World Council of Churches

A worldwide fellowship of churches seeking unity, a common witness and Christian service

CHAPTER 4 Ethical Perspectives

CHAPTER 4, Ethical Perspectives

01 January 1970

The HIV/AIDS pandemic confronts Christians and churches with many difficult ethical questions. How should churches respond to their own members who are living with or affected by HIV/AIDS? Should churches actively promote measures to limit the spread of HIV infection? How should resources for care, prevention and basic research be distributed? How can conditions favouring the spread of HIV/AIDS be corrected - and what do the churches have to say about such matters? What is the individual responsibility of Christians in this area? How can Christians and the churches decide about such matters?

The distinctive character of Christian ethical reflection

In approaching the challenge of HIV/AIDS, Christians are motivated by urgent imperatives passionately felt: to show Christ's love for the neighbour, to save lives, to work for reconciliation, to see that justice is done. Making decisions in this area, however, requires gathering the latest and most accurate information, wrestling with deeply sensitive issues and weighing differing and sometimes conflicting views and interests. That is to say: the passionate concern must energize and inform a process of discernment, which needs to be undergirded by Bible study, prayer and theological reflection.

Christians make ethical choices in accordance with certain principles, which follow from their understanding of the biblical witness and their faith convictions. These are stated in various ways by different Christians and Christian traditions, but they are likely to include the following points:

  • because all human beings are created and beloved by God, Christians are called to treat every person as of infinite value;
  • because Christ died to reconcile all to God, Christians are called to work for true reconciliation - which includes justice - among those alienated one from another;
  • because we are "members one of another", being built up by the Spirit into one body, Christians are called to responsible life within community.

Applying these principles - the infinite value of each person, the gospel imperative for reconciliation, the call to responsible life within community - to the concrete challenges HIV/AIDS poses day by day to Christians and the churches involves gathering information about each specific problem, exploring all available options, weighing the benefits (and potential difficulties) of each and finally asking, "which of the possible courses of action best expresses Christ's love for all those concerned?"

This process of discernment is often difficult: the results of various courses of action may not be fully evident, none of the available options may be wholly satisfactory, the biblical mandate for some contemporary situations may not be clear, or Christians may disagree on how to apply a particular theological principle to a specific problem. This makes it all the more important that Christians and churches reflect on the ethical issues together rather than separately, that they respect and dialogue with views different from their own and that they work together to respond to the challenges posed by HIV/ AIDS to both church and world.

Churches are expected to give both spiritual direction and moral guidance - not only within their own communities but also in the larger society - about issues raised by the HIV/AIDS pandemic. Thus in addition to their internal and ecumenical discussions, they should continue to play a responsible role in discussions of such issues in society as a whole, including more specialized considerations of biomedical ethics. Speaking from their own faith convictions they enrich the wider debate, in which they encounter those who appeal to general ethical principles such as the unconditional value of all persons, benevolence and justice.

Of the crucial contributions the churches have to make to this wider debate, two may be mentioned. First, because of their commitment to truth , the churches should emphasize the need for accurate information and for open discussion of the issues in the process of ethical decision-making. The process of discernment leaves no room for judgments based on superficial generalizations or stereotypes, on fear, or on incomplete or false information. It is essential to draw on medical and other expertise for an accurate factual understanding of the challenge of HIV/AIDS, though this is a background to - and not a substitute for - the process of ethical decision-making itself. The churches can do much to promote, both in their own lives and in the wider society, a climate of sensitive, factual and open exploration of the ethical issues posed by the pandemic.

Second, in accordance with their emphasis on personal and communal responsibility , the churches should promote conditions which support persons in making ethical choices. Speaking of personal responsibility implies a degree of personal freedom. This is directly related to the HIV/AIDS pandemic: it is well known that HIV spreads more freely when cultural and socio-economic factors make the exercise of personal and social responsibility difficult. Indeed, many persons today are so disempowered that they have lost the freedom to choose courses of action which are ethically and practically better. For example, women, even within marriage, may not have the power to insist on the practice of such effective preventive measures as abstinence, mutual fidelity and condom use.

The churches' ethical response to the issues raised by HIV/AIDS is inspired by the gospel. If this response is to make its strongest and widest witness and help as many persons as possible, it should commend itself not only to those within the church but also to reasonable people of good will in modern pluralistic and secularized societies.

To be convincing, this response will have to be informed . Entry into the ethical dialogue requires a comprehensive knowledge of basic ethical principles, a grasp of the personal and social dimensions of the problem, and clear scientific and technical information. A well-informed, transparent and verifiable ethical discussion and decision-making process on the part of the churches will surely meet with a ready response today. People in all societies have high expectations of receiving, through ethical considerations, answers to their burning questions and moral dilemmas. Churches in particular are looked to for moral guidance, and they have a unique opportunity to convey to the world a relevant message in a time of moral and political crisis. This message should be a contribution to a peaceful and just coexistence of individuals and nations.

The churches' witness is hampered by the considerable disagreement within the Christian community on how to approach certain ethical issues, threatening the spirit of "unity in diversity" which characterizes the ecumenical movement. The challenges and possibilities are identified in the following statement from the Joint Working Group between the World Council of Churches and the Roman Catholic Church:

Renewed expectations rise in and beyond the churches that religious communities can and should offer moral guidance in the public arena... Pressing personal and social moral issues, however, are prompting discord among Christians themselves and even threatening new divisions within and between churches... In a prayerful, non-threatening atmosphere, dialogue can locate more precisely where occur the agreements, disagreements and contradictions. And dialogue can affirm those shared convictions to which the churches should bear common witness to the world at large. Furthermore, the dialogue can discern how ethical beliefs and practices relate to that unity in moral life which is Christ's will. [1]

As the churches reflect on the meaning of the HIV/AIDS pandemic and look for solutions to the many problems it causes, they will inevitably engage in ethical discussion in the wider society. The following sections explore the relation between the perspectives and principles characteristic of this wider ethical reflection and the distinctive features of Christian ethical commitment.

Ethical perspectives and principles

Ethics is the systematic study of moral reasoning in theory and practice. It clarifies questions about right and wrong, but also demonstrates their complexity: most ethical theories, and many moral judgments, are contestable. Some norms, values or principles have found sufficiently wide agreement for codes of professional practice or laws to be based on them, but no ethical theory or decision-making method yields unequivocal conclusions which convince everybody. Too many different beliefs, philosophies, cultural backgrounds and life experiences influence our views of right and wrong. Nevertheless, meaningful and constructive frameworks developed by ethical reflection over the ages can be used to examine the facts and values in question, leading to a degree of consensus, or at least a mutual understanding of divergent views.

1. Ethical perspectives: two approaches

Ethical reflection asks about the "rightness" of particular actions. In the philosophical tradition, such reflection has proceeded from one of two starting points: either from the norms which are understood to govern human behaviour, or from the consequences which follow from that behaviour. A brief review of these two broad approaches - known as "deontology" and "consequentialism" (or "utilitarianism") respectively - will serve to introduce our discussion of specific forms of ethical reflection in the context of HIV/AIDS.

Deontology.
The doctrine of duty, or "deontology", is characteristic of some of the oldest ethical systems in all cultures. It focuses on the "intrinsic" or given duties and values formulated as commandments and rules for human behaviour, which determine our actions. These are understood to be a matter of principle and to have, in themselves, their own undeniable justification.

The formulation and justification of these deontological values can originate from different perspectives. The Ten Commandments in the Old Testament (Ex. 20:1-17; Deut. 5:6-21), for example, are an ethical code based on divine revelation. The Golden Rule - "Do to others as you would have them do to you" (Luke 6:31) - is found in the New Testament and echoed in varied forms in many world religions; it serves as a general guideline for assessing human behaviour. Deontological philosophical reasoning - for example, Immanuel Kant's "supreme moral law" ("Act only on that maxim which you can, at the same time, will that it should become a universal law") - is intended to convince all reasonable people by its inherent logic. In sum, there are, according to this approach, moral rules and values which can be regarded as being universal and as forming the basis for principles and ideals to be translated into concrete moral actions.

Consequentialism (utilitarianism).
Alternatively, consequential-ism or utilitarianism claims that the question of right or wrong is decided by the consequences of an action. The moral quality of an action does not depend on the action itself, but on its "utility" in benefitting persons, that is, its effectiveness in promoting happiness or in achieving the "greatest good for the greatest number". Since this theory is based on only one moral principle, the principle of utility, there can be no conflicts between alternative principles of behaviour: to arrive at a decision about right and wrong, it is necessary to calculate net benefits and to balance alternative solutions, taking into consideration the resources available and the needs of the people concerned.

The supremacy of utility as a principle does not mean that just any type of action can be justified so long as it results in greater benefit for a person or group of persons. A particular version of this theory, called "rule utilitarianism", regards truth-telling, respect for life, keeping promises and so on as essential elements of the fabric of human life. These moral rules are to be observed because the overall benefit of keeping them is greater than that derived from neglecting them, even if disregarding them in individual cases might produce some benefit. The principle of utility, however, is still regarded as the supreme principle in the event that moral rules come into conflict with each other.

2. Ethical principles

These obviously broad and general perspectives on ethical reflection need to be supplemented by more concrete principles of ethical analysis, which can serve as guidelines for making ethical decisions in specific situations, In the area of health-care ethics today, the most widely used framework incorporates four principles: (1) respect for persons, (2) beneficence, (3) non-maleficence, and (4) justice.[2] Each of the four principles represents a prima-facie duty - that is, each is morally binding unless it conflicts with one of the others. But the framework does not provide a method for choosing between conflicting principles or determining the scope of their application (for example, regarding the first, there may be disagreement about who counts as a "person").

While these general principles may be used to analyze ethical issues and problems in many fields, it is especially helpful here to explore them in relation to medical ethics. Doctors, nurses and other health-care professionals urgently need ethical guidelines when treating patients and others affected by HIV/AIDS, testing new drugs or seeking personal and social measures to limit the spread of the disease; and there has been intense ethical reflection within the health-care community on issues related to HIV/AIDS. This offers an important resource for Christian ethical reflection and can also illustrate how the four principles could be applied in other areas (for example, to ethical problems arising in pastoral care and counselling for those affected by HIV/AIDS).

In medical ethics generally, and in ethics related to HIV/AIDS in particular, problems often arise which involve extremely complex and intrinsically ambiguous issues. Facing a choice between different notions of what is "right" and "wrong" in a specific situation, one can often find "conclusive" arguments to support several or perhaps all of the possible decisions. In itself this set of principles cannot resolve such situations; there might be mutually-exclusive decisions, each of which is supported by certain of the principles while violating others. This creates an ethical dilemma: often the question facing us is not whether or not to violate certain theories or principles, but which possible alternative violates them more or less .

But even if these principles cannot in themselves resolve ethical dilemmas, they do add an accessible ethical dimension to the international scientific vocabulary and provide a common language in which to address, analyze and discuss questions of cross-cultural concern. An additional advantage is that this framework can be employed by the two main schools of thought in philosophical ethics (deontology and consequentialism or utilitarianism) and accepted by adherents of many religious traditions. Even when those with different philosophical or religious views qualify the principles or their scope, the common core language remains "ecumenical". Moreover, these particular principles were originally identified by examining ethical codes and standards (especially of the health-care professions) which had been deeply influenced by Judaeo-Christian history.

Principle One: respect for persons

While many would agree that a person cannot or should not be considered as a distinct entity outside of relationships or community, the focus of the term in this principle is the human being capable of exercising a degree of autonomy, however limited. Autonomy is, literally, "self-rule" - the capacity to think, to make decisions and to act, for oneself. It may be limited by immaturity, by lack of relevant information or by physical constraint. The capacity for autonomy is a matter of degree, and is greater or less in different persons at different times. Ensuring maximum respect for the autonomy of people who area inarticulate, impaired or constrained may require special skills in listening or enabling, or in the political arena.

To exercise their autonomy, people need access to relevant information on which to base their decisions, as well as a degree of liberty which ensures that they make these decisions without undue coercion or manipulation.

 

Principles Two and Three: beneficence and non-maleficence

Beneficence is literally "doing good"; non-maleficence is "not doing harm". The first of these principles speaks of the duty to enhance the welfare of other people if one is in a position to co so. The second reflects what has been considered the most important moral principle for physicians since the time of Hippocrates: "Above all, do not harm." Together these two duties require physicians to produce not medical benefit with minimal harm. In order to determine what is in the best interests of a person who is temporarily or permanently unable to express his or her own autonomy, not only medical evidence but also the insights of other carers and friends may have to be taken into account.

 

Principle Four: justice

The principle of justice or fairness is more wide-ranging than the previous three, and thus may be appealed to if they are in conflict. While the principles of respect for persons and beneficence are concerned more (though not exclusively) with individual ethics, justice is more concerned with social ethics, with the treatment of persons in communities, with the question of right and wrong actions within and between communities, societies or nations.

Justice is especially concerned with the distribution of goods, services and resources. All human beings are presupposed to be of equal worth; and attributes like status, gender, wealth or merit do not justify inequalities. Not all inequalities are unfair: people have very different needs, and while those with equal needs should be treated equally, those with unequal needs should be treated unequally, that is, differently but with, the claims of justice or fairness.

Justice is concerned with formulating criteria for resolving conflicts which arise between people because of widely differing conceptions of what people "deserve" or do not "deserve". These depend not only on a person's convictions, but also on his or her relative position within the local, national or global community. In the context of HIV;'AIDS, justice is related both to questions about the distribution of scarce resources in health cure and to the larger issues of poverty and economic constraints as contributing factors to the spread of HIV.

Christian and other ethical approaches in relation to the four principles

These principles are, as noted earlier, acceptable to the two main schools of thought in philosophical ethics. Respect for persons corresponds both to Kant's (deontological) imperative always to treat people as ends and not means and to John Stuart Mill's (utilitarian) requirement that everyone should be free to determine his or her own actions so long as these do not infringe on the autonomy of others. Both schools also accept beneficence and non-maleficence, although they may disagree on the scope of these principles, on how to work out their implications and on whether beneficence is an obligation for everyone or a praiseworthy virtue. Justice, too, is an agreed goal, though pursued by different strategies. For example, libertarian ethics leaves distributive justice largely to market forces, while egalitarian ethics demands that all people get the same share. Some theories restrict liberty in order to achieve a greater degree of justice; others (for example, Rawls's contract theory) give liberty priority over equality - but only if allowing inequalities is actually to the benefit of the least advantaged. [3]

Most other contemporary approaches to medical ethics are compatible with and complementary to the four-principles approach. Case-based methods, which attempt to revive the best methods of traditional casuistry, relate concrete examples to agreed principles. Narrative or story-telling ethics (which resembles the Christian method of telling parables) can also relate constructively to the four principles. Virtue ethics , which emphasizes that the right choices are most likely to be made by "good" people, focuses on other aspects of the moral spectrum which need to be taken into account. The same is true of care approaches, which emphasize context, relationships, the particular persons and circumstances involved and compassion.

The only serious effort to replace the four principles is the common morality approach. This offers a deductive method which, it is claimed, can find the correct answers to specific ethical questions. But there are two main difficulties with this: (1) the exclusive claims it makes for its own interpretations of "rationality" and "common morality" are contestable; (2) the proposed deductive system of decision-making is not only very complicated, but also depends on getting people to agree about a series of more or less abstract value judgments before they can reach the correct concrete judgment about the ethical question in hand.

Turning again to Christian ethics, another approach - which would also be relevant for general ethical behaviour - is proposed by H. Richard Niebuhr, who describes ethics-in-a-relationship as a "dialogue of responsibility". The two ethical questions Niebuhr discerns are "What is going on in this situation?" (in other words, one must be well-informed) and "What is the fitting thing to do?" (that is, the action which best fits the dialogue at this point and allows it to continue). Because the "fitting" action will depend on particular circumstances, it can never be specified in the abstract or in advance. Thus responsible discernment is required of those involved in making the necessary ethical choices. [4]

Christian ethics derives from theological reflection on Scripture and the churches' response to revelation. Rather than putting forward a single comprehensive ethical theory, it embraces principles and values drawn from historical and personal Christian experience and, for some, from natural law. It is deontological in seeing obedience to God's living Word as the supreme rule for conscience and community. But its incarnational and eschatological orientation regards as God-given the human freedom to respond to the complexity and ambiguities of ordinary moral experience - an opportunity to grow, through mutual forgiveness, in grace and understanding.

The WCC-Roman Catholic Joint Working Group text cited above also mentions other Christian resources, in addition to the Bible, for moral reflection. These include the liturgy, traditional moral teaching, catechisms and sermons, time-honoured pastoral practices, wisdom distilled from past and present experience, and the arts of reflection and spiritual discernment. Given the complex social, scientific and technical issues posed by HIV/AIDS in the modern context, it is important to recognize that

the biblical vision by itself does not provide Christians with all the clear moral principles and practical norms they need. Nor do the Scriptures resolve every ethical case...

Nevertheless, there is a general consensus that by prayerfully studying the Scriptures and the developing traditions of biblical interpretations, by reflecting on human experiences, and by sharing insights within a community, Christians can reach reasonable judgments and decisions in many cases of ethical conduct . [5]

These judgments and decisions of Christian ethics are in harmony with the four principles of bioethics as described above. But they also go beyond them, since they derive from notions of relationship. God relates to all creation, both its human and non-human aspects, which in turn are in relation with each other. Thus a principle such as the autonomy of persons may be found in the unconditional value of all creatures (Matt. 10:29-30), or in Paul's respect for the conscience of the Gentiles (Rom. 2:4). Yet as God not only respected the freedom of the world but also loved it (John 3:16), so Christians should not only respect the autonomy of others, but ought to love their neighbours also.

For Christians, beneficence is a basic duty, but Christian ethics goes beyond the moral rule of beneficence which is required of everyone at all times. Because it comes within the command to "love your neighbour as yourself' (Matt. 22:39; Mark 12:31; Luke 10:2528), beneficence, wherever possible, includes benevolence (or goodwill). Jesus taught as a characteristic feature of the values of the kingdom of God not only doing what is required by law but doing more out of love: going also "the second mile" (Matt. 5:41). [6]

While we may not find a comprehensive theory of distributive justice in the Bible, "justice" is an important and frequently-used biblical concept. It is a relational concept asserting the inescapable interrelatedness of all things. Equality is again supported by the story of creation itself, and the Bible reminds us repeatedly that our first and foremost concern has to be those who are in greatest need. In Old Testament terms, those in greatest need were the widows, orphans and strangers, towards whom all Israelites had special obligations. In the New Testament it is the poor, despised and marginalized who first understand the message of the kingdom of God, and Jesus Christ meets us in the least of his brothers and sisters. It must be remembered that all these groups are exactly those who are nowadays most affected by HIV/AIDS.

Ethics applied to some issues raised by HIV/AIDS

The bioethical problems raised by HIV/AIDS are often complex and ambiguous, and the arguments for one choice or another are seldom if ever conclusive. Yet practical decision-making is urgently required. The people involved in this decision-making are of all faiths or none, and differentiating among the possible solutions requires sound facts and technical information. In order to go beyond rhetoric, therefore, Christian ethical insights in this realm must first be expressed in a language that can be understood by all informed people of good will, then translated into meaningful action. The application of the four principles to the particular problems and questions posed by HIV/AIDS can be regarded as a touchstone for the validity and the soundness of the arguments. In what follows we shall look more closely at nine of these issues.

1. Discrimination

Discrimination against people living with HIV/AIDS unfortunately occurs in all societies and communities, and has become an important obstacle to effective means against the further spread of the pandemic. Discrimination makes the whole community - both those who discriminate and those discriminated against - more vulnerable to the spread of HIV. In a situation of stigmatization, prejudice and gossip, both groups are less likely to accept the presence of HIV in the community and to co-operate in the prevention of the factors which lead to increased vulnerability to HIV. Resistance to discrimination against people affected by HIV is thus an integral part of prevention.

All the ethical principles require that no one be discriminated against because of attributes such as race, gender, religion or being affected by a particular disease. The principles of beneficence and non-maleficence are clearly violated in the case of discrimination, since it causes considerable harm not only to those who are discriminated against but also, eventually, to those who discriminate. Again, justice demands that people be treated equally and fairly so that they receive the care and attention they need.

2. Confidentiality

Confidentiality means that information which persons wish to keep to themselves or share only with a person they trust (such as a doctor or counsellor) in fact remains secret. Such a relationship of mutual trust is protected by special obligations. Confidentiality of personal health information is implied by the principle of respect for persons, and required by traditional medical ethics. Lack of privacy inhibits responsible decision-making.

This fact is particularly important in relation to sensitive information such as a person's HIV serostatus, ways of infection or symptoms of AIDS. By maintaining confidentiality and trust, doctors or counsellors may have an opportunity to influence behaviour, thereby reducing the risk of the transmission of HIV infection to others; whereas disrespect for the principle of confidentiality may lead people infected with HIV to fear that their status could be disclosed to others, thus driving them underground and impairing the positive opportunities of the doctor-patient relationship.

However, there may be situations of conflicting principles, in which someone discloses his or her HIV serostatus to a doctor or counsellor but refuses to reveal it to others who are at risk through mutual relationships. The dilemma of the doctor or counsellor (which is heightened if he or she is caring for both partners) is whether to respect the first client's autonomy or to breach confidentiality in order to avoid potentially fatal harm to the partner. The principle of autonomy demands strict confidentiality and prohibits the disclosure of this information to a third party. The principles of beneficence and non-maleficence demand that the life of persons be protected by providing them information they need to avoid a serious infection. But that in turn may make it less likely that such information will be confined to doctors or counsellors in the future. So in this particular case respecting the duty of non-maleficence may have long-term consequences which are medically more harmful than beneficial.

Both principles have to be balanced, and each particular case has to be treated with extreme care and sensitivity throughout the process of ethical decision-making. Every attempt must be made to help the client to disclose the information to his or her partner voluntarily. Only when this fails utterly may the doctor or counsellor consider overriding the principle of confidentiality, always on a strict need-to-know basis. [7]

Decisions of this kind are agonizing for those who have to make them. In fact, they are relatively rare, since a normally trustful doctor or counsellor-patient relationship will almost always be able to avoid steps which might violate confidentiality. Much more common is the need to ensure that confidentiality is not breached inadvertently or carelessly.

3. Sex, AIDS and health education

In some cultural environments, people refuse to talk about sex, AIDS and aspects of sexual health. Many people of good will fear that more open talk about sex and sex education will result in a corresponding increase of promiscuous behaviour. Clearly the church has a moral responsibility to minimize communal and personal vulnerability to conditions in which sexually transmitted disease might spread, and education is a major contribution towards this goal (see above, pp.10-13).

In spite of understandable reservations, research has revealed that education about sex, AIDS and health in general, particularly with children and young people, does not result in increased sexual activity. [8] The responsibility of the church in facilitating sound, well-resourced education is thus evident.

Equipping people, particularly children and youth, with the ability to make sound moral decisions is the most effective way of achieving responsible moral behaviour. But education is more than knowledge. Increasing the number of facts people know will not necessarily turn them into well-equipped decision-makers. Effective education is responsive to the cultural context into which information is introduced, and involves the mutual participation of educators and students (see above, p.11).

4. Condoms

The promotion and use of the condom, a simple technical device to prevent the exchange of body fluids during sexual intercourse, has raised considerable concern among Christians and churches. Some have perceived this as contradicting the teaching that abstinence from or mutual fidelity within sexual relationships is the safest method of HIV prevention (see above, p.11). Others have also raised questions about the safety and efficacy of condoms, although a carefully designed study cited by the World Health Organization offers clear scientific evidence that the condom is a safe and effective means of protection from sexually transmitted diseases.

Condom breakage and slippage has been analyzed, both through studies in which participants have been surveyed about their condom use and through studies in which participants have been given condoms and asked to report on various aspects of their use. One US consumer survey of almost 3300 people reported condom breakage rates of less than one percent.

Laboratory studies have also boon carried out to assess leakage of a variety of micro-organisms, including HIV. These studies have demonstrated the ability of intact latex membranes to prevent the passing of HIV, herpes and hepatitis B viruses, cytomegalovirus and chlamydia trachomatis, even after mechanical stimulation.

Conclusion of the study :

Condoms, when used, consistently and correctly, are highly effective at reducing the risk of infection from HIV and other sexually transmitted diseases. Therefore, efforts focused on improving condom quality, availability and use represent a critical aspect of public health strategies to contain these diseases.

"A Response to Recent Questions about Latex Condom
Effectiveness in Preventing Sexual Transmission
of the AIDS Virus", prepared by the Program for Appropriate
Technology in Health (PATH),
Seattle , USA , January 1994

Ethical questions are raised in connection with the effects on behaviour of the use and promotion of condoms. Some would argue that the promotion of condom use might increase promiscuous sexual behaviour; while others contend that sexual behaviour is largely determined by other factors, and that what condoms affect is not the frequency of sexual intercourse but the unwanted consequences of this behaviour, that is, the sexual transmission of diseases.

So far, no conclusive studies have shown that the promotion and use of condoms influence promiscuous sexual behaviour. But the implications of the conflicting arguments here will be influenced by the ethical principles applied. For example, there might be a conflict between the desire to protect people's moral integrity by reducing incentives for sexual promiscuity and the desire to protect human life by averting a potentially lethal infection.

The principle of respect for persons favours self-determination, which would require promoting access both to information about protection from infection and to the protective device itself. On this view, even if condoms also have negative effects, it would be paternalistic to withhold from people the information they need in order to decide for themselves whether to use them.

If the promotion of condoms could reduce the risk of HIV transmission, the principles of beneficence and of non-maleficence would imply a moral obligation to save lives by enabling people to protect themselves. The principle of justice would demand that all those who need a protective method have access to it - and not only those who live in societies where these methods are freely available or who have the ability to pay.

Because of these arguments many Christian health professionals and counsellors have decided, on the grounds of pastoral responsibility and after careful consideration, to provide their clients with condoms when specifically requested. This is done without claiming that condom use is or should be the only answer to the question of HIV prevention. Condoms are only one of a range of methods to prevent HIV transmission. The primary aim must be to change behaviour and social conditions in a way which puts people at a lower risk of coming into contact with the virus. All choices have to be presented to the people concerned, and every effort must be made to empower them to make responsible decisions for their own lives, based on the options available according to current knowledge and experience.

After careful consideration of the ethical questions and of the technical details, the following conclusion was drawn: Without blessing or encouraging promiscuity, we recognize the reality of human sexual relationships and practice and of the existence of HIV in the world. Scientific evidence has demonstrated that education on positive measures of prevention and the provision and use of condoms help to prevent transmission of the virus and the consequent suffering and death for many of those infected. Should not the churches, in the light of these facts, recognize the use of condoms as a method of prevention of HIV?

5. Clean needles for people addicted to injectable drugs

Among people addicted to injectable drugs the sharing of needles and syringes is one of the principal ways of HIV transmission. Providing clean needles and syringes to those who use these devices is thus a method to prevent unintended HIV transmission caused by  unsterile instruments. As a technique, this does not pose any ethical problem. But since the use of certain injectable drugs, such as heroin, is illegal in many countries, and since societies try to discourage their use, the provision of the means to inject these drugs may be questioned ethically. [9]

Intervention programmes for drug addicts have used various methods of HIV prevention, including the introduction of needle-exchange schemes. Evaluations of comprehensive programmes in several cities have shown that the combination of these methods has been effective in regard to HIV prevention without increasing the use of drugs. [10] There is thus a strong moral obligation, based on all four of the principles, to apply these methods, since they have the potential to save lives.

Again it should be remembered that needle-exchange programmes and other interventions are only one method for reducing the many risks and threats to human life posed by the use of narcotic drugs. The best way, of course, of reducing HIV transmission through infected needles would be the primary prevention of drug use itself. All programmes, irrespective of their methods, should be culturally acceptable, accessible and based on voluntary participation.

After careful consideration of the ethical questions and of the technical details the following conclusion was drawn: Without blessing or encouraging the use of narcotic, intravenously applied drugs, we recognize the reality of human addiction to these drugs and the practice of sharing needles for the application of these drugs, which carries a high risk of HIV transmission. Studies on established programmes have demonstrated that education and the provision of clean needles help to reduce the risk of viral transmission and the consequent suffering and death for many of those infected by this way. Should not the churches, in the light of these facts, recognize the need for appropriate education and for the provision with clean needles for all those who are addicted to injectable drugs?

6. HIV testing

Respect for persons requires that no one should be forced to undergo a diagnostic or therapeutic procedure affecting his or her future without all the information needed to make an independent and informed decision about whether or not the procedure should be performed. Explicit consent is not required for all laboratory tests. For routine investigations which carry no particular risk and are necessary for treatment, a patient's general consent or evident wish to be treated is sufficient. But the HIV test is different from such routine investigations, not only because the condition diagnosed is still incurable, but also because of its personal, social and economic consequences for the people concerned, who will face discrimination and stigmatization once their infection is made public.

Therefore HIV testing should be done only if informed consent of the person concerned has been obtained without any form of coercion or persuasion, and if appropriate pre- and post-test counselling is provided. This implies that compulsory HIV testing for any purpose - including testing for admission to jobs, education, entry into countries, medical treatment - is to be regarded as unethical. Moreover, testing before marriage, if recommended, must be voluntary on the part of both partners.

Voluntary testing, in combination with counselling and under strict observance of confidentiality, is often requested by people who would like to know their HIV-serostatus to help them to make responsible decisions about their future life. This service should be made available wherever possible.

A potential conflict could arise between the individual rights of a person infected with HIV and the rights of a society wishing to protect a large number of its members by control mechanisms which restrict those individual rights (see below, pp. 73-74). Arguments of utility have been used during some past epidemics to justify overriding the individual's rights to informed consent or to confidentiality in favour of the rights of the majority. In practice, however, these extreme measures are neither necessary nor useful in the case of HIV infection. Taking into consideration the experience after the first decade of the HIV pandemic, there is now international agreement that the best way of prevention is providing information and seeking voluntary co-operation - not coercion or compulsory testing.

7. Research

Several ethical problems are posed by research related to HIV/ AIDS, including research on human subjects in the development of new drugs, access to experimental drugs by desperately ill patients and guidelines for the conduct of vaccine development and trials.

International codes and guidelines regulate ethical preconditions for all research studies involving human subjects. The Nuremberg Code (1947), the Declaration of Helsinki of the World Medical Association (1975) and the International Guidelines for Ethics and Epidemiology of the Council for International Organizations of Medical Sciences (CIOMS) (1990) protect the rights of those who take part in any form of trial in the search for new treatments or vaccines. These codes clearly state that persons should only be invited to participate voluntarily, and after informed consent has been given, in trials which are scientifically worthwhile and in which the risks to subjects have been minimized.

Trials related to HIV/AIDS are no exception to this, but problems arise when taking part is the only hope desperately ill patients have for receiving any potentially effective treatment. The principle of non-maleficence obliges researchers to increase only slowly and in careful stages the number of persons receiving an experimental therapy, as evidence accumulates of its effectiveness and of the absence of harmful side-effects. This may conflict with the autonomy of patients who wish to decide for themselves whether or not to risk the side-effects of a potentially beneficial therapy. Yet if the wishes of too many such patients are granted, the trial may be invalidated, an unproven or even harmful drug promoted and research on promising alternatives delayed - all to the detriment of future patients. Such conflicts can be overcome only by the ethical sensitivity, forbearance and mutual understanding of researchers and patients alike.

Research on experimental therapies may require that some subjects receive, for purposes of comparison, not the therapy itself, but a placebo - something ineffectual and harmless which however looks like the actual therapy. The ethical problems of this are intensified in HIV vaccine trials. Research into the effectiveness of an experimental vaccine may require the subjects to be at continuing risk if the trials are to demonstrate whether a potential vaccine is effective or not. Here the ethical problem is compounded by the possibility that participation may create a false sense of security and also that the risk could be reduced by health education.

In addition to these concerns following from the principle of non-maleficence, there are considerations of justice, which arise when those recruited are too poor or too ill-informed to decline to participate. At the very least, justice requires that risks and benefits in the development, production and distribution of potential therapies and vaccines are shared globally, without placing vulnerable groups or countries at a disadvantage.

8. Allocation of resources

The just allocation of resources is a major presupposition for an adequate care of people living with HIV/AIDS and for effective prevention of the spread of the infection. This applies to all levels of social and economic structures.

At the community level, personal, financial, emotional and spiritual resources must be mobilized to achieve the full participation of persons living with AIDS in the life of the community, and to give them the care required for their physical and emotional well-being. At the national level HIV/AIDS has to receive the degree of attention, support from leaders in society and government and mobilization of resources which is warranted by the significance of the problem, in terms both of the human suffering involved and the social and economic implications of the pandemic for the country. Globally, the international community has to ensure that adequate measures are taken for the fight against a worldwide pandemic, which affects all regions and continents.

So far, the distribution of resources for the treatment and care of AIDS patients and the prevention of HIV transmission has been extremely unequal: although more than 80 percent of all HIV infections occur in less-affluent countries, they receive only a small portion of the international resources spent on HIV/AIDS. [11] This raises serious questions of distributive justice. Justice requires the most care for those in greatest need. This means, in practice, that available resources should be redistributed, giving all countries a fair share and enabling them to establish programmes adapted to their local situations. From a short-term political and economic perspective, this may seem unrealistic. But the aims of such an action - to reduce both the burden on those directly affected and the further spread of the infection - is consonant with the global common good at a time when, economically as well as epidemiologically, world populations are becoming increasingly interdependent.

9. The duties of health professionals to treat persons living with AIDS

Unfortunately, there are reports of people living with HIV/AIDS being refused entry to health-care institutions - including those of the churches - and of being refused by individual health-care professionals whom they have approached for treatment, help or advice. Neither ethically nor historically can these attitudes be justified. Access to health care is a right for all persons, including those infected with HIV. There are no medical or moral grounds for any restriction of this right.

Some health professionals have referred to the increased risk of contracting HIV which might arise from treating persons living with AIDS. This concern is not supported by the studies so far conducted on the occupational risks of health professionals. Very few health professionals who are HIV-positive can be proven to have contracted the infection though actions related to their professional duties.

Given proper observation of normal precautions, the risk of acquiring the infection occupationally is very small. Statistically, a needle prick with HIV-infected blood will lead to an infection in only three cases in a thousand. [12] Consequently the international bodies regulating professional conduct have so far insisted that people infected with HIV should be treated in the same way as other patients; and the refusal of treatment would be considered as a gross violation of the rules of professional conduct. This view would be supported by all four of the principles of bioethics.

 


[1]   "The Ecumenical Dialogue on Moral Issues: Potential Sources of Common Witness or of Divisions. A Study Document of the Joint Working Group of the Roman Catholic Church and the World Council of Churches," 1.2-4, The Ecumenical Review , Vol. 48, no. 2, April 1996, pp. 144f.

[2]   See Tom Beauchamp and James Childress, Principles of Biomedical Ethics , 4th ed., New York, Oxford UP, 1994; Ranaan Gillon, Principles of Health Care Ethics , Chichester, UK, John Wiley & Sons, 1994.

[3]   John Rawls, A Theory of Justice , New York , Oxford UP, 1972, p.302.

[4]   See H. Richard Niebuhr, The Responsible Self: An Essay in Christian Moral Philosophy , New York , Harper & Row, 1963.

[5]   "The Ecumenical Dialogue on Moral Issues", III.1, loc. cit ., p.147.

[6]   John Habgood, "An Anglican View of the Four Principles," in Gillon, op. cit ., pp.55-64. 7 Kenneth Boyd, "HIV Infection and AIDS: The Ethics of Medical Confidentiality".

[7]   Kenneth Boyd, "HIV Infection and AIDS: The Ethics of Medical Confidentiality", Journal of Medical Ethics , Vol. 18, 1992, pp. 173-79.

[8]   Results of the Research Study "Does Sex Education Lead to Earlier or Increased Sexual Activity in Youth?", by M. Baldo, P. Aggleton and G. Slutkin of the WHO, as presented at the IXth International AIDS Conference, Berlin , June 1993, documentation no. PO-D 02-344.

[9]   M. O'Brien, "Needle Exchange Programs: Ethical and Policy Issues", AIDS & Public Policy Journal , Vol. 4, no. 2, 1989, pp.75-82.

[10]   Erik von Ameijden et al., "Interventions among Injecting Drug Users: Do They Work?", in AIDS, Vol. 9 (suppl. A), 1995, S75-S84.

[11]   Cf. "Vaccine Briefing", Global AIDS News (World Health Organization), no. 2, 1994, p.5.

[12]   D. K. Henderson, et al., "Risk for Occupational Transmission of HIV- I Associated with Clinical Exposures", in Ann. Int. Med. , Vol. 113, 1990, 740-46.

 

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