The History and Background of AIDS; Condom Campaigns
Gonzalo Herranz, department Bioethics, University of Navarra
discussion paper congress First congress for Life and the Family
Anonymous Movement for Life Corporation/Human Life International
Pontifical Catholic University, Santiago, Chile
Saturday, August 20, 1994, 4:15 p.m.
1. The epidemiological history of HIV infection
2. The History of Scientific Endeavor
B. The response from professionals
1. Vocation and heroism versus staff withdrawal
2. AIDS prevention and condom campaigns
Greetings and thanks
It is said that AIDS has brought about a revolution in medicine and medical ethics. In my view, rather than a revolution, the epidemic caused by HIV has been a revelation, one that has served to highlight both the hidden strengths and weaknesses of medicine and doctors, as well as the Degree which medicine depends on general policy and pressure groups. But above all, it has shown that medicine is a business to the core.
It is impossible summary twelve-year history summary AIDS in just a few moments, as it encompasses so many sub-stories:
The history of the epidemic, and its future.
The History of Scientific Endeavor
The response of professionals: dedication and heroism in the face of staff withdrawal.
Prevention: Firmness, Education . Misguidance.
1. The epidemiological history of HIV infection
The history of AIDS is, to begin with, made up of the cold data of epidemiology, which reflect individual stories of recklessness and cruelty, but also of submission heroism; they account for past deaths and suffering, and predict future deaths and suffering. It is always helpful to consider some data in order to grasp the magnitude of the problem. Some refer to transmission mechanisms and risk factors; others to data that measure the extent of the epidemic and its further spread.
Throughout the early 1980s, the mechanisms of HIV transmission were gradually identified and precisely determined, and at-risk groups were characterized. Some of these groups, although highly significant from an epidemiological standpoint, represent a very small proportion of cases: these are patients (hemophiliacs, hematology or surgical patients, etc.) who have received blood transfusions or blood products from HIV-positive individuals, or who have undergone organ transplants or artificial insemination using semen donated by HIV-infected individuals. Another small issue of doctors or nurses who accidentally injected themselves with contaminated blood. But the main groups of infected individuals, as is well known, come from other sources. At the start of the epidemic, it was found that most patients were gay men, and it was soon confirmed that transmission occurred during homosexual practices. It was not long before a issue of intravenous drug users were observed among AIDS patients or HIV carriers. What has been a cause of greatest concern in recent years is the spread of the disease among the general population, transmitted through heterosexual intercourse. Although this phenomenon is particularly widespread in large parts of Africa, all statistics—from developed and developing countries alike—indicate a rise in issue women affected, with the added risk of transmitting the disease to their children.
AIDS is, in quantitative terms, a medical problem of the greatest magnitude. data international organizations indicate that more than 600,000 cases of full-blown AIDS have been detected in over 150 countries. It is acknowledged that this figure is considerably lower than the actual number, as data Eastern Europe and Third World countries are highly incomplete. In 1992, the WHO estimated that the global total of AIDS cases, agreement an optimistic projection that places great confidence in preventive strategies, would increase approximately tenfold over the next eight years, rising from an estimated 1.5 million cases in 1992 to 12–18 million by the year 2000. During that same period, the cumulative number of adults and children infected with HIV will triple or quadruple, rising from 9–11 million today to 30–40 million by the turn of the century. The outlook is particularly bleak in sub-Saharan Africa, the region where the epidemic began and which has been hardest hit by it, with more than 7 million adults and children currently infected. The status Southeast Asia and India is worsening at an alarming rate every day. The WHO predicts that between now and the end of the 1990s, the infection will spread more rapidly in Asia than in Africa. We must not forget that conditions in Latin America are conducive to the rapid spread of the epidemic.
It is not easy to grasp the full significance of these figures in terms of the pain and death they represent. Considering the social and economic consequences of the epidemic can help us appreciate the terrible human tragedy it entails and take its prevention seriously. AIDS primarily affects young or average adults average are not only in the prime of their productive lives but also serve as the main support for their young children and elderly relatives. Some analyses by the WHO and the World Bank suggest that the deaths of these individuals will lead to social collapse and economic chaos in the countries hardest hit by the disease. As a dramatic illustration of this bleak future, it is noted that by the turn of the century, between 10 and 15 million uninfected children, mostly in sub-Saharan Africa, will have lost their mothers to AIDS and will be left abandoned, because the extended family—the traditional refuge where an orphaned child could grow up—is also being undermined by the pandemic. Lacking resources and with no hope of receiving Education, these children will, in turn, become easy victims of HIV infection. AIDS has already undone the improvements in infant mortality achieved through public health efforts in recent decades.
The implications for Economics are staggering. Treating the disease is exacting a tremendous economic toll, quickly bankrupting Economics and their families, and consuming a disproportionately large share of the resources available to national health systems. A few figures will suffice. In the United States, treating a typical AIDS patient over the course of their illness costs around $85,000. In 1990, the year in which 40,000 AIDS patients died in the United States, the U.S. government spent $1.6 billion on research medical care for the disease—more than it spent on cancer and heart disease.
The picture is far bleaker in poor countries. Already today, in some African cities, people with HIV account for 80% of adult patients admitted to many hospitals. If development countries development to meet the medical needs of people living with HIV, they would have to spend more than half of budget on them. Poor countries will not be able to solve the problem. Many voices, from the Pope to the directors of the WHO Global AIDS Program, have called for global solidarity on an unprecedented scale to address, in the coming years, the complex and universal consequences of the AIDS pandemic. status is already unsustainable. But what lies ahead is far worse. And what lies ahead depends decisively on the preventive measures that are implemented. This is what gives HIV prevention its overriding ethical character.
2. The History of Scientific Endeavor
That history includes brilliant chapters of scientific achievements and laboratory ingenious laboratory work, as well as chapters that reveal the human frailties of researchers—eager for fame, anxious to claim priority, and fanatical about their own hypotheses. HIV infection is, on the scientific front, a subject of discussion intense as it is in society at large: there are scientists who do not agreement HIV is the causative agent of the disease, on what the reliable markers of its progression are, whether it is inexorable, or whether there are infected individuals capable of spontaneous recovery. The controversy centers above all on which areas should be researched: what types of new drugs and vaccines should be investigated, what constitutes a truly effective prevention policy, and whether funds should be spent on patient care or on research. The public, and especially those who are HIV-positive, are impatient because, after having invested vast sums in research, the results seem meager to them and the finding solutions too far off. Many must resign themselves to dying before the drug or vaccine that could save them arrives.
Tens of thousands of articles—ranging from research to knowledge dissemination general public—have already been published on the infection. There are several international journals—and, among developed nations, each country has at least one of its own—dedicated exclusively to publishing on the disease in its many aspects. research AIDS has already enriched virology, pharmacology, immunology, epidemiology, internal medicine, and many of its specialties.
Much has been accomplished, however. Many of the molecular mechanisms the virus uses to invade the human body and slowly but surely weaken the immune system have been unraveled. Every week, leading medical journals keep us constantly informed about the ever-changing and often new aspects of the disease.
The scientific gains spurred by the pandemic are impressive. We now have a molecular-level understanding of the virus’s structure. Thanks to this, we have learned new things about the mechanisms of our immune system’s defenses against pathogens. We have increasingly early, affordable, and safe methods for diagnosing the disease—methods that will also benefit the detection of many other infectious agents. design and vaccine design procedures have been refined that will in turn help advance the search for cures for many other diseases.
Amid all these achievements, we suffer because the disease resists being defeated by a vaccine or a cure. research a vaccine that provides immunity against the disease, a treatment that halts the progression of the infection in asymptomatic HIV carriers, or a therapy that cures patients already suffering from AIDS presents an extremely complex landscape, in which purely scientific interests, political ambitions, commercial interests, and, obviously, serious research ethics issues are intertwined.
In practical terms, what has been achieved so far to improve patient outcomes is not much, but it is something. Treatment of opportunistic infections and therapy aimed at slowing viral replication have resulted in a B in survival time. The development new chemoprophylaxis protocols for these infections and the combined use of zidovudine with new nucleotide analogs (such as ddI and ddC, for example) offer new hope for prolonging life.
There have been problems here as well. Rigorous clinical trials take a long time—too long for those who see death approaching. And they cost too much money, which seems like a small price to pay for those who depend on finding a life-saving treatment.
There are many factors that have made AIDS an exceptional, privileged disease. One of them, which I mentioned earlier, is the disproportionate, enormous amount of money spent on research .
Predictions about the future spread of the epidemic, along with the specific health policies that developed countries have adopted in response, make the search for agents to prevent and treat the disease an extremely attractive prospect for the pharmaceutical industry. The precedent set by zidovudine, the drug that has single-handedly dominated the market in recent years, has prompted many pharmaceutical companies to invest heavily in the search for new drugs to treat those infected with HIV. research work research the battle for market share are in full swing.
Another notable aspect of AIDS— research —has been the decisive, though not always beneficial, influence exerted by certain AIDS activists. They began by pressing for the acceleration of the slow drug essay approval processes for treatments for the disease. They secured many concessions through their street demonstrations, their group political authorities, their active presence at scientific conferences, and their negotiations with pharmaceutical companies to lower the prices of available drugs or force the essay of new ones. With the financial aid the media and that mix of violent intimidation and rational debate, they managed to change the Food and Drug Administration’s rigid rules on clinical trials. Researchers, who absolutely needed patients infected with the virus to conduct their therapeutic experiments, had no choice but to agree to many of the activists’ demands in the face of their threat to boycott ongoing trials. Using all their political power—which in the United States is considerable at both the local and national levels—activists have made AIDS a top priority for funding. They have argued that AIDS is different from other diseases because, being both epidemic and infectious, if an effective drug or vaccine were discovered, the problem would be solved once and for all. They also add, with a biased view of social justice, that AIDS affects young people, whereas cancer and heart disease typically affect people who have already lived long enough.
What has been the result this intervention in the design and conduct of clinical trials? Not very encouraging. While the positive principle that the group must always receive the best available treatment—even if it changes during the course of essay—has been reinforced, exclusion criteria have been relaxed; trials conducted in children are now carried out simultaneously with those in adults, rather than later as previously mandated by rule ; and, finally, trials in pregnant women—previously virtually prohibited—have been authorized. Yet it must be acknowledged that this has paved the way for a dangerous relaxation of the safe standards previously in force. Many trials conducted in accordance with the new practices have yielded only confusing and useless results. Here, as in other fields, solidarity—which is the solid foundation of the financial aid and altruistic financial aid provided to AIDS patients—runs the risk, if separated from the criteria of scientific rigor and distributive justice, of becoming irresponsible favoritism
B. The response from professionals
1. Vocation and heroism versus staff withdrawal
[section yet developed]
2. AIDS prevention and condom campaigns
This is not the first time that here in Santiago, in this very classroom the Catholic University, I have spoken about medicine as an ethical force. I did so in one of the lectures I gave at the Medical congress held in July 1988. At that time, I cited some examples that showed how any doctor’s office—whether that of a rural physician, an insurance company doctor, or a university professor—is a place where people are ethically shaped, where the doctor exerts a powerful influence on the patient’s conscience and behavior.
Nothing test the power of the physician as a moral agent test than the messages promoting the prevention of sexually transmitted diseases—including the HIV epidemic—as they have appeared in successive global educational campaigns aimed at curbing the HIV epidemic.
When the spread of the disease began to have a tangible impact on the general population as a result of casual sexual contact, health authorities began, some 8 or 9 years ago, to alert the public and issue a warning that, in the absence of effective treatments, the only defense against the disease is the implementation of a vigorous prevention program. The elements of that program are basically an information campaign about the disease and how it is transmitted. The message is disseminated through brochures mailed to all citizens, public service announcements on television, radio, and in the press, as well as by providing access to sterile syringes or teaching simple sterilization teaching to drug users, and, finally, by promoting the concept of safe or safer sex through the use of condoms or non-penetrative sexual practices.
I would like, by the way, to highlight a point that is rarely discussed: the massive, practically universal campaign to destroy the innocence of millions of children and adolescents through teaching “safer sex” teaching —the diabolical indoctrination to which they have been subjected, via the “safer sex” educational package, into the internship autoeroticism, mutual masturbation, and “light” forms of homosexuality, all with the purpose avoiding penetrative sex. The souls of an entire generation of innocents have been sullied by these perverse teachings. There is talk of the massive scale that child abuse is reaching in advanced societies, but it is difficult to find a parallel to this campaign of sexual abuse orchestrated by the rulers of many countries with the approval progressive educators. I believe this is a little-reported aspect of the Education campaign, whose psychopathological and spiritual effects will need to be closely monitored.
Let us return to our speech. It is worth noting that the condom recommendation was made intuitively or based on the unreliable data inferred from experience with other sexually transmitted diseases. There was no serious programs of study at the time about its protective efficacy. It was initially claimed that the leave prevalence of AIDS in Japan was due to the consistent use of condoms for both contraception and prevention of sexually transmitted diseases.
It is still too early to know with any certainty the medium and long-term results of such campaigns deadline. Preliminary data reports a slowdown in the epidemic, but unfortunately much less than estimated. As is always the case, the data results have been described by some as encouraging, by others as seriously worrying. In general, there is a strong sense of disillusionment among health authorities.
To what extent it is not the scientific criteria of sound preventive medicine that have guided AIDS prevention campaigns in some places, but rather certain ideological prejudices— sample happened in Spain. It is worth learning about this history.
In 1989, the Ministries of Health and Social Affairs jointly launched a prevention campaign that, as is the case everywhere, was primarily aimed at young people and teenagers. It was the famous campaign promoting condom use, with the slogan “Put it on, put it on!”
The message, across various media, was conveyed with a festive and carefree tone that appeals so much to certain young people who like to joke about serious matters. The campaign lacked biological soundness, reference letter data , and data on effectiveness. It was a tremendous psychological manipulation in favor of casual, protected sex. It acted as yet another stimulus to youthful permissiveness, leading many to believe that the condom, with its dual effectiveness as a contraceptive and an STD preventative, is the magic talisman of pleasure, rendering those who use it invulnerable to all dangers and risks. We will have to wait until 1996 to see the effect the campaign has had on the incidence of AIDS. Unfortunately, many HIV-positive men and women, who will then be between 20 and 30 years old, will discover that they are victims of the optimistic and irresponsible “put it on, put it on” campaign.
In an interview—which, curiously enough, took nearly a year to be published—I accused the campaign’s promoters of irresponsibility for a very serious reason: the severe, deliberate, and biased distortion of a message that, while devoid of any moralizing intent and free from religious connotations, set forth guidelines based on the standard, classical principles of preventive medicine. A substantial part of the message of simple preventive good conduct, proposed by the leading authority on the subject, the Centers for Disease Control and Prevention (the famous CDC) in Atlanta, Georgia, in the United States, was deemed by Spanish government ministries to be an rule and puritanical rule and was eliminated with the stroke of a pen. This is the story.
After careful consideration and lengthy discussions among experts, the CDC published a series of articles on AIDS prevention throughout 1988 in its official journal, the *Morbidity and Mortality Weekly Report*. One of them, graduate in the Prevention of Sexually Transmitted Diseases,” appeared in February 1988. In its Introduction, which I translate in full, it stated the following: Prevention is the most effective strategy for curbing the spread of sexually transmitted diseases (STDs). Behavior that eliminates or reduces the risk of one STD will likely reduce the risk of other STDs. Preventing one case of an STD can result prevention of many subsequent cases. Abstinence and sexual intercourse with a mutually faithful, uninfected partner are the only fully effective preventive strategies. Correct use of a condom during every sexual act can reduce, but not eliminate, the risk of contracting an STD. Individuals at risk of infection or who know they are infected with the human immunodeficiency virus (HIV) should be aware that condom use cannot completely eliminate the risk of transmission for themselves or for others.”
The Weekly bulletin , published by the Subdirectorate General for Health and Epidemiological Information of the Spanish Ministry of Health and Consumer Affairs, reproduced in its issue No. 1801—almost a year late—a summary article cited above. I still have my doubts as to whether this is truly a summary, or whether we are instead dealing with a article . Because it does not seem that summary translation summary the full text can summary called summary , from which two things have been removed: first, the information specific to the United States regarding administrative regulations for quality control of batches of condoms, whether manufactured in the U.S. or abroad, which is entirely reasonable; and second, the following lines: a) in the cited Introduction: Abstinence and sexual intercourse with a mutually faithful and uninfected partner are the only fully effective preventive strategies. And b) in the final paragraph: Recommendations for the prevention of STDs, including HIV infection, should emphasize that the risk of infection is effectively eliminated only through abstinence or sexual intercourse with an uninfected and mutually faithful partner.
When comparing the American original and the Spanish Ministry’ssummary,summaryone cannot help but suspect that what took place was not simply an honest attempt to summarize—to condense the essence of the original text into concise terms—but rather that a substantial portion of the document was struck through with the red pencil of ideological censorship. To the censor, the content of the crossed-out sentences must have seemed unscientific, irrational, and inappropriate for a tolerant and sexually liberated context. Officials at the Ministry of Health, so as not to risk appearing moralistic and prudish, preferred to be perverse. They crossed out those sentences driven by their ideological prejudices, without realizing that they were destroying a rule hygienic-sanitary rule . And they were wrong: because sexual abstinence and sexual relations with an uninfected and mutually faithful partner, in addition to being human behaviors full of dignity and moral values, constitute biological behaviors full of common sense and incomparably more effective from a preventive standpoint.
In the wake of the campaign, a association that defends family values and the sanctity of life, Acción Familiar, filed a lawsuit with the National Court citing the lack of scientific basis and the fraudulent nature of the condom campaign. The high court’s ruling overturning the campaign caused a strong but fleeting impact. Apparently, the court ruling has convinced the ministries of the need to be more cautious in the future: this year, following the recommendations of a committee experts who claimed that the low use of condoms among adolescents and young adults was due to their high price, they limited themselves to offering a issue of condoms at a reduced price during the months of May through July.
It’s a shame that the people who launched that campaign and this one didn’t look into the results of similar campaigns carried out in other European Union countries a year or two earlier.
They would learn, for example, that these campaigns often promote the internship promiscuity and casual sex as a form of irresponsible play, in which nothing and no one is taken seriously.
They would find that, following the campaign, the rate of condom use remained very leave, as it did not reach 25% of sexual encounters in most surveys. As a publishing house noted, ...the results of the prevention campaign, unfortunately, ... have ranged from disappointing to downright irresponsible. Behavioral change is the surest form of protection. But it seems that it has not been possible to bring about this change quickly or widely enough, not even among high-risk groups.
They would also learn that, according to a survey by the Allensbach Institute for Public Opinion Research in what was then the Federal Republic of Germany, more than 40% of young men and women criticized the campaign’s promoters for their obsessive focus on mere sexual biology and their complete lack of reference letter moral values, chastity, and faithful love. The safe sex campaign mistreated young people, for by trivializing love and reducing it to mere genitality, it stripped them of their moral responsibility.
And that is precisely the view of those who are seriously committed to Education . Dr. Theresa L. Crenshaw of San Diego, California, President of the association of Sex Educators, Counselors, and Therapists, stated in her testimony before the congress that , for health reasons, people must be told that if they want to live safely, they must give up casual and promiscuous sex. And even while acknowledging that condoms, when used in combination with spermicides, can help in the fight against AIDS, we must insist on the need to emphasize the importance of behavioral change. The resignation of many health authorities is gravely irresponsible; faced with the inescapable threat of AIDS, they meekly limit themselves to slightly curbing its spread by recommending condoms. We must tell people clearly that they must avoid all sexual activity with anyone other than their ‘committed partner.’ The message from Dr. Crenshaw and the association chairs is this: that people can change their sexual behavior, but they will not do so if we do not trust them, if we do not speak plainly to them, if we limit ourselves to offering them ‘safe sex.’
The campaign failed in its goal making condom use widespread. Under the guise of lightheartedness and frivolity, the Spanish campaign sought not only to undermine the moral value of sexuality; it never hid its intention to serve as a massive introduction to contraceptive practices for younger generations.
Both in its (im)moral aspect and in its medical-preventive dimension, it was a massive fraud. Not only did it attempt to destroy the moral values of young people and promote the internship perverse substitutes for sexuality; it also spread a serious epidemiological exaggeration. Instead of telling people that AIDS prevention must be taken very seriously, it deceived everyone by claiming that condoms are very safe. A senior official from the National AIDS Plan declared that condoms are 100 percent safe. In the samepublishing house cited above, the following is stated: “In the case of AIDS, prevention is not simply better than cure: it is the only cure. (...) The resources to prevent the spread of HIV are tremendously simple, and the list of strategies to be followed is very straightforward. But heterosexual and homosexual contacts and intravenous drug use continue to drive the spread of the epidemic (...) No one has been able to bring about the necessary behavioral change.”
I believe that people’s justified skepticism regarding the supposed effectiveness of condoms plays a significant role in this lack of response. A procedure has a long-standing and deeply rooted reputation for being ineffective in preventing STDs and pregnancy—a reputation passed down orally over many years—cannot be dispelled by a simple advertising slogan: what is needed is a rational and well-documented argument.
What do we really know about the effectiveness of condoms? What should a conscientious and serious doctor say about this? A colleague of mine—a professor of public health at a Spanish university, an agnostic but scientifically rigorous scholar—told me that one day a student asked him in class the actual effectiveness of condoms. He simply admitted that he didn’t know, which prompted him to conduct a critical meta-analysis of the published literature on the topic. This study will appear shortly in the journal Medicina Clínica, published in Barcelona.
I have read the draft it contains data interesting data . For example, numerous health authorities have provided misleading information about data was actually unknown or had not been rigorously verified. The presentation condoms as a virtually foolproof method has led the public to underestimate the risks associated with heterosexual intercourse and is, paradoxically, contributing to the spread of the disease. A serious analysis of the data the bibliography conclude that condoms can partially reduce HIV transmission, with an effectiveness of around 70%. Until a vaccine or a fully effective treatment becomes available, no public health strategy—other than abstinence and sexual relations with an uninfected and mutually faithful partner—can provide absolute safety. For this reason, public Education is of fundamental importance: doctors and health authorities should convey with sincere honesty the message that the protection provided by condoms is limited. Only then can individuals adopt manager informed behavior.
It should be clarified that the data the condom’s only relative effectiveness were not discovered after the campaign. These were data—albeit of questionable scientific quality—that were available at the time health authorities launched their campaign on a virtually global scale. This was revealed in one of the most comprehensive and critical reports on the topic, conducted by the University of Zurich and the Swiss AIDS Information Office, which states that: “The condom has been recommended in several countries as the most important means of protection against HIV infection, (...) but before the HIV epidemic, the condom had little standing as resource prevent pregnancy or reduce the risk of contracting STDs. To prevent a deadly infection such as AIDS, it is essential to use and recommend only safe methods of protection. The programs of study recent programs of study AIDS prevention show that the assumption that condoms offer reliable protection against HIV is a dangerous illusion. In programs of study designed programs of study , it has been shown that employment does reduce the risk, but a residual risk remains, ranging from 13% to 27% or more.”
The responsibility is, therefore, very serious. Not only because condoms present that wide—albeit poorly quantified—window for HIV infection, but also because a assessment of their effectiveness is practically impossible for us to conduct. We will never be able to design prospective experiments to measure their protective effect against HIV transmission. No research committee research approve an experiment comparing two groups—one using condoms and the other not—in which initially uninfected subjects would engage in predefined sexual intercourse with infected subjects over a specified period of time, in order to evaluate the net protection rate conferred by condoms. The issue is further complicated by the fact that subject an experiment subject be replaced by a simulated one that could be conducted in vitro.
In truly humane relationships between doctors and patients, disagreements may occasionally arise, but there should never be any deception or abuse, from either side. Being an expert in epidemiology does not justify engaging in deceptive practices or concealing data significant data , unless one holds a zoological, non-human view of humanity.
The failure of condom campaigns lies not only in the falsification or presentation of data . It also lies in the many thousands of lives cut short by an incurable and cruel disease. Ultimately, it lies in the loss of the immense moral and biological benefits that could have resulted had those campaigns been inspired by a truly humane view of humanity.
But in Spain, it does not appear that the violence is limited to the manipulation of the CDC’s epidemiological guidelines. The government, in a show of strong-arm tactics, also announced its purpose not purpose tolerate conscientious objection from doctors and pharmacists who did not cooperate with its campaign and who refused to prescribe or dispense condoms. I do not believe this was a serious or firm decision, but merely a gesture to weaken the moral resistance of some, or to satisfy the power-seeking of a few. But, had it been carried out, it would have been a tremendous mistake, both in the realm of civil coexistence and in the realm of health and scientific policy. In the first case, it would constitute an sample intolerance, unbecoming of a modern state that respects individual freedoms and which, moreover, enshrines the inviolability of conscience in our Constitution. It would also be a violent imposition of a particular moral opinion which, lacking arguments, is quick to brand non-collaborators as intolerant. No one, including doctors or pharmacists, can be compelled, in a state governed by the rule of law, to disconnect their moral convictions from their professional actions, to practice a public morality different from their personal convictions, or, in short, to act against their conscience. Never, and much less after the Nuremberg Trials, can anyone who has acted against their own conscience invoke, in their defense, that they did so by following orders from superiors: such a reason lacks validity both ethically and legally. How much everyone, especially politicians, needs to meditate deeply on Veritatis Splendor!
Furthermore, it constitutes an intrusion by political authorities into the realm of scientific debate, which is unbecoming of a truly free and modern society. If a doctor or pharmacist judges, based on reliable data , that condoms do not provide acceptable protection against HIV, they may decide not to recommend or dispense them. Moreover, they are morally obligated not to recommend or dispense them. Their decision is based on serious scientific and moral reasons, and they will make this clear to their patients or customers. They should calmly inform them that, although condoms offer relative protection—the risk rate is between 25 and 15 percent, meaning they fail in one out of every four to six sexual encounters—as long as AIDS remains a fatal disease, the protection is insufficient and the risk overwhelming. “The idea that, by using a condom, one can have truly safe sex with an HIV-positive partner is a dangerous illusion”—that is the conclusion of a Danish study on the non-equivalence of the terms ‘condom use’ and ‘truly safe sex.’
That safe sex is an illusion, an unattainable goal: that should be the message of the government campaign, for it is the message that doctors—and pharmacists as well—must convey. Modern medical ethics has placed the need for jointly made decisions to be free and informed at the forefront of the doctor-patient relationship. Freedom can only be exercised ethically when one has the necessary information, when ignorance has been dispelled—that is, when the morally significant data knowledge have been understood—in order to act conscientiously and freely. We are no longer in the era of harsh paternalism, when the patient was limited to passively following the decisions that the doctor, wisely, made for him. The patient cannot be kept in the dark. Nor can he be deceived. The doctor’s office and the pharmacist’s counter are places of high ethical tension, where each person must be treated as an ethically mature human being. In truly ethical relationships, disagreements may arise with some frequency. But there is no room for deception or abuse in either direction. Disagreement should be polite, respectful of people, limited to the point of disagreement, and justified. For this reason, I cannot help but think that the campaign in favor of condoms was fraudulent, as it was designed to create a false sense of security by concealing crucial pieces of information. It has particularly mistreated young people, as it stripped them of the best part of their moral responsibility, trivializing love and reducing it to mere sexuality.
I do not believe the AIDS epidemic will ever subside with condoms and subject Education that comes with them. It is a very weak Band-Aid for containing the enormous erotic pressure and sexual habits that uninhibited pornography is creating in society. In contrast to their vigorous, albeit belated, policy of cracking down on drug trafficking, governments remain culpably passive in the face of this dangerous environmental contamination of promiscuous sex—or actively participate in it through their media outlets. It is hypocritical to think that containing AIDS can come from mere Education sexual physiology: sex is more than just its biology.
Let us reconsider this aspect of medical ethics, as it is subject reflection. The doctor’s office is a highly influential moral agency, since medical advice inevitably has moral implications. Doctors must therefore possess a keen and critical moral sense in order to decide what messages to convey to their patients, especially when it comes to expert guidelines.
Neither doctors nor ordinary citizens can overlook a fundamental fact: the guidelines established by epidemiologists, health policymakers, and demographers depend directly on the view that they—the experts, each and every one of them—hold of human beings and humanity. At the heart of every political decision—and, for that matter, every health policy decision—lies a specific anthropology, a particular way of understanding humanity, as professed by the politician, the health official, or those currently leading the WHO, PAHO, or the CDC. And also, inevitably, underlying every health policy decision is a moral framework that can be tremendously reductionist and partisan. What is serious about this, what constitutes an abusive and degrading abuse of power, is presenting, in the name of science, that anthropology and that morality as the only acceptable orthodoxy, which marginalizes—if not prohibits or persecutes—any other vision of humanity and the good life. The lecture Population and development the United Nations has convened in Cairo next month is a flagrant example of this monolithic and exclusionary policy.
We are seeing this in the attention toward the Pope’s pleas, in the deaf ears turned to his teachings. We have seen how there is a growing intolerance for dissent among public health officials, to the point of denying conscientious objection to those who disagree with their doctrines and practices. While they forcibly impose their minimalist and utilitarian ethics on us, they hammer into everyone’s mind—as if it were a message from Big Brother—the slogan that, in a pluralistic society, no one can impose their convictions on anyone else. To live together in peace, we must adhere to their minimal civil ethics, which we are all obliged to accept.
But such behavior is inhumane; it is untenable. It amounts to imposing on others, through the force of legislation or management assistant regulations, a private ethical opinion which, in the case of the safe sex campaign, presupposes, at the very least, a purely zoological view of human nature, an idolization of sexual liberation, and a defeatist morality that assumes most young people are sex-addicted, programmed for promiscuity, prefer erotic love to chaste love, and trivialized pleasure to a commitment to fidelity.
I’ll wrap this up now. AIDS has truly been a whirlwind that has swept through the field of medicine. It has divided hearts. As we have seen, it has provoked sectarian reactions and discriminatory behavior among medical professionals. But it has also given rise to submission generous acts of submission . Some went so far as to say it was a scourge from God: in reality, it is a blessing, an opportunity. In the 12 years of the epidemic, we have been able to see, in the face of this great test, the formidable capacity that medicine and humanity have to make mistakes, but also the wonderful strength that, with God’s grace, we humans possess to rectify those mistakes—sometimes drawing from them heroism and holiness, other times a new confirmation of the wisdom of natural law.
Thank you very much.