Ethical issues in AIDS prevention, diagnosis and treatment
Gonzalo Herranz, department of Bioethics, University of Navarra.
lecture Delivered at the association Guatemalan Bioethics Centre.
Guatemala, April 1995.
II. The obligation to care for the HIV-infected patient
III. Ethics of diagnosis. HIV testing
1. Free and Informed Consent for test HIV
2. The ethical use of a positive result
The introduction publishing house to a recent issue in the Journal of Medicine and Philosophy, devoted exclusively to considering the moral significance of AIDS, began by quoting words Osler had written in 1905 to emphasise that syphilis was the disease that students of internal medicine needed to know most thoroughly: "Know syphilis in all its manifestations and relations, that, in clinical practice, all the rest will be added to you". Osler's words were paraphrased by the magazine's presenters in these terms: To know Acquired Immune Deficiency Syndrome in all its manifestations and moral relations is tantamount to knowing biomedical ethics, or at least the main of its content and ambitions.
I fully agree with agreement. This means that I take an excessive risk when I try to summarise in the small terms of a lecture the abundant content of problems that AIDS has raised. For, although it is true that AIDS does not cover the entire field of medical ethics, a very complete course on discipline could be given by taking as a starting point cases and problems of this special disease. The most salient ones, in alphabetical order, would be, for example: abortion, financial aid medical suicide, informed consent for diagnosis, prenatal diagnosis, Education epidemiological diagnosis of the population, clinical trials of new drugs, euthanasia, assessment for employment and life insurance, obligation to attend, health policy, professional risk, professional secrecy, etc. AIDS has not posed any entirely new problems, but it has presented with great urgency and intensity a very wide repertoire of medical-ethical challenges. But, basically, what AIDS has done is to put the doctor's humanity at test : at a time of therapeutic triumphs, the doctor is suddenly left without technical resources, armed only with compassion, faced with an incurable disease, without effective treatment.
And while there have been steady advances in our knowledge of AIDS since 1981 that have shown us the biological, epidemiological, clinical, therapeutic and social dimensions of the disease, there has also been much reflection on the ethical obligations of physicians towards HIV-infected patients.
In order to provide a detailed explanation of medical ethics as applied to AIDS, it seems most appropriate to purpose to analyse how the professional duties imposed by the current Code of Medical Ethics apply to AIDS patients. It will then become clear how medical ethics enriches the relationship between doctors and HIV-infected patients with ethical and human values.
I. The duty of science 
Of all the physician's obligations, I like to assign first place to his or her duty to science, to the skill that the state of the medical art demands at any given moment. All professional codes state that the physician must keep himself fully trained in his scientific training , that he has the duty and responsibility to keep his scientific knowledge up to date and to improve his professional skills.
Such an obligation to know is particularly urgent today for several reasons with regard to the spectrum of HIV-related diseases: because the physician must be able to recognise its very varied clinical manifestations affecting different systems and organs; because our knowledge in this field is evolving remarkably rapidly and needs to be updated frequently; because almost everything related to AIDS is still subject to a sometimes sensationalist treatment by some media, which creates irrational fears or misconceptions in the public, which the physician must dispel with current and critically evaluated information.
In particular, the doctor is obliged to know precisely, apart from the clinic of the disease and the mechanisms of its contagion, the validity of the diagnostic tests and their accuracy Degree , in order to avoid errors, which are particularly annoying here; the effective preventive procedures, both those that people have to apply in ordinary life, and those that the doctor and his assistants have to keep in the consulting room, the operating room, the laboratory, the conference room autopsy operating room or the hospital; the treatments accepted at any given time to combat the basic disease and opportunistic infections; and the legal or administrative provisions that seek the best care and protection of patients. Finally, but first and foremost, the physician must also be aware of the deontological standards by which the care of the sick must be guided.
Obviously, this duty to keep knowledge up to date is particularly incumbent on, among others, doctors who hold positions of responsibility in professional bodies, or in entities that programme and manage public health, on professors of medicine and on those who run sections of knowledge dissemination on medicine or health in the public opinion media. A very important part of their educational mission statement is to dispel discriminatory errors and prejudices that are the result of ignorance, misinformation or malevolence, such as school or social discrimination.
II. The obligation to care for the HIV-infected patient
AIDS patients have the same right to attendance as any other patient. Discrimination on grounds of moral conduct or sexual orientation has no place here. It is not acceptable to reject the patient on the grounds of the risk of contagion that health care workers may incur. It is deontological rule that a competent doctor should not refuse to attend to a sick person.
Such conduct is based on two constant traditions of medical ethics: that of not discriminating between people who request the doctor's financial aid , and that of not shying away from the risks that caring for the sick sometimes entails. Indeed, the Spanish Code of Medical Ethics, echoing the WMA's Geneva Declaration, states, on the one hand, that "Physicians must care for all their patients with the same conscience and application , whatever their religion, race, nationality, political ideas, social status or feelings"; and, on the other, that "In the event of catastrophe, public danger or risk of death, physicians may not abandon their patients, unless they are obliged to do so by qualified authorities, provided that this does not violate their professional conscience". These are principles of high moral standing and the vast majority of physicians conform their conduct to them.
It has happened, however, that some physicians have openly refused to treat AIDS patients or have used subterfuge to divert them to other institutions or colleagues. In the early years of the epidemic, the figure was as high as 60 per cent among surgeons in the United States. This is reprehensible, improper conduct, which should be investigated and, if necessary, punished according to the rules of medical ethics. The phenomenon is not new: historians have reminded us that some great figures in medicine (Galen and Sydenham, for example) fled in the face of great epidemics, while many anonymous physicians risked their lives to serve the plague-stricken.
It should be made clear that when medical ethics obliges us to care for the HIV-positive patient, it is not imposing heroic conduct on us: it simply obliges us to behave competently, since we know in detail both the mechanisms of contagion of the disease and the precautions that must be applied in the medical care of patients in order to avoid it.
Moreover, no conscientious doctor has ever put up a sign in his office saying " Admissions Office". Whether in the country or in the city, people live in peace in the knowledge that the doctor is obliged to treat all who come to him with the same respect, whatever their convictions, their reputation or their customs. It is true that the physician, like any citizen, has the right to freely determine his or her ideas and convictions and not to be disturbed by them. But he cannot ethically give a different and discriminatory attention to his patients because they are more or less sympathetic to his ideology, because they lead lifestyles that inspire his sympathy or repulsion, or because their treatment is too risky or too psychologically or emotionally demanding.
Assuming due skill, once the doctor-patient relationship has been initiated, the physician assumes a moral commitment to maintain it indefinitely. He or she cannot unilaterally suspend it for superficial reasons. The mere fact that the patient is HIV-infected does not justify refusal. It must be clear that the reasons for fail the doctor-patient relationship, once initiated, must be serious, objective, and linked to some fundamental aspect of medical care; they cannot consist of mere subjective prejudice or reasons of convenience or comfort. While there may in fact be some legal differences in the duty of care between self-employed doctors and those working under contract in institutions, public or otherwise, both have exactly the same ethical obligation not to discriminate, to welcome, to gain the trust of their patients. As the UK GMC document of June 1993, HIV Infection and AIDS: Ethical Considerations, states: The doctor/patient relationship is based on mutual trust, which can be fostered only if information is exchanged freely, honestly, openly and with understanding between doctor and patient. Acceptance of this principle is fundamental to solving the problems that often arise in AIDS care. The committee expects physicians to provide the same high standard of care to HIV-positive patients as they provide to any other patient. Worryingly, there is a small issue group of physicians who refuse to provide such patients with the necessary treatment and care. And while it is entirely correct that a physician, lacking the knowledge, skills and tools necessary to provide investigation or treatment for a patient, should then refer that patient to a competent colleague, it is unethical for a physician to refuse to treat or investigate, while having those skills and tools, on the grounds that the patient is suffering or may suffer from a disease that may expose the physician to risk staff, or because he or she judges that the patient's lifestyle may have contributed to the disease for which the patient is seeking treatment. Professional misconduct of this nature subject is to be considered serious. The Spanish Medical Association has declared that unjustified refusal of the AIDS patient by the physician is serious professional misconduct.
III. Ethics of diagnosis. HIV testing
Biological tests are now available that can reliably establish a diagnosis of HIV infection. If done correctly, they are very safe. And there is a very serious obligation not to make mistakes in performing or reporting these tests, because of the serious consequences of a false positive or false negative diagnosis.
Very few diagnostic procedures are as fraught with ethical implications as an HIV-positive test . An HIV-positive result can nowadays have unusually far-reaching consequences for the patient, as it can condemn him or her to cruel social discrimination, loss of career opportunities, difficulties in obtaining health and life insurance, stigmatisation due to the risk of infecting others, and so on. A positive diagnosis is a life-changing life event of the first magnitude.
At the same time, however, it happens that test is essential for the medical management of those infected by the virus, among other things, to establish therapeutic measures for the sick individual, to organise a reasonable prevention policy to protect their relatives as well as the doctors and nurses who take care of them, or to obtain reliable epidemiological data to inform us objectively of the magnitude of the epidemic.
A diagnosis of HIV-positive or HIV-negative revolves around decisions of enormous importance to the individual and the physician, as well as to the community. Naturally, the conscience of the physician is solicited by competing tensions or incompatible claims. It is not uncommon, therefore, for physicians to be confronted with conflicting duties.
The ethical implications connected with the internship of HIV diagnostic tests, now that the question of their reliability has been overcome, are essentially twofold: one concerns the voluntary and consensual nature of the test; the other, the correct use of the positive result for the benefit of the patient.
1. Free and Informed Consent for test HIV
The physician is morally obliged to apply for to obtain the patient's consent to practice test. One of the great achievements of contemporary medical ethics has been the acceptance that nothing should be done without the tacit or express, but always free and informed, consent of the patient. Except in cases of urgency, incapacity or grave and justified inappropriateness, the physician must obtain this consent before proceeding with diagnostic or therapeutic decisions. In ordinary circumstances, such consent should be sought whenever diagnostic procedures involve the extraction of samples or the application of invasive techniques, whether the tests performed are for diagnostic-differential purposes or are part of a routine screening programme, as for example in the case of pregnant women or in pre-operative tests.
Many physicians assume that the trust that presides over the ordinary doctor-patient relationship implicitly authorises the physician to perform all examinations necessary to establish the diagnosis, and that consent is therefore assumed. Therefore, whenever test HIV is necessary for the diagnosis of a patient, it can be assumed that, if the patient does not object to it or prohibit it, he or she implicitly authorises it. It is, however, preferable to ask for prior consent, which, if given in the right tone and with the right words and reasons, will only rarely be refused. In such a case, it would be necessary to negotiate his consent, and to try to persuade him with patience and good reasons. He can be told that there are indirect procedures (CD4+ lymphocyte count, presence of personal history and intercurrent illnesses) that would allow a highly probable presumptive diagnosis to be made.
But if a patient were to object to an HIV test, test , it would be unethical to do so, as it would constitute a lack of loyalty to the patient. If, after exhausting all remedies, the patient's refusal persists and the physician in conscience feels that not only does the necessary trust to continue the relationship with the patient is lacking, but that the professional relationship is so impoverished in quality that it is placed in an absurd and deliberate status of uncertainty that it forces unfounded decisions, then the physician may terminate the relationship in the absence of the requisite trust. As the UK GMC document of June 1993, HIV Infection and AIDS: Ethical Considerations, states: The doctor/patient relationship is based on mutual trust, which can be fostered only if information is exchanged freely, honestly, openly and with understanding between doctor and patient. Acceptance of this principle is fundamental to solving the problems that often arise in AIDS care.
There has been much debate as to whether there are circumstances in which it is justified to carry out an HIV test without the patient's consent and behind his or her back, test . status The following scenario is already common: a doctor suspects that a patient, who is to undergo an invasive examination or surgery, may be HIV-positive and, in order to take precautions to avoid infecting the patient's caregivers, decides to perform an HIV test without informing the patient.
For many physicians, the reasons for such conduct are obvious: to avoid risk to the physician and his staff and to spare the patient the suffering of knowing that he or she is under suspicion. But in the view of many other physicians such action is flawed: it violates the trust inherent in any doctor-patient relationship and deprives the patient of his right to consent or not to consent to an action that affects him - he has an inalienable right to be treated and respected as a capable person. Consequently, the physician must obtain consent: he must face the problem, speak frankly to his patient on the assumption that the patient is a moral agent capable, if properly informed financial aid , of making a fair and reasonable decision.
Only for those who offer blood, cells, tissues or organs for donation or transplantation should test be mandatory, and then their free acceptance cannot reasonably be doubted.
2. The ethical use of a positive result
The physician is obliged to make correct use of the positive result for the benefit of the patient. Once the positivity of the test has been duly confirmed, the doctor must communicate it to the patient, explaining the significance of the result to the patient with skill and humanity.
It is not easy to break the news to a patient that he or she is infected with HIV. However, the experience accumulated by many clinicians who are sensitive to the human values of medicine, advises always telling the truth, the whole truth, assuring them that they will never lack the doctor's attendance and leaving a way out open to hope. Communicating news that can turn the life of a human being around is an act that requires a great deal of professional skill . The therapeutic possibilities and prognostic perspectives should be explained with precision, always depending on the personality and clinical form of each case. It is true that some groups of AIDS patients, such as drug addicts, are very refractory to any committee or have a strongly diminished capacity to act responsibly. Thus, for example, he/she should inform the healthy HIV-positive patient about the prognostic possibilities open to him/her, and advise him/her about the hygienic measures he/she should responsibly apply in his/her daily life to eliminate the risk of infecting others and to receive antiretroviral treatment and prevention of opportunistic infections. The patient with an AIDS-related infection should be provided with objective information about the possibilities of treatment and about the ethical and administrative requirements to obtain it.
IV. Professional secrecy
The patient is the sole holder of diagnostic information. Physicians should help their patients to overcome the difficulties that may arise around diagnostic confidentiality by talking openly and honestly with them about the implications of their illness, the need to protect the safety of those with whom they live, or the need to provide medical care.
No one will be able to give you the care you need if you are not made aware of your specific status . But while anyone involved in his or her clinical care must be informed, the obligation to maintain confidentiality must be scrupulously guarded, given the potentially devastating effect on a person's reputation that a diagnosis of AIDS or even simple HIV seropositivity can have at knowledge dissemination . Care should be taken to avoid potential leaks of information. The number of people who know their diagnosis because they are actively involved in the patient's care should be kept to a minimum: issue .
When the patient is referred to another colleague, the patient may choose to inform the colleague either by asking the patient himself to disclose his condition to the new physician, or by informing the colleague in writing and with due assurance, after having advised the patient of this fact.
Frequent and seemingly venial breaches of this precept, endemic in some hospitals, such as officiousness, frivolous hallway or lift comments, and overly conspicuous conventional signs of seropositivity at the bedside or on the cover of medical records, must be vigorously condemned. Neglect of this kind subject can seriously damage the quality of the doctor-patient relationship.
But there is a limit to the obligation of secrecy. There are cases in which certain obligations of justice impose themselves on the conscience of the doctor with overwhelming evidence, since it is clear that it is necessary to avoid contagion in the family environment, and, when there is a serious and identified risk of contagion, in the work, social, sporting, etc. environment. Strictly informing those concerned constitutes an ethical duty of equal or greater force than that of preserving confidentiality. On such occasions the physician will try to persuade the patient that preserving confidentiality is more a malevolent complicity than a moral requirement, and will try to obtain the patient's consent to warn those at risk. If the patient refuses to do so, the physician may consider it his or her duty to inform the spouse or sexual partner.
V. Epidemiology and ethics
AIDS has been given exceptional status. The epidemiology of AIDS and the historical timing of its emergence combined to create a very special set of circumstances, totally new in the history of medicine. In its early years, the disease was predominantly linked to homosexuals, particularly in the United States. What made this circumstance particularly relevant was that white and class average -high gay men were organised as group for political and social action before the epidemic broke out. Consequently, they were in a position, and did so with all their energy, to demand a set of exceptions, privileges and rights, which had, as a first consequence, to install the disease on a plane of exceptionality. No one dared, in the face of the political and public power of homosexuals, to declare the disease compulsory.
The strongly contested internship of anonymous HIV screening has been recommended in many quarters in order to have data on the spread of the epidemic. In Spain, cases detected are reported anonymously and voluntarily to the National AIDS Follow-up Commission, which periodically publishes the incidence and mortality data . As a consequence of this voluntary speech , we have an incomplete knowledge of the real extent of the disease and our estimates of its future development remain inaccurate.
To remedy this status some have proposed the possibility of including HIV infection in the list of notifiable diseases. Almost all health experts agree agreement to exclude nominal reporting, as its epidemiological advantages are cancelled out by the rejection of such a measure. An acceptable alternative could be mandatory reporting with a guarantee of anonymity through the application of encrypted key systems that would be absolutely protected from the risk of information desecration. So far, no system has been found that would satisfy the most zealous protectors of secrecy.
topic However, the most ethically burning issue surrounding AIDS is the Education of the population with a view to reducing the number of infections. It is inevitable that in any "AIDSEducation ", alongside certain technical rules of daily hygiene, information, advice and recommendations are given to the public about so-called lifestyles, in particular about sexual behaviour and intravenous drug use.
Nothing test strengthens the power of the physician as a moral agent more than messages for the prevention of sexually transmitted diseases.
When the disease began to affect the general population in a tangible way as a result of casual sexual contact, the health authorities began, nine years ago now, to alert the population and to spread the warning that, in the absence of effective remedies, the only defence against the disease is the implementation of a vigorous preventive programme. The elements of this programme are basically an information campaign about the disease and the ways in which it is transmitted. The message is disseminated by means of leaflets sent by post to all citizens, advertising messages on television, radio and in the press, and also by facilitating the use of sterile syringes or teaching of simple procedures for their sterilisation among drug addicts, and finally by spreading the notion of safe or safer sex through the use of condoms or non-penetrative sexual practices.
I would like, between parentheses, to highlight a point that has been little commented on: the massive, practically universal, operation of destruction of innocence to which millions of children and adolescents have fallen victim on the occasion of the teaching of safer sex: the diabolical induction to which they have been subjected, through the didactic package of safer sex, to the internship of autoeroticism, of reciprocal masturbation, of light forms of homosexuality, all with the purpose aim of avoiding penetrative sex. The souls of an entire generation of innocents have been smeared with these perverse teachings. There is talk of the massive dimensions that child abuse is reaching in advanced societies, but it is difficult to find a parallel to this sexual abuse operation mounted by the rulers of many countries with the approval of advanced educators. I think this is an under-reported aspect of the sexual Education campaign, the psychopathological and spiritual effects of which will have 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 good preventive medicine that have presided over AIDS prevention campaigns in some places, but rather certain ideological prejudices, can be seen at sample what happened in Spain. It is worth knowing the history. In 1989, the Ministries of Health and Social Affairs jointly carried out a preventive campaign which, as everywhere else, had young people and adolescents as its main target group. It was the famous campaign in favour of condom use with the slogan ¡Póntelo, póntelo!
The message, in the different media, was conveyed with the festive and carefree air that is so flattering to certain young people, who are fond of joking about serious things. The campaign lacked any biological sense, reference letter to data scientific , to data quantitative efficacy. It was simply a psychological manipulation in favour of easy and protected sex. It acted as a further stimulus to youth permissiveness, because it made many believe that condoms, with their double effectiveness as contraceptives and STD prophylactics, are the magic talisman of pleasure, making those who use them invulnerable to all dangers and risks. We will have to wait until 1996 to see what effect the campaign has had on the incidence of AIDS.
The campaign was based on a serious, deliberate and tendentious distortion of a message that, lacking in itself any moralising intention and far removed from any religious connotation, dictated criteria based on the common, classical rules of preventive medicine. A substantial part of the message of simple preventive good conduct, proposed by the Centers for Disease Control, Atlanta, Georgia, must have been considered in the Spanish Ministries as an oppressive and puritanical rule and was eliminated with the stroke of a pen. This is the story.
The CDC, after mature reflection and lengthy expert discussions, published a series of articles on AIDS prevention in its official organ, the Morbidity and Mortality Weekly Report, throughout 1988. One of them, graduate Condoms in the prevention of sexually transmitted diseases, appeared in February 1988. In its Introduction, which I have translated in full, it stated the following: Prevention is the most effective strategy for curbing the spread of sexually transmitted diseases (STDs). Behaviour that eliminates or reduces the risk of one STD will probably reduce the risk of other STDs. Prevention of one case of STD may result in the avoidance of many subsequent cases by result . Continence and sexual intercourse with a mutually faithful and uninfected partner are the only fully effective preventive strategies. Correct use of condoms with every act of sex can reduce, but not eliminate, the risk of contracting an STD. Individuals who are susceptible to infection or who know they are infected with human immunodeficiency virus (HIV) should be aware that condom use cannot completely eliminate the risk of transmission to themselves or others. The bulletin Epidemiological Weekly, of the Spanish Ministry of Health and Consumer Affairs, reproduced, almost a year late, the above-mentioned article of the MMWR. This is obviously a censored article . The translated text lacks the lines in the Introduction that read: Continence and sexual intercourse with a mutually faithful and uninfected partner are the only totally effective preventive strategies. And missing, in the final paragraph, are these others: Recommendations for the prevention of STDs, including HIV infection, should emphasise that the risk of infection is only efficiently nullified by continence or sexual intercourse with an uninfected and mutually faithful partner.
The Ministry of Health officials must have found the deleted phrases inappropriate in a scientific, tolerant and sexually liberated context. In order not to run the risk of appearing moralistic, they crossed out these phrases because of their ideological prejudices, without realising that they were destroying a strictly hygienic and health-related rule . And they were wrong: because sexual abstinence and sexual intercourse with an uninfected and mutually faithful partner, as well as being human behaviour full of dignity and moral value, constitute a biological behaviour full of common sense and preventive efficacy.
It is a pity that those who launched that and this campaign did not ask about the results of similar campaigns in other European Community countries a year or two earlier. They would have learned, for example, that these campaigns had encouraged the internship of promiscuity, of casual sex as a game; that, after the campaign, the rate of condom use was still very low leave, as it did not reach, in most surveys, 25% of such sexual relations. As a Lancet publishing house noted, ...the results of the prevention campaign have, unfortunately,.... have ranged from disappointing to downright irresponsible. Behaviour change is the sure way to protect. But it seems that it has not been induced quickly and widely enough, even among high-risk groups. They would also learn that according to a survey conducted by the high school Allensbach Demoscopy in the then Federal Republic of Germany, more than 40% of boys and girls reproached the campaigners for their obsessive fixation on mere sexual biology, for the total absence of reference letter to moral values, to chastity, to faithful love.
And that is also the opinion of those who are seriously involved in sex Education . Dr. Theresa L. Crenshaw of San Diego, California, President of the association American Association of Sex Educators, Counsellors and Therapists, said in her testimony before the US congress , that for health reasons, people must be told that if they want to live safely, they must renounce casual and promiscuous sex. And while recognising that condoms (...) can help in the fight against AIDS, we must insist on the need to emphasise the importance of behaviour change. The resignation of many health authorities, who, faced with the irremediable threat of AIDS, are softly limiting themselves to slowing down its spread a little by recommending condoms, is gravely irresponsible. People need to be told clearly that they should avoid all sexual activity with anyone other than a 'committed partner'. The message from Dr Crenshaw and the association she chairs is this: people can change their sexual behaviour, but they won't if we don't trust them, if we don't talk to them clearly, if we just offer them sex light.
The Spanish condom campaign spread a gross epidemiological exaggeration. Instead of telling people that AIDS prevention has to be taken very seriously, that prevention is not simply better than cure, but that it is the only cure we have, it deceived everyone by saying that condoms are very safe. Ideological fanaticism led a senior official of the National AIDS Plan to declare on TV that condoms are 100 per cent safe.
In fact, people do not believe in the claimed efficacy of condoms. What do we actually know about the efficacy of condoms? A colleague, a Professor of Public Health at a Spanish University, agnostic but scientifically upright, was asked one day at class about the real effectiveness of condoms. He simply confessed that he did not know, which prompted him to make a critical and meta-analytical study of the literature on topic. He was surprised to find that many health authorities have provided fraudulent information, fabricating or exaggerating data. A serious analysis of the data of bibliography allows us to affirm that condoms can partially reduce HIV transmission, with an effectiveness of around 70%. The health Education of the population is of fundamental importance: doctors and health authorities should convey with sincere honesty the message that the protection provided by condoms is limited. Only in this way will individuals be able to adopt a conscientious behaviour manager .
Neither doctors nor ordinary citizens can forget a fundamental fact: the rules laid down by epidemiological experts, health politicians and demographers depend directly on the idea that they, the experts, each and every one of them, have of man and humanity. Underlying all political decisions and, for that matter, all health policy decisions, is a particular anthropology, a specific way of understanding mankind, the one professed by the politician, the health expert, or those who at any given moment run the WHO, PAHO, or the CDC. But such behaviour is inhuman, it is not acceptable. It is tantamount to imposing on others, by force of legislation or regulation management assistant, a private ethical opinion, which in the case of the safe sex campaign presupposes, at the very least, a merely zoological idea of man, an idolisation of sexual liberation, and a defeatist morality, which thinks that most young people are sex addicts, are programmed for promiscuity, prefer erotic love to chaste love, trivialised enjoyment to a commitment to fidelity.
VI. research clinical
There have been, and are, no shortage of problems here either. Rigorous clinical trials take too long, too long for those who see death approaching. And they cost too much money, which seems too little to those whose survival depends on the finding of a life-saving remedy.
Among the factors that define AIDS as an exceptional, privileged disease is the enormous, disproportionate amount of money spent on research. Predictions of the future expansion of the epidemic and the special health policy that advanced countries have adopted in the face of it, make the search for agents to prevent and treat the disease an enormously attractive venture for the pharmaceutical industry. The precedent set by zidovudine, the drug that single-handedly dominated the antiretroviral market until recently, has prompted many pharmaceutical firms to invest heavily in the search for new drugs to treat HIV-infected people. The work of research and the fight for market share is feverish.
Another unique aspect of AIDS has been the decisive influence that certain activist groups have had on the way research is conducted. They began by pushing for speeding up the slow essay and licensing procedures for drugs to treat the disease. group They won many concessions through their street demonstrations, their lobbying of political bodies, their active presence at scientific congresses, and their negotiations with pharmaceutical companies to lower the price of available drugs or to force an accelerated essay of new ones. With the help of the media financial aid and an effective mix of violent intimidation and rational discussion, they have succeeded in changing the Food and Drug Administration's rigid rules on clinical trials.
Researchers, who obviously have an absolute need for patients infected with the virus to conduct their therapeutic trials, have had no choice but to accede to many of the activists' demands in the face of their threat to boycott ongoing experiments. Using all their political power, which in the United States is considerable at both local and national levels, the AIDS lobby has managed to put research on the top of the list of priorities for money. They have argued that AIDS is different from other diseases because, being epidemic and infectious, if an effective drug or vaccine could be discovered, the problem would be solved once and for all. They add, with a peculiar view of social justice, that AIDS attacks young people, whereas cancer and heart disease usually attack people who have lived long enough.
What has been the result of this interventionism in the scheduling and conduct of clinical trials? Not too encouraging. On the positive side, the requirement that the group control must always receive the best treatment available has been reinforced, even if this treatment changes during the duration of the trial essay; the exclusion criteria have been relaxed; trials in children have been carried out simultaneously with those in adults, and not later, as previously stated in the established rule ; and, finally, trials in pregnant women have been authorised, which had previously been practically forbidden. On the negative side, it must be acknowledged that the doors have been opened to a dangerous relaxation of the safety standards hitherto in force. Many tests carried out under the new practices have produced only confusing or useless results. Here, as in other fields, solidarity, which is the solid foundation of the generous and altruistic financial aid to AIDS patients, runs the risk, if separated from the criteria of scientific rigour and distributive justice, of turning into irresponsible predilection.
Epilogue
I will end now. Truly AIDS has been something of 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 behaviour among medical professionals. But it has also given rise to incredibly generous submission currents. Some went so far as to say it was a scourge from God: in reality, it is a grace, an opportunity. In the 14 years of the epidemic, we have been able to see, in the face of this great test, the formidable capacity of medicine and humanity to make mistakes, but also the marvellous strength that, thanks be to God, we men have to rectify these mistakes, to draw from them sometimes heroism and sanctity, sometimes a new proof of the wisdom of natural law.
Thank you very much.