that occurs in 40 to 60 percent of infected persons, the infection is characterized by a period often lasting several years in which few symptoms appear (the asymptomatic carrier state), followed by the actual symptomatic autoimmune deficiency syndrome, whose duration is also measured in years. It is still believed that all HIV-infected persons will eventually develop AIDS and die, although recent reports of people who have remained in an asymptomatic carrier state for more than ten years cast some doubts on this. There is no cure, and the HIV-infected person is infectious throughout all phases of the infection.

The Plague Model

Plague is a disease that has followed human beings since ancient times. It is mentioned in the Bible and by the early Greek writers. Plague was the cause of the Black Death that exterminated many communities in Europe in the 1300s, and even today plague epidemics occur regularly in developing countries. It is caused by the bacterium Yersinia pestis, which affects a range of rodents, including the common brown and black rats. Normally it occurs as an epizootic disease in the rats and is transmitted from the rat population to the human population by fleas that leave their dead hosts and attack humans. In humans the disease can take two forms. Bubonic plague, which is the most common form, is mainly a disease of the lymphatic system and gives rise to high fever and grossly swollen and painful lymph nodes. The other form, pulmonary plague, is our main interest here.

Pulmonary plague occurs when the plague bacterium affects the lymphatic system and the blood vessels in the lungs of the infected person. Here the bacterium gains access to the airways and becomes airborne, with an extremely high transmission rate. Although pulmonary plague is bacterial, its mode of infection is paralleled by several viral infections, including such common ones as measles and flu. Anybody present in the same house or apartment as a victim of one of these diseases will, at least in principle, be infected. Experimental work shows that the inhalation of one single plague bacterium belonging to one of the virulent strains is sufficient to cause a potentially lethal infection. Today, thanks to antibiotics, the mortality rate for pulmonary plague has dropped from virtually 100 percent to approximately 10 percent.

Plague is a relatively short-lasting disease in both its pulmonary and its bubonic form. Within a two-week period the patient will either have recovered or be dead, thus in either case becoming noninfectious. An isolation and quarantine regime is therefore possible, and has been a main feature of the control of plague epidemics since ancient times.

The Hemorrhagic Fever Model

Lassa, Ebola, Junin, Machupo, and Marburg fevers are caused by different vira belonging to the family-filoviridae. These diseases occur in Africa and South America. They all seem to be enzootic in indigenous rodent populations and are acquired when humans come into contact with these populations, but once the disease has crossed the species boundary, human-to-human transmission does occur, with a high transmission rate through contact with excreta or blood from infected patients. The vira can cross intact mucous membranes, and direct blood-to-blood contact is not necessary. The infection rate of the African hemorrhagic fevers is therefore much higher than for HIV infection.

These diseases have all caused deaths among personnel caring for infected persons, and transmission in the hospital environment can only be prevented through strict barrier procedures. The diseases have a mortality rate of 20 to 50 percent if untreated, but supportive treatment (and antiviral treatment in the case of Lassa fever) brings the mortality rate down to almost zero. In Marburg fever, clinical disease can be followed by a short asymptomatic carrier state.

The Lepra Model

Lepra has, like plague, been with us for many years and has traditionally been fought by expelling its victims from society. The disease is caused by a mycobacterium distantly related to the bacterium causing tuberculosis and has a very low transmission rate. The bacterium, which cannot be grown in culture, can only infect humans (and, under experimental conditions, nine-banded armadillos). Until the end of the nineteenth century, lepra was still common in Europe; indeed, the lepra bacterium was initially isolated from patients in Bergen, Norway.

Lepra has a wide range of clinical manifestations depending on the cellular immune response of the infected person. Some such persons are virtually noninfectious. Transmission occurs primarily through prolonged exposure to the bacteria, which are shed in large quantities from the nasal lining of victims with the lepromatous form of the disease. The disease is also transmitted through direct inoculation from lepromatous skin lesions. Children are much more susceptible than adults, and the main mode of transmission in populations where lepra is endemic seems to be vertical transmission from infected adults to children living in the same household. Not all persons exposed to the bacterium will become infected. The treatment for the disease, though effective, may last more than ten years. It is impossible to find an exact viral analogue to lepra, but children infected with cytomegalovirus (CMV) or measles in the womb often acquire a permanent infection and continue to shed large quantities of vira for many years.

Liberty, Safety, and Reciprocity

What would have happened if the mode of transmission for AIDS had conformed to one of the three models mentioned above? It seems safe to assume that both the public policy adopted to cope with the disease and the conception of the individual diseased person's responsibility would have been radically different.

In the debate about AIDS, attention has been focused on questions about testing--including the issue of mandatory testing--on whether there are obligations to inform others about one's HIV status or obligations not knowingly or recklessly to infect others, and on whether enforced quarantine is an appropriate response toward infected persons who persistently engage in behavior that carries risk for others.

Further analysis of the three models of transmission presented above will show that the answers given to these questions in public debate are mainly based on the peculiar mode of transmission of the human immunodeficiency virus, and only to a very limited extent take account of the lethal nature of the disease. Because the risk of transmission, even during anal intercourse, can be minimized (but not abolished) through the use of a condom, it has been possible to choose or permit to develop a public policy where the full autonomy of the individual carrier is at least in principle protected and the protection of others is left, by and large, to their personal sense of responsibility and indeed to their self-regarding prudence.

A liberal public policy of this sort is of course constantly under strain. On the one hand there is pressure, sometimes immense, to encroach on the autonomy, rights, and civil liberties of the individual carrier for the real or imagined protection of society, or indeed of other, less grandiose interests. These will include the real or imagined interests of employers and fellow workers, insurance corporations, and others. On the other hand, the civil rights of the individual carrier are vigilantly protected.

One way of understanding and of trying to reconcile these conflicting pressures within a generally liberal framework has recently been suggested and forms the background to a European initiative in understanding the ethics of AIDS.[5] This approach is basically contractarian in character, but it may also be characterized more beneficently in terms of the recognition of a reciprocity of obligations.

The approach involves the idea that the mutual obligations holding between the person infected by HIV and society should be understood within a framework of reciprocity, and it is argued that:

Those citizens for whom protection

against infection with HIV

has failed should be shown the

same concern and respect as

other citizens; they are entitled to

the same consideration in access

to employment, health care, and

other areas of social provision, as

any other citizen.[6] The quid pro quo (in contractarian terms) or the reciprocal obligation on the part of those infected by HIV would involve the obligation to disclose their status to sexual partners and health care professionals where nondisclosure poses any risk to the life or health of these others.

If this were to become the generally accepted basis of relations between those with deadly communicable diseases and others within society, then, in the case of AIDS at least, it might reasonably be expected that the general acceptance of reciprocal obligations would lead to a diffusion of the tension between those who are infected and those who believe they are not. This latter group would be assured that any risks of infection to which they might become exposed would be fully voluntary, and those capable of infecting them would know that responsible disclosure would not result in stigma or discrimination or in the compromise of their civil rights. Of course, the process of achieving such a state of affairs would almost certainly be slow and painful, but as mutual confidence and respect grew and fear receded, one could reasonably expect to arrive at a humane and responsible solution to the problem of containing a deadly disease like AIDS.

But if it seems fruitful to explore this as a model for approaching the ethics of AIDS, to what extent does this intuition depend not on the state of our moral and political theory, or indeed on the moral sensibility of individuals and society, but on the rather more contingent or "brute" facts of the epidemiology of AIDS? One way to answer this question is to see what the implications of the reciprocity thesis would be if it were applied to our three present scenarios.

First, however, we should consider one alternative model for assessing our obligations to people who are infectious in the ways we have been considering. As we have indicated, the response to AIDS, whether by accident or design, has been suprisingly liberal, although this, as we have suggested, may be more a function of the mode of transmission of HIV than of any other single factor. However, the assessment of liberal responses to more contagious diseases must be made in the light of other possible alternatives. While there are many such, the most obvious counterpoise to choose is one that is essentially conservative--a model most likely to appeal in the panic that inevitably follows the identification of a lethal disease with a more threatening mode of transmission.

The conservative model we want to offer for consideration has attracted much philosophical attention, although little in the context of infectious or contagious diseases, or indeed of health care more generally. It is neither contractarian nor beneficent but sees the problem of coping with deadly communicable disease in terms of threat and self-defense. In addition to the considerations we have just rehearsed, there may be merit in considering such a stark model of social relations against the background of a threatening epidemic because of the many salutary and instructive reminders it offers. Some of these concern the fragility of the cooperative presuppositions of society when faced with a deadly threat; others raise questions about the scope and range of the right to self-defense against the threat of disease or disability both for ourselves and for others.[7] Equally important perhaps are questions about the extent to which the proximity of the threat statistically, psychologically, physically, and geographically engages the right to personal initiatives in self-defense.

Anarchy, State, and Utopia

The title of this section is of course also the tide of an influential book by Robert Nozick, in which the model we are about to consider appears. Nozick's book is notorious for containing large measures of anarchy, virtually no state, and a vision of society that few would call utopian. In an early part of the book he considers our obligations to people he characterizes as "innocent threats."

I shall not pursue here the details

of a principle that prohibits physical

aggression, except to note that

it does not prohibit the use of

force in defense against another

party who is a threat, even though

he is innocent and deserves no

retribution. An innocent threat is

someone who innocently is a

causal agent in a process such that

he would be an aggressor had he

chosen to become such an agent.[8] It is clear from the gloss Nozick offers on this passage that he means we are entitled to kill innocent threats where there is no other way of protecting ourselves from the danger they pose. Of course it is crucial in the case of AIDS to understand the scope of the proviso, implicit rather than explicit in Nozick, that there is no other way of protecting ourselves. A crucial moral issue will be the extent of the costs we should be prepared to pay before concluding that they are so high that we cannot afford them. For to conclude that we cannot or need not afford them is to conclude that we are entitled not only to protect ourselves against such costs but also against those who would (albeit innocently and perhaps unwillingly) impose them on us. Thus the idea that force is presumptively a legitimate response to innocent threats is an important background assumption in thinking about the threats posed by communicable disease.

It is also important to understand that the Nozickian model implies the potential for a Hobbesian war of everyman against everyman, because those who would defend themselves against innocent lethal threats also constitute innocent lethal threats to those they see as aggressors. That is, if one may defend oneself against innocent lethal threats by killing, if necessary, those who pose such threats, then both sides to this "defensive war" are aggressors, albeit innocent ones. We use the term 'aggressors' because each person in this scenario is a threat to the other, and the threat that each poses is the others' only reason for retaliation and hence for posing a threat in turn. The person with a highly infectious disease poses a threat to others just by walking into transmission distance. The noninfected individual, seeing an infected person approaching and finding no other obvious method of defense, may, to borrow the outmoded language of nuclear deterrence, consider a preemptive strike.

The difference between the Nozickian position and that encapsulated in the reciprocal obligations thesis is perhaps one of emphasis or outlook. Nozick expresses the problem in terms of threats and aggression. The reciprocal obligations approach sees the resolution of the problem of conflicting interests in the recognition of mutual obligations within a shared and consensual morality. But when, if ever, is it appropriate to shift the emphasis; How great must the costs of these other ways of defending ourselves be before they become so unrealistic as to warrant the drastic measures of self-protection defended by Nozick? This is a question to which we must return in the context of the three models of transmission we have outlined.

The Plague Model

If HIV infection followed the plague model of infection we would have large numbers of infected persons walking around for years spreading the infection to everybody in their vicinity. Each infected person could infect thousands before he or she eventually developed symptoms and died, and all those infected would themselves be doomed. Such a state would therefore not only endanger individual persons, but would endanger the entire fabric of society. History tells us about the immense impact of the Black Death on European societies in the 1300s, but the impact of plague-model HIV disease would be much larger. Stephen King, the well-known writer of horror stories, has captured some of this in his book The Stand, describing the aftermath of an epidemic of genetically engineered lethal flu, but even he has probably not been able to capture the full extent of the effects of such an epidemic.

Given the extremely high transmission rate of a plague-model epidemic there is no way infectious persons could participate in social life (unless they were equipped with self-contained space-suits). They would have to be quarantined, but in contrast to real plague, where the necessary duration of isolation is measured in days or weeks, the carriers of this new disease would have to be isolated for years, for the rest of their natural lives.

The only way persons infected with plague-type HIV could discharge their side of the obligations that flow from the reciprocity thesis would be to accept quarantine. It follows from the reciprocity thesis that such a large sacrifice of liberty on the part of the individual must lead to a wide-ranging obligation on society to reciprocate. How could such an obligation be discharged by society? The short answer is, of course, Only with great difficulty. A society, an isolation colony if you like, would have to be set up with all the amenities of a small modern state. If infected persons could not sustain all the main services and necessities of such a society from within, then these would have to be provided from without. Medical assistance could of course also be provided from without by suitably space-suited personnel. To say that all this would be less than ideal and more than expensive is an understatement.

One solution on a global scale might be to establish a number of international isolation colonies. If this were to happen, some nation-state or indeed a number of nationstates would have to set aside the space, while the resources would have to be found by the international community. Alternatively, and perhaps more likely in the short term, each individual state would have to find a site, either by evacuating an existing city and its environs or by building a microsociety on a "greenfield" site. This sounds fanciful perhaps, but if the alternative is the Nozickian "war of defense" it may be a cost that every society ought, or ought to try, to pay.

The Hemorrhagic Fever Model

If the hemorrhagic fever model came into reality, the carrier of the disease would not pose any threat in normal social contact, but his or her excreta would be highly infectious. Infectious persons could therefore in principle live a normal life among other people in society, if it could be ensured that nobody came into contact with their excreta. It follows from the reciprocity thesis that these persons would have an obligation to protect other people from infection, and that society would have an obligation to make it possible for the carrier to participate in normal social life. The discharge of- these reciprocal obligations would not be as hard as it would be in the plague model, but it would be very difficult because it would put stringent limits on the behavior of the person with the disease. Not only would the person have to practice safe sex, he or she would have to have a private bathroom that was disinfected regularly. The person could never use a public toilet, could never spit on the street, could never kiss any noninfected person, and could never participate in any activity where he or she could be injured and acquire a bleeding wound.

If carriers of the disease agreed to restrict their social activities in this way, society would have an obligation to provide the necessary facilities--private lavatories in the workplace, and so on--and would also have an obligation to compensate carriers for the restrictions imposed on their lives. Such compensation could take many forms, but it would have to include protection against unfair hiring, insurance, and housing policies.

Given the relatively high infectiousness of the hemorrhagic fevers, it is predictable that the fears of the non-infected part of the population would be even greater than has been the case in the present AIDS epidemic. Those with the disease could therefore only be expected to fullfil their side of the bargain if they were to be protected against the manifestations of this fear.

The Lepra Model

Finally, the lepra model raises unique problems of its own. It is natural to assume that we ourselves have special obligations toward our own children, obligations that go beyond reciprocity. In the same way, a society's obligation to protect the safety of its citizens must be interpreted to be more significant in those cases where the citizens are not able to protect themselves, and this is notably the case when we think of the problems posed by children and families. This means that both society and the individual parent would have a special obligation to ensure that children were not exposed to risk of infection. In the case of real lepra this is a minor problem because sufferers under treatment are not highly infectious, but in the case of an untreatable lethal viral disease with the same mode of transmission the problem assumes a different magnitude. Not only would any children living in the same household as a carrier be at high risk, the risk would also be present for a long time (several years), and one can foresee very difficult psychological problems among older children who would be aware of the risk posed for their health by the parent they depended on and loved. On the other hand, a policy whereby children were removed from carrier parents also causes great psychological trauma to both parents and children.

Lesson for the Future

It should be clear by now that the epidemiology and mode of infection of a given epidemic disease will be crucial in determining the ways in which societies attempt to cope with it. A society may be liberal or conservative, but the response to a plague-model epidemic with a lethal and untreatable disease will necessarily have to be different from the response to an epidemic with an epidemiology like AIDS or like lepra. Although liberal and conservative societies could still differ widely in their coping strategies, it would be within a totally different range of responses.

Further, it is important to realize that the peculiar features of the epidemiology not only determine the range and intensity of the available responses, they also determine part of the specific content of the responses. This is perhaps best illustrated by the lepra model outlined above. The plague and the hemorrhagic fever models differ mainly in the degree of infectiousness of the causal agent, but the lepra model shows some qualitative differences as well. The low rate of infection and the possibility of decreasing this rate even further by simple means (face masks, etc.), on the one hand, and the special sensitivity of children, on the other, mean that sufferers of this kind of disease would probably be able to participate in the daily life of society with very few restrictions, but not within their own homes. Society would have to intervene to protect the interests of the children. Thus, the epidemiology of the disease prompts a very specific social response, neither wholly liberal nor wholly conservative, which threatens the idea that persons have a special fight to be protected from the interference of public officials and regulations in their own homes. In short, this particular epidemiology requires die reverse of normal liberal conventions about the role of state and individual. Society would have to intervene in the privacy of the home, but could leave wider social interaction unregulated.

In a similar way, reflection shows that the present reaction to the AIDS epidemic is strongly influenced by the specific features of AIDS epidemiology. The HIV carrier represents no risk to others in normal social and commercial life. However, within the health care sector, where bodily interventions and the attendant risk of blood-to-blood contact are parts of normal daily activity, things are somewhat different. The only real risk of transmission outside the health care setting occurs during sexual intercourse or among needle-sharing drug users, and even here the risk is very small if safe sex practices are used and needle-exchange programs are implemented. In this context reciprocity would demand disclosure of HIV infection to sexual partners, but it is evident that there is limited scope for regulation in general and no foothold for a policy along Nozickian lines. The HIV carrier poses no general threat, and, with effective public education, individual citizens can be left to protect themselves.

What follows from these examples when we talk about the general ethics of communicable diseases? If we are right in our assumption that it is not so much any sort of moral progress but rather features peculiar to the natural history of HIV infection that have been responsible for the relatively humane social and political response to AIDS, then we need to think now about what our response should be to future and different epidemics. Or what our response to AIDS might have to be if the virus mutated to mirror one of the disease models we have been considering.

Where the communicable disease is lethal, there seem to be two possibilities. We could move immediately to a Nozickian approach and see things in terms of threats and aggressors and draw our battle lines accordingly. This is perhaps what many people would feel disposed to do. The alternative is of course that we could attempt to discharge our mutual obligations to one another, albeit at some considerable cost.

What we need and so far lack is a conception of the level of cost we ought to be prepared to meet before concluding that we are entitled to see those with communicable diseases as threats against which we must aggressively protect ourselves. This is not only a philosophical question concerning the level of hardship we should be prepared to undergo before resorting to measures that threaten the liberty and the very lives of the innocent, it is also a complex economic question. We will not be able to think adequately and realistically about the level of hardship we should be prepared to bear until we have a sense of the economic costs that will in part create that hardship. There are, however, immense difficulties in the way of our achieving an adequate picture of those costs. Because of the lack of the necessary economic data for the calculation, the analysis would require the incorporation of a great number of ad hoc assumptions and would therefore probably be more misleading than illuminating. And even if valid data could be found, the analysis would have to be specific for one society at one specific point in time.

From our perspective the philosophical problems inherent in the analysis of such a cost threshold are more interesting but just as complex as the economic problems briefly outlined above. What is really at issue here are a number of subproblems, such as, When can a moral society legitimately abandon, imprison, or exterminate innocent citizens? What would the effect be of a public policy of abandonment, confinement, or extermination? Which is the relevant sum to consider--total societal costs for all sufferers or individual lifetime costs for each individual infected person? If the survival of the society as a society were at stake, and if abandonment or extermination were the only possible ways to save it, then the threshold would (probably) have been passed, but even here some would argue that a society that could only survive at such cost would not deserve to survive at all. The question of whether this threshold has been passed at less global levels of hardship is much more complicated.

It is obvious that quite different answers would be given to this question depending on whether, for example, total societal costs or individual lifetime costs were seen as the relevant sum to consider. If total societal costs are what matters, society would be obliged to care for a few people with very expensive needs (a few people with plague-model disease), but not for a lot of people with less expensive needs (many people with hemorrhagic fever-model disease). If individual lifetime costs are what matter, the result would be exactly opposite. Although it is obvious that the two ways of looking at costs give opposite policy solutions, it is unfortunately not equally obvious which of the two points of view is more plausible or even more appealing.

At the lower levels of hardship we will also have to engage with the very old problem about when the life of some persons may be sacrificed for the well-being of other persons. We cannot here present a full solution to this problem, but given the current projections of the number of HIV-infected people in the future, it may be an issue that will soon have to be seriously addressed.


This paper was written in pursuance of the commission of the European Communities Biomedical and Health Research Programme: "AIDS: Ethics, Justice and Europe an Policy." The authors gratefully acknowledge the stimulus and support provided by the commission, the helpful suggestions of the editors of the Hastings Center Report, and also the invaluable advice of Dr. John Pickstone.


[1.] Although some people with HIV disease might see this claim more skeptically, we believe that in essence the response has been liberal, particularly when compared with possible alternative scenarios to which we will come in a moment. [2.] Stephen S. Morse, "AIDS and Beyond: Defining the Rules for Viral Traffic, " in AIDS: The Making of a Chronic Disease, ed. Elizabeth Fee and Daniel Fox (Berkeley and Los Angeles: University of California Press, 1992), pp. 23-48. [3.] Most medical information in this paper is taken from Ernest Jawetz, Joseph L. Melnick, and Edward A. Adelberg, Review of Medical Microbiology, 16th ed. (Los Altos, Calif.: Lange Medical Publishers, 1984); and Dion R. Bell, Lecture Notes on Tropical Medicine, 3d ed. (Oxford: Blackwell Scientific Publications, 1990). [4.] For an interesting literary treatment of the first occurrence of Marburg fever see "The Green Monkeys: Revenge in the Rhineland," in Great Medical Disasters, ed. Robert Gordon (London: Hutchinson, 1983). [5.] Charles A. Erin and John Harris, AIDS: Ethics, Justice and Social Policy," The Journal of Applied Philosophy, in press. It is this idea that forms the background to the Commission of the European Communities Biomedical and Health Research Programme project entitled "AIDS: Ethics, Justice and European Policy." [6.] Erin and Harris, "AIDS." [7.] This may also have implications for our entitlement to prevent or treat disability by various means, including genetic engineering and prenatal diagnosis. Such concerns are beyond our present remit, but see John Harris, Wonderwoman and Superman: The Ethics of Human Biotechnology (New York: Oxford University Press, 1992), chs. 4, 7, and 9; and his "Should We Attempt to Eradicate Disability?" in Applied Ethics and Its Foundation, ed. Edgar Morscher, Otto Neumaier, and Peter Simons (Dordrecht: Kluwer, 1993). [8.] Robert Nozick, Anarchy, State, and Utopia (New York: Basic, 1974), p. 34. For a discussion of Nozick's views in the context of health care see John Harris, The Value of Life (London: Routledge, 1985), ch. 4. [9.] It is interesting to note that Cuba is already employing quarantine for all citizens with HIV. Other countries such as Sweden have also employed enforced quarantine in the case of those infected with HIV (drug-addicted prostitutes, for example) who are deemed especially liable to engage in unsafe sexual practices.


For a National Conference Ethical Issues in Health Care Reform:

The Search for New Solutions

Cosponsored by University of Florida Health Science Center

The American Medical Association

The Hastings Center

Washington, D.C.

31 March-1 April 1995

The University of Florida Health Science Center, the AMA, and The Hastings Center are pleased to invite proposals and abstracts for scholarly papers to be presented at a national conference on the progress of health care reform to be held in the spring of 1995.

Abstracts should be a maximum of 600 words. Papers dealing with the following broad issues will be particularly welcome: access to health care; rationing; futile treatments; ethical aspects of decisionmaking in managed care settings; conflicts of interest and financial incentives for health professionals; personal responsibility for health status; professional autonomy and ethics.

Submissions from researchers in all disciplines relating to health policy and biomedical ethics are welcome. Please send five (5) copies of the abstracts to Bruce Jennings, Executive Director, The Hastings Center, 255 Elm Road, Briarcliff Manor, NY 10510. Fax: (914) 762-2124.

Submission Deadline: 15 May 1994

Authors will be notified by 1 July 1994 and will be asked to submit their full paper by 1 March 1995. The conference organizers expect to arrange publication of accepted papers in a volume of conference proceedings.

John Harris is professor of applied philosophy and research director of The Centre for Social Ethics and Policy, University of Manchester, United Kingdom; Soren Holm is a research fellow in the Institute of Biostatistics and Theory of Medicine, University of Copenhagen, Denmark.

John Harris and Soren Holm, "If Only AIDS Were Different!" Hastings Center Report 23, no. 6 (1993): 6-12.
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Author:Harris, John; Holm, Soren
Publication:The Hastings Center Report
Date:Nov 1, 1993
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