Correspondence
AIDS Prevention
N Engl J Med 1996; 335:1398-1400October 31, 1996
- Article
To the Editor:
In his essay on the responsibilities of people with human immunodeficiency virus (HIV) infection to their sexual partners (June 6 issue),1 Bayer concludes that personal responsibility has a central role in AIDS prevention and that “matters of sexual ethics are not moralistic diversions. They are at the heart of AIDS prevention.” However, only a minority of HIV-infected people can be expected to tell their partners about their infections.2 The effectiveness of disclosure decreases in direct proportion to the increasing number of partners.3 Bayer and Toomey earlier acknowledged that many persons who know they are infected fail to inform their sexual partners; they stated that “it will be necessary for public health departments to undertake the task of notification.”4
Although matters of sexual ethics are important to individuals, they are not at the heart of AIDS prevention for the group at risk. Prevention requires adequate funding and authorization for health departments to receive reports of HIV infection so that partner notification, contact tracing, and counseling can be done effectively by those with the knowledge and expertise to do so. Many states still do not mandate the reporting of HIV infection in persons who do not have AIDS, making appropriate intervention impossible. As of 1992, only 30 states had any requirements for the reporting of such infections, and only 10 states required the patient's name to be reported in every instance. Since AIDS develops on average more than 10 years after HIV infection, delaying reporting until AIDS is diagnosed effectively negates programs aimed at controlling the epidemic.5 In 1996, 15 years after the first report of AIDS in the United States, the Florida legislature finally mandated the reporting of HIV infection. Ostensibly, this occurred after years of debate over whether requiring such reporting would decrease voluntary testing.
There is a real danger that Bayer's focus on sexual ethics as the heart of AIDS prevention will serve as ammunition for those seeking to ward off the enactment of national guidelines for the timely and effective reporting of HIV infection.
5 ReferencesDavid P. Johnson, M.D.
Bay Pines Veterans Affairs Medical Center, Bay Pines, FL 335041
Bayer R . AIDS prevention -- sexual ethics and responsibility. N Engl J Med 1996;334:1540-1542
Full Text | Web of Science | Medline2
Landis SE ,Schoenbach VJ ,Weber DJ , et al. Results of a randomized trial of partner notification in cases of HIV infection in North Carolina. N Engl J Med 1992;326:101-106
Full Text | Web of Science | Medline3
Marks G ,Richardson JL ,Maldonado N . Self-disclosure of HIV infection to sexual partners. Am J Public Health 1991;81:1321-1322
CrossRef | Web of Science | Medline4
Bayer R ,Toomey KE . HIV prevention and the two faces of partner notification. Am J Public Health 1992;82:1158-1164
CrossRef | Web of Science | Medline5
National survey of HIV infection reporting practices. Baltimore: AIDS Administration, Department of Health and Mental Hygiene, 1993.
To the Editor:
When people with HIV infection are sexually active, they put their partners at great risk of catching a dreadful and fatal disease. Why the lengthy and inconclusive discussion of the ethics of such behavior?
Saul B. Gilson, M.D.
469 Fort Washington Ave., New York, NY 10033To the Editor:
According to Bayer, I used the legal maxim “to one who consents, no harm is done” to argue that people who do not protect themselves from HIV and AIDS have no claim on those who infected them. The arguments I made in my book1 concerned only gay men and intravenous drug users. I referred to this maxim to show that according to it, when people freely consent to being harmed, they are not being wronged. I did not, however, argue that because people have consented to being harmed, they have no moral claim against others. In fact, I argued that some people with HIV or AIDS have a moral claim against society for certain compensatory benefits.1
Whether one has a moral duty to disclose one's HIV status depends on the context. The most important factor to consider is whether there is sufficient trust to support a duty to disclose. If we posit a duty to disclose HIV status, people will rely on the disclosure as a guide to how they should behave — that is, whether they should engage in protected or unprotected sex. Given what is at stake, the information they receive has to be trustworthy.
Trust is not a part of all sexual relationships; it is not a feature of impersonal sexual relationships. In that context, it would be foolhardy to trust sexual partners to disclose their HIV status. People in such relationships do not have the kind of incentives that would encourage them to tell the truth systematically. They do not have a long-term investment in the relationships. The same would not be true of other contexts in which it is reasonable to rely on the word of others. Although Bayer may regret the presence of the commercial maxim “let the buyer beware,” in the context of sexual relationships that maxim may be exactly what morality requires. As the moral principle “ought implies can” suggests, morality does not impose unrealistic duties on people.
Bayer calls the position that holds that there is a duty to disclose one of “personal responsibility,” and he calls the view that supports safe sex the “ideology of self-protection.” Surely, the latter is more aptly called the position of personal responsibility. People who practice safe sex are taking personal responsibility for what happens to them.
1 ReferencesPatricia M.L. Illingworth, J.D., Ph.D.
Northeastern University, Boston, MA 02115Author/Editor Response
Dr. Bayer replies:
To the Editor: It may appear to Gilson that AIDS prevention and sexual responsibility are simple matters. But what may seem obvious from the viewpoint of a person's responsibility to a partner becomes complex from the perspective of public health. How to prevent infection in a population without undermining individual responsibility is anything but simple.
Johnson suggests that moral considerations are not crucial to preventing AIDS. What is needed, he suggests, is reporting of the names of those with HIV infection and notification of their partners. But partner notification depends on being able to appeal to the infected person's sense of responsibility, so that the names of contacts who need notification can be obtained. More important, reporting the names of newly identified people with HIV infection and following that up by notifying the partners can play a useful part only at the time of diagnosis. People who are infected have not only a past but also a future, and in that future they may have many sexual partners with whom there are different degrees of psychological intimacy. The challenge, therefore, is to motivate them to protect those partners by using condoms and making clear that there is a risk of infection.
Illingworth's claims today remain no different than they were in 1990, when she published AIDS and the Good Society. 1 Her moral assertions rest on empirical assumptions about what people expect of each other in the context of sexual intimacy. These assumptions need to be examined. In an ongoing empirical study I am conducting with Robert Klitzman at the HIV Center for Clinical and Behavioral Studies at Columbia University, we have rarely found a person who was lied to or was deprived of information about a sexual partner's infection who did not respond with outrage. As relationships became more emotionally intense, the expectation of truth telling increased.
Finally, after my article appeared, I received a letter from the associate director of one of the nation's oldest AIDS service organizations informing me that that organization had come to recognize the importance of altruism to AIDS prevention and had embarked on a thorough review of its efforts, so that this moral concern could be taken into account. With those on the front lines of prevention coming to recognize that the model of self-protection is insufficient, it is now time to confront the difficult questions posed by this new perspective with clear thinking and systematic empirical investigation.
1 ReferencesRonald Bayer, Ph.D.
Columbia University School of Public Health, New York, NY 10032- Citing Articles (1)
Citing Articles
1
Gary Marks, Scott Burris, Thomas A. Peterman. (1999) Reducing sexual transmission of HIV from those who know they are infected: the need for personal and collective responsibility. AIDS 13:3, 297-306
CrossRef
