AIDS and Bioethics
Antonio Pardo.
department of Humanities Biomedical Sciences, University of Navarra.
article published in Ciencia Digital, December 2000, http://www.cienciadigital.net/diciembre2000/opinion_art.html
The emergence of acquired immune deficiency syndrome (AIDS) in the 1980s has changed the diagnostic orientation of many previously rare diseases that frequently present as a complication of this infection. But it has also brought back to the fore a series of medical ethics issues that seemed to be non-existent in the modern medical internship . For example, the risk of contracting a fatal infection from caring for a patient, an issue that seemed to have been forgotten with the advances in antibiotic therapy, has reappeared.
In order to outline the bioethical issues raised by AIDS, we will consider separately the aspects relating to prevention, diagnosis and treatment. We will touch only on very basic aspects, while others, for reasons of length, will have to remain unaddressed.
Prevention
The transmission of AIDS was initially linked in our environment to risky practices: homosexual relations and injecting drug addiction through the sharing of syringes. Today, the picture is changing, and the frequency of cases due to heterosexual intercourse is increasing every day. In fact, it is the most frequent route of acquisition in some countries.
To avoid transmission through needle sharing or sexual intercourse, the only effective measure is to eliminate these risky practices: curing the addiction, and "abstaining from sex or having sex with a healthy, mutually faithful partner are the only completely safe measures of prevention".1 In addition, the use of condoms can reduce the risk of sexual transmission.
Condoms are known to fail a lot2, especially when used by adolescents3. The reason for their failure (which varies between 8 and 31% according to programs of study) does not lie in their poor performance employment, although this factor may play a role, but in their inability to establish a net barrier in such an intimate contact . Moreover, their regular recommendation in official health campaigns leads to the false belief that they are effective, thus encouraging biologically dangerous relationships. It is B the irresponsibility of such campaigns, which lie openly or covertly, and not just about a trivial issue but about a risk of death.
In the same vein, the dissemination in some Spanish regions of an "anti-AIDS kit", consisting of a packet containing a syringe and a condom, shares the same health irresponsibility. In such campaigns, the only people who lose out are drug addicts, who are not helped as individuals to overcome their addiction, but rather are considered impossible and given the means to continue their fatal downhill slide, and those who have sex with the falsely safe condom.
Another aspect of prevention concerns vertical transmission, i.e. from a sick mother to her child. In the prevention of vertical transmission, it is only very recently that emphasis has been placed on the possibility of almost completely limiting transmission during pregnancy and breastfeeding. In the past, it was almost systematic to resource contraception or sterilisation of women to prevent the birth of sick children. Today, it has been shown that, with proper treatment, such transmission can be reduced to negligible numbers; this, coupled with the longer life expectancy of properly treated patients, opens the door to a full and satisfying family life for women with the disease. To suggest contraception or sterilisation to these patients from entrance is today an unnecessary cruelty that adds to the suffering of the disease.
Lastly, a vaccine is still awaited at development , in which great hopes are placed, especially by people who, for various reasons, may be infected, especially the staff healthcare workers who have to care for these patients. A vaccine for haemophiliac patients is less important today, as clotting factors are already being produced by means of engineering Genetics, without the need to resort to concentrates extracted from plasma, which are very easily contaminated.
Diagnosis
The diagnosis of AIDS poses a potential conflict of interests: on the one hand, knowing whether a person has the disease is essential to be able to treat him/her adequately, and to avoid the risk of contagion to third parties, especially the healthcare team that treats him/her. On the other hand, the patient may consider that the fact that it is known that he/she has the disease may mean that this information will be disseminated, with the consequent social discredit for him/her, and therefore prefer not even to go to test for diagnosis.
In this respect, an obligation of strict confidentiality of the care team is paramount. Only the guarantee of strictly observed professional secrecy4 allows for the trust necessary for the correct treatment of the patient, which would otherwise be practically impossible. This guarantee must start with cutting off hospital corridor comments, which endanger the patient much more than direct questions.
Medical confidentiality, however, is not an absolute obligation. In the face of possible harm to third parties or danger to society, the physician must urge the patient to disclose his or her illness to those who might be affected (in this case, especially a spouse or partner)5. If the patient refuses, the physician should disclose this secret, only to the extent necessary to avoid harm,6 just as a psychiatrist may do if he suspects that one of his patients may commit murder. Ideally, however, this should be done by the patient himself, in the presence of the doctor, so that he can clarify any doubts that the person concerned may have.
In any case, the medical team must take into account the real risks for third parties, without being misled by false alarmism: it must repeatedly make it clear to the public that living with a sick person on a daily basis, without sexual relations, is not contagious. This applies to the schoolmates of a sick child or to the partners of work. For this reason, it is often not necessary to disclose the patient's status , as it is not a danger to anyone. Such a knowledge dissemination could trigger problems arising from the prejudice of easy contagiousness, and bring the patient's reputation down, as the disease is almost automatically associated with the lifestyles mentioned above.
Treatment
When it comes to treatment, the basic ethical principle is non-discrimination of these patients, either because they may infect the health care team with a fatal disease, or because of the repulsion that may be caused by the lifestyle that has led to the disease7 . This does not mean that the healthcare team should act foolishly, subjecting themselves to undue risk: it is reasonable to take appropriate precautions, such as double-gloving employment at operating room, appropriate measures for the handling of the patient's biological secretions, etc.
One particular discrimination is that of differential access to treatment for people living in developed or resource-poor countries: a campaign is needed to facilitate access to treatment for these less affluent communities.
Finally, some of these patients, because of their radically disordered way of life, do not follow their medication properly and develop resistance to the usual drugs within a short period of time. It is also part of the ethics of AIDS to submit to the reasonable treatment suggested by the doctor.
Notes
(1) Morbidity ans Mortality Weekly Report. Condoms for Prevention of Sexually Transmitted Diseases, JAMA 1988; 259:1925-7. This sentence core topic was deleted in the Spanish translation of this report: bulletin Epidemiológico Semanal, 1988; nº 1801; 1-3.
(2) Guillén F, Aguinaga I. Effectiveness of condoms in preventing HIV infection in HIV-positive partners. Med Clin 1995; 105: 541-8.
(3) Alessandri R, Friedman Z, Trivelli L. Condoms and Adolescent HIV: A Medical Evaluation. Linacre Quarterly 1994 Aug; 61(3): 62-74.
(4) Alberola I, Moya J. El Sida: Medicina y ética. Madrid. Palabra, 1991. 173 pp.
(5) Spanish Medical Association. Code of Medical Ethics and Deontology, chapter IV.
(6) Id., art. 18.
(7) Id., arts. 4.2 and 21.1.