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Ethical Dilemmas in HIV Infection: What Have We Learned?

Published online by Cambridge University Press:  29 April 2021

Extract

The acquired immunodeficiency syndrome (AIDS) has raised perplexing ethical and public policy dilemmas. Early in the epidemic, closing of bathhouses, testing blood donors for human immunodeficiency virus (HIV) infection, and notifying seropositive blood donors evoked passionate controversies. Current dilemmas include testing and using promising new treatments, notifying partners of seropositive persons, and, most recently, restricting the clinical activities of seropositive health,care workers who perform invasive procedures.

These dilemmas about HIV infection involve scientific judgments, cultural norms, and social values. In the HIV epidemic, public rhetoric and political pressure have been prominent. On the one hand, some persons have launched moralistic crusades against homosexuals and injection drug users. For these persons, AIDS symbolizes the breakdown of traditional family values and the social order. On the other hand, some advocates for persons with HIV infection have used confrontational tactics such as sit-ins and disruptive demonstrations.

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Article
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Copyright © American Society of Law, Medicine and Ethics 1992

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References

Barnes, M., Rango, N.A., Burke, G.R., et al., “The HIV-infected Health Care Professional: Employment Policies and Public Health,” Law, Medicine & Health Care 1990, 18: 311330; Gostin, L., “The HIV-Infected Health Care Professional: Public Policy, Discrimination, and Patient Safety,” Law, Medicine & Health Care 1990, 18: 303-310.Google Scholar
Jonsen, A.R., Toulmin, S., The Abuse of Casuistry: A History of Moral Reasoning. Berkeley: University of California Press, 1988.Google Scholar
Bayer, R., “Public Health Policy and the AIDS Epidemic: An End to HIV Exceptionalism?” N Engl J Med 1991, 324: 15001504.CrossRefGoogle Scholar
Kolata, G., “Private Study of AIDS Drug: Guarded Praise and Warning,” New York Times September 20, 1989: A14.Google Scholar
Shilts, R., “S.F.-Based Group Reports on Underground Compound Q Tests,” San Francisco Chronicle September 20, 1989: A4; Hilts, P.J., “Severe Side Effects Are Seen in Experimental AIDS Drug,” New York Times September 27, 1989: A15.Google Scholar
Kolata, G., “Critics Fault Secret Effort to Test AIDS Drug,” New York Times September 19, 1989: B7.Google Scholar
Delaney, M., “The Case for Patient Access to Experimental Therapy,” J Infect Dis 1989, 159: 416–9.Google Scholar
Hulley, S.B., Cummings, S.R., ed., Designing Clinical Research. Baltimore: Williams and Wilkins, 1988.Google Scholar
Byar, D.P., Schoenfeld, D.A., Green, S.B., et al., “Design Considerations for AIDS Trials,” N Engl J Med 1990, 323: 13431348.Google Scholar
Rothman, D., “Ethics and Human Experimentation: Henry Beecher Revisited,” N Engl J Med 1987, 317: 11951196.Google Scholar
Levine, C., “Has AIDS Changed the Ethics of Human Subjects Research?” Law, Medicine & Health Care 1988, 16: 167173; Levine, R.J., “Uncertainty in Clinical Research,” Law, Medicine & Health Care 1988, 16: 174-182.Google Scholar
Levine, C., Dubler, N.N., Levine, R.J., “Building a New Consensus: Ethical Principles and Policies for Clinical Research on HIV/AIDS,” IRB 1991, 13: 117.Google Scholar
Volberding, P.A., Lagakos, S.W., Koch, M.A., et al., “Zidovudine in Asymptomatic Human Immunodeficiency Virus Infection,” N Engl J Med 1990, 322: 941949.Google Scholar
See supra note 12.Google Scholar
Fletcher, R.H., Fletcher, S.W., Wagner, E.H., Clinical Epidemiology. Baltimore: Williams & Wilkins, 1988; see also supra note 8.Google Scholar
Byar, D.P., Simon, R.M., Friedewald, W.T., et al., “Randomized Clinical Trials: Perspectives on Some Recent Ideas,” N Engl J Med 1976, 295: 7480; Sacks, H., Chalmers, T.C., Smith, H., “Randomized versus Historical Controls for Clinical Trials,” Am J Med 1982, 72: 233-240.Google Scholar
Sacks, , et al., supra note 16.Google Scholar
Ruskin, J.N., “The Cardiac Arrhythmia Suppression Trial (CAST),” N Engl J Med 1989, 321: 386388.CrossRefGoogle Scholar
Fisher, B., Constantino, J., Redmond, C., et al., “A Randomized Clinical Trial Evaluating Tamoxifen in the Treatment of Patients with Node-Negative Breast Cancer Who Have Estrogen-Receptor-Positive Tumors,” N Engl J Med 1989, 320: 479484; The EC-IC Bypass Study Group, “Failure of Extracranial-Intracranial Arterial Bypass to Reduce the Risk of Ischemic Stroke: Results of an International Randomized Trial,” N Engl J Med 1985, 313: 1191–1200.Google Scholar
Fischl, M.A., Richman, D.D., Grieco, M.H., et al., “The Efficacy of 3‘-Azido-3’Deoxythymidine (Azidothymidine) in the Treatment of Patients with AIDS and AIDS-Related Complex: A Double-Blind Placebo-Controlled Trial,” N Engl J Med 1987, 317: 185191; Leoung, G.S., Feigal, D.J., Montgomery, A.B., et al., “Aerosolized Pentamidine for Prophylaxis Against Pneumocystis Pneumonia. The San Francisco Community Prophylaxis Trial,” N Engl J Med 1990, 323: 769–75; See also supra note 13.Google Scholar
CDC, “Guidelines for Prophylaxis against Pneumocystis Carinii Pneumonia for Persons Infected with Human Immunodeficiency Virus,” MMWR 1989, 38 (supp 5): 19; Lambert, B., “U.S. Urges Treatment for Million with AIDS Virus,” New York Times July 9, 1989: A12.Google Scholar
“AIDS, Drugs, Need and Greed,” New York Times September 29, 1989: A18; Freudenheim, M., “One Hope for AIDS Patients Is Hostage to the Market,” New York Times September 3, 1989: E5; Hilts, P.J., “AIDS Drug's Maker Cuts Price by 20%,” New York Times September 19, 1989: A1; Kolata, G., “Criticized on AIDS Drug, Maker Giving Some Away,” New York Times October 12, 1989: A1, A15; Kolata, G., “AIDS Group Plans to Buy Drug for Less in Europe,” New York Times September 25, 1989: A11.Google Scholar
Whitley, R.J., “Gancyclovir—Have We Established Clinical Value in Treatment of Cytomegalovirus Infections,” Ann Intern Med 1988, 108: 452454.CrossRefGoogle Scholar
Freedman, B., “Equipoise in Clinical Trials,” N Engl J Med 1987, 317: 141145; B. Freedman, the McGill/Boston Research Group, “Nonvalidated Therapies and HIV Disease,” Hastings Center Report 1989, 14–20.CrossRefGoogle Scholar
Broder, S., “Controlled Trial Methodology and Progress in Treatment of the Acquired Immunodeficiency Syndrome (AIDS): A Quid Pro Quo,” Ann Intern Med 1989, 110: 417418.Google Scholar
See supra note 9.Google Scholar
Feinstein, A.R., “An Additional Basic Science for Clinical Medicine: II. The Limitations of Randomized Trials,” Ann Intern Med 1983, 99: 544550.Google Scholar
Cotton, D., Feinberg, J., Finkelstein, D., “Participation of Women in a Multicenter HIV Clinical Trials Program in the United States,” VII International Conference on AIDS. Florence: June 16–21 1991: Abstract Tu.D. 114; See also supra note 12.Google Scholar
Kolata, G., “U.S. Rule on Fetal Studies Hampers Research on AZT,” New York Times August 25, 1991: A13.Google Scholar
Jacobson, M.A., Bacchetti, P., Kolokathis, A., et al., “Surrogate Markers for Survival in Patients with AIDS and AIDS Related Complex Treated with Zidovudine,” BMJ 1991, 302: 7378.Google Scholar
See supra note 20.Google Scholar
Machado, S.G., Gail, M.H., Ellenberg, S.S., “On the Use of Laboratory Markers as Surrogates for Clinical Endpoints in the Evaluation of Treatment for HIV Infection,” J Acquir Immune Defic Syndr 1990, 3: 10651073.Google Scholar
The Cardiac Arrhythmia Suppression Trial (CAST) Investigators, “Preliminary Report: Effect of Encainide and Flecainide on Mortality in a Randomized Trial of Arrhythmia Suppression After Myocardial Infarction,” N Engl J Med 1989, 321: 406412.CrossRefGoogle Scholar
Kolata, G., “U.S. Panel Urging Sale of AIDS Drug Before Full Tests,” New York Times July 20, 1991: A1.Google Scholar
Kolata, G., “For New FDA Policy, Dismay and Delight,” New York Times July 28, 1991: A13.Google Scholar
Marshall, E., “Quick Release of AIDS Drugs,” Science 1989, 245: 245, 247; Hilts, P.J., “How the AIDS Crisis Made Drug Regulators Speed Up,” New York Times September 24, 1989: E5; Shilts, R., “A Testing Limbo for AIDS Drugs,” San Francisco Chronicle February 1, 1989: A1; Shilts, R., “AIDS Drug Approval System Under Attack,” San Francisco Chronicle February 2, 1989: A1; Shilts, R., “Speeding Discovery of AIDS Drugs,” San Francisco Chronicle January 31, 1989: A1, A8–A9.Google Scholar
Igelhart, J.K., “The Food and Drug Administration and Its Problems,” N Engl J Med 1991, 325: 217220.Google Scholar
See supra note 7.Google Scholar
Abrams, D.I., “Alternative Therapies in the Treatment of HIV Infection,” AIDSFILE 1989, 3: 12; Booth, W., “An Underground Drug for AIDS,” Science 1988, 241: 1279-1281.Google Scholar
Smith, R., “Doctors, Unethical Treatments, and Turning a Blind Eye. Questions after the Selling of an Unethical Treatment for AIDS,” BMJ 1989, 298: 11251126.Google Scholar
Hilts, P.J., “F.D.A., in Big Shift, Will Permit Use of Experimental AIDS Drug,” New York Times September 29, 1989: At; Kolata, G., “AIDS Studies Head Seeks Wide Access to Drugs in Tests,” New York Times June 26, 1989: A1.Google Scholar
See supra note 35.Google Scholar
See supra note 43.Google Scholar
Leary, W.E., “Payment Policy on New Treatments Draws Fire,” New York Times March 2, 1989: B6.Google Scholar
Sec supra notes 5 and 6.Google Scholar
Kolata, G., “Innovative AIDS Drug Plan May Be Undermining Testing,” New York Times November 21, 1989: A1.Google Scholar
See supra note 35.Google Scholar
Bok, S., Secrets. New York: Pantheon Books, 1982; Beauchamp, T.L., Childress, J.F., Principles of Biomedical Ethics, 2nd ed. New York: Oxford University Press, 1983: 228-237.Google Scholar
Gostin, L.O., “The AIDS Litigation Project: A National Review of Court and Human Rights Commission Decisions, Part II: Discrimination,” JAMA 1990, 263: 20862093.Google Scholar
Novack, D.H., Detering, B.J., Arnold, R., et al., “Physicians' Attitudes toward Using Deception to Resolve Difficult Ethical Problems,” JAMA 1989, 261: 29802985.Google Scholar
Beauchamp, T.L., Childress, J.F., Principles of Biomedical Ethics, 2nd ed. New York: Oxford University Press, 1983: 107147.Google Scholar
Bayer, R., Private Acts, Social Consequences: AIDS and the Politics of Social Health. New York: The Free Press, 1989.Google Scholar
Rutherford, G.W., Woo, J.M., “Contact Tracing and the Control of Human Immunodeficiency Virus Infection,” JAMA 1988, 259: 36093610.Google Scholar
Gostin, L., Curran, W.J., “Legal Control Measures for AIDS: Reporting Requirements, Surveillance, Quarantine, and Regulation of Public Meeting Places,” Am J Public Health 1987, 77: 214218.CrossRefGoogle Scholar
Association of State and Territorial Health Officials, National Association of County Health Officials, U.S. Conference of Local Health Officers, Guide to Public Health Practice: HIV Partner Notification Strategies. Washington, D.C.: Public Health Foundation, 1988; Special Initiative on AIDS, American Public Health Association, Contact Tracing and Partner Notification. Washington, D.C.: American Public Health Association, 1988; Toomey, K. Cates, W., “Partner Notification for the Prevention of HIV Infection,” AIDS 1989, 3 (suppl 1): S57-S62.Google Scholar
Andrus, J.K., Fleming, D.W., Harger, D.R., et al., “Partner Notification: Can It Control Epidemic Syphilis?” Ann Intern Med 1990, 112: 539543.Google Scholar
See supra note 57.Google Scholar
See supra note 3.Google Scholar
Rennert, S., AIDS/HIV and Confidentiality: Model Policy and Procedures, Washington, D.C.: American Bar Association, 1991: 1531.Google Scholar
Gostin, L.O., “The AIDS Litigation Project: A National Review of Court and Human Rights Commission Decisions, Part I: The Social Impact of AIDS,” JAMA 1990, 263: 19611970.Google Scholar
Fehrs, L.J., Fleming, D., Foster, L.R., et al., “Trial of Anonymous versus Confidential Human Immunodeficiency Virus Testing,” Lancet 1988, ii: 379382.CrossRefGoogle Scholar
Johnson, W.D., Sy, F.S., Jackson, K.L., “The Impact of Mandatory Reporting of HIV Seropositive Persons in South Carolina,” IV International Conference on AIDS. Stockholm: June 12–16 1988: Abstract 6020.Google Scholar
Judson, F.N., Vernon, T.M., “The Impact of AIDS on State and Local Health Departments: Issues and Few Answers,” Am J Public Health 1988, 78: 387393.Google Scholar
Devlin, P., The Enforcement of Morals. New York: Oxford University Press, 1965.Google Scholar
Kathleen K. v. Robert B., 150 Cal. App. 3d 992, 198 Cal Rptr. 273 (1984).Google Scholar
CDC, “Partner Notification for Preventing Human Immunodeficiency Virus (HIV) Infection—Colorado, Idaho, South Carolina, Virginia,” MMWR 1988, 37: 393396, 401-402.Google Scholar
Williams, A.E., Creedon, K.W., American Red Cross Collaborative Study Group, et al., “Behavioral Changes in Former Blood Donors in the Year Following Notification of HIV Seropositivity,” IV International Conference on AIDS. Stockholm: June 12–16 1988: Abstract 8064.Google Scholar
See supra note 55.Google Scholar
Rennert, S., AIDS/HIV and Confidentiality: Model Policy and Procedures, Washington, D.C.: American Bar Association, 1991: 6573.Google Scholar
Presidential Commission on the Human Immunodeficiency Virus Epidemic, Report of the Presidential Commission on the Human Immunodeficiency Virus Epidemic, Submitted to the President of the United States, June 14 1988: 7578, 119140.Google Scholar
See supra notes 58 and 73.Google Scholar
See supra note 73.Google Scholar
Sande, M.A., “Transmission of AIDS: The Case Against Casual Contagion,” N Engl J Med 1986, 314: 380382.Google Scholar
Redelmeier, D.A., Tversky, A., “Discrepancy between Medical Decisions for Individual Patients and for Groups,” N Engl J Med 1990, 322: 11621164.CrossRefGoogle Scholar
Calabresi, G., Bobbitt, P., Tragic Choices. New York: W.W. Norton & Company, 1978.Google Scholar
Edgar, H., Sandomire, H., “Medical Privacy Issues in the Age of AIDS: Legislative Options,” Am J Law & Medicine 1990, 16: 155222.Google Scholar
See supra note 72.Google Scholar
Cal. Health and Safety Code, §199.25 (West 1988 & Supp. 1990); N.Y. Pub. Health Law, §2780 et seq. (McKinney 1990).Google Scholar
American College of Physicians Health and Public Policy Committee, Infectious Diseases Society of America, “The Acquired Immunodeficiency Syndrome (AIDS) and Infection with the Human Immunodeficiency Virus (HIV),” Ann Intern Med 1988, 108: 460469; Council on Ethical and Judicial Affairs, “Ethical Issues Involved in the Growing AIDS Crisis,” JAMA 1988, 259: 1360-1361.Google Scholar
Lambert, B., “In War on AIDS, a Tangle of Rules about Tracing, Testing, and Telling,” New York Times July 9, 1989: E6.Google Scholar
Piorkowski, J.D., “Between a Rock and a Hard Place: AIDS and the Conflicting Physicians' Duties of Preventing Disease Transmission and Safeguarding Confidentiality,” Georgetown Law Journal 1987, 76: 169202; Gammill v. United States, 727 F.2d 950 (1984); Rodman, Davis v., 147 Ark. 385, 227 S.W. 612 (1921); Blackmon, Hofmann v., Fla., 241 So.2d 752 (1970); Derrick v. Ontario Community Hospital, 47 Cal. App. 3d 145, 120 Cal Rptr. 566 (1975).Google Scholar
Tarasoff v. Regents of the University of California, 551 P2d 334 (Cal 1976).Google Scholar
See supra note 56.Google Scholar
See supra note 52.Google Scholar
Keeton, W.P., Prosser and Keeton on the Law of Torts, 5th ed. St. Paul, Minn.: West Publishing Co., 1984: 179185.Google Scholar
Flora, J. A., Thorensen, C.E., “Reducing the Risk of AIDS in Adolescents,” American Psychologist 1988, 43: 965970.CrossRefGoogle Scholar
See supra note 58.Google Scholar
Brandt, A.M., No Magic Bullet: A Social History of Venereal Disease in the United States since 1880. New York: Oxford University Press, 1987.Google Scholar
Blendon, R.J., Donelan, K., “Discrimination against People with AIDS: The Public's Perspective,” N Engl J Med 1988, 319: 10221026.CrossRefGoogle Scholar
CDC, “Mortality Attributable to HIV Infection/AIDS—United States, 1981–1990,” MMWR 1991, 40: 4144.Google Scholar