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Private Acts, Social Consequences.

Private Acts, Social Consequences

Near the end of Private Acts, Social Consequences, Ronald Bayer quotes from William McNeill's Plagues and Peoples, whose unsettling thesis is that "humanity's vulnerability" to infectious disease will "surely remain as it has been hitherto one of the fundamental parameters and determinants of human history" (p. 232). By placing his argument within this broad ecological context, Bayer reminds us that both individual and collective freedom is always conditioned in unchosen ways. In the case of AIDS, natural factors outside human choice have presented our species with a threatening challenge not only to our technical resourcefulness but also to our capacity for moral response.

Bayer has written the social history of the politics of the worst epidemiological threat to strike American society in generations. He has done so while carefully examining the effect different responses may have on the delicate balance between individual liberty and the common welfare on which the nation's identity depends. Bayer weaves the complex story of the nation's often confused efforts to cope with the epidemic into a lively narrative. But it is the particular strength of his book that it enables the reader not only to learn about AIDS and the politics of public health, but to learn from the experience as well.

Bayer sees AIDS as both a profound moral and political challenge and an unexpected test of the nation's capacities for "social reason" and mature moral response. His thesis is clear: Because AIDS is both lethal and transmitted through essentially private, often intimate actions among individuals, it bears home on us as few events have that the "collective fate" depends upon "private choice" (11). Yet this very reality upsets our usual expectations. Being dependent upon "private choices" means that, barring a sudden biomedical breakthrough, only a "culture of restraint and responsibility" can eventually minimize the threat of AIDS.

If Bayer is correct in this assessment--and his analysis of the dim prospects of success for coercive public health measures such as quarantine, mandatory screening, and so forth is exhaustive and convincing--then defending the public against AIDS will require a greatly expanded ability for social learning. Bayer argues most of the time by cases, examining the gay bath house controversies in New York and San Francisco of the early '80s, and the later battles over mandatory screening proposals, among others. Again and again his analysis reveals a troubling pattern of a profound disjunction between the magnitude of the common threat as described by public agencies and the incapacity of those same public agencies to defend the public against that threat by directly intrusive measures except in a relatively few marginal cases. This felt incongruity between threat and response has produced widespread fear and calls for coercive measures. However, as opposed to the epidemics of early in the century, public health officials in this case have had to fashion policies in a much more contentious environment.

Public health officials may have wished to proceed by means of the old forms of intervention such as mandatory screening and quarantine. But, Bayer notes, these impulses have collided directly with a rising civil libertarian tide sanctioned by the courts and aggressively advanced by well-organized activists in the gay men's and women's community. AIDS has appeared in American society just at the moment that public attitudes about the legitimacy of stigma and social ostracism have begun to soften considerably. For this reason, advocates of the (certainly justified) demands for protection of the civil liberties of gays and other at-risk and socially stigmatized groups have been remarkably successful in opposing interventions that might threaten these rights.

At the same time, public perception of the collective costs of individual behaviors such as smoking and substance abuse has also increased awareness of interdependency. This has heightened demands to control public risks as well as for the logical correlate, individual responsibility, hence the conflicting pressures felt by office holders with responsibility for meeting the AIDS emergency. In such a situation, there simply is no uncomplicated response that can be both effective and morally responsible.

Bayer's answer is to call for education toward a public culture of "restraint and responsibility" capable of influencing individuals in the same direction. To achieve this long-term end will demand "statesmanlike leadership" on the part of public health officials in recognizing the several dimensions of the problem. They must disseminate "not only knowledge" but equally "an appreciation of the moral claims imposed by the threat of HIV infection" (241). This means showing restraint, blocking responses motivated by fear or hatred of the victims, and yet devising "bold" experiments" adequate to the moral complexity of the situation. For example, Bayer proposes that aggressive educational efforts plus confidential and anonymous screening programs can both advance public health and still protect the privacy of those at risk.

Bayer argues that leadership in this task must by default fall to public health officials. This effort will nonetheless create conflicts, for the officers charged with organizing the campaign within a situation of moral complexity "will be compelled to face the legacy of their own past efforts to control infectious diseases, the pressure of elected officials responding to social anxieties...and the fears of those most at risk for HIV infection" (242). While this assessment seems accurate, Bayer never adequately explains how this needed leadership is to be developed among officials whose tradition has been "an authoritarian history rooted in the experience of confronting epidemics in a fundamentally different socio-political milieu" (242).

In the end, Bayer concludes, the struggle "will be waged at a popular level by ordinary men, women, and adolescents as they seek to carve out private lives," and so a positive outcome depends upon the widespread acceptance of "the profound moral responsibilities posed by AIDS" (243). This process of mutual persuasion demands a great collective moral engagement and a new degree of trust and mutual respect between citizens and public authority. Bayer's argument for this conclusion is powerful and, I think, convincing. Yet his reliance on public health officials, many of whom he shows in case after case to have misapprehended the nature of the problem at hand, seems a weak conclusion after so penetrating an analysis.

Particularly as AIDS becomes more and more a disease of the minority poor, our common capacities for responsibility and leadership are likely to be placed under even greater strain. Here his analysis could benefit from supplementation by other recent work such as David Kirp's Learning by Heart, a study of moral leadership as it affects decisions regarding acceptance or rejection of AIDS-infected children in the public schools. But if Private Acts, Social Consequences is finally only suggestive of the means for effecting its proposals, it puts the AIDS epidemic in a context that is both historically rich and conceptually sophisticated, one that prompts the right questions and opens the possibility of wise deliberation. This is an important contribution.
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Author:Sullivan, William M.
Publication:The Hastings Center Report
Article Type:Book Review
Date:Sep 1, 1990
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