This thoughtful reflection on a valuable questionnaire survey of patients' attitudes regarding being told that their dentist had been infected with hepatitis B is of very direct relevance to HIV, as the authors show.1 The measured tone and analytical approach are a welcome change from the stridency that has characterised some of the debate elsewhere. I am very conscious that more time and effort has gone into drafting and redrafting, amending, revising and refining policy in this area than in any (...) other area of HIV control, with the probable exception of blood transfusion. Yet this is the setting that has the lowest risk among all established routes. Why has it been so hard to establish a satisfactory policy and practice to deal with this situation?Many factors, of course, apply. However, much seems to stem from a prevailing view, fostered by recent political administrations, that health care can be delivered in a risk-free way. This has also been linked with a “blame culture”, where adverse outcomes are seen as someone's fault, and where the professions are regarded with distrust. It has been fuelled by levels of concern about risk for HIV that have stemmed more from media “stories” about risk than careful risk assessment.Hence Blatchford et al comment that public anxiety about HIV relative to hepatitis B was a factor in assessing how the incident was handled, implying that HIV was of greater concern - even though the risk of transmission is some two orders of magnitude less. Interestingly, they also comment that, because the risk of death with HIV is higher than for hepatitis B, this balances the overall risk. I am not sure of the validity of this argument, …. (shrink)

A group of activist clinicians have offered to volunteer for clinical trials of live attenuated HIV vaccines. This has provided an important conceptual challenge to medical ethics, and to work on the development of HIV vaccines. In exploring these issues, this article highlights how the HIV field has altered the content as well as the tone of ethical discourse. The balance of expertise and authority between research subjects and triallists is profoundly changed, raising questions about the limits of voluntarism and (...) differing perspectives on risk-benefit analysis. Care is needed to ensure that the novelty of the situation does not confuse the central ethical and scientific issues. (shrink)

Dr de Zulueta articulates some important and commonly held concerns about the anonymised screening programme for HIV in pregnant women, which is one of a number of such programmes that are current. However, in my view, many of these concerns reflect a failure to understand two key distinctions.In both these regards, there is a danger of putting up a “straw man” for challenge. In this commentary, I wish to pick up some of these issues to help to resolve the apparent (...) ethical tensions that Dr de Zulueta has set out.Firstly, the unlinked seroprevalence surveillance programmes, including that on pregnant women, comprise research studies that are designed to inform policy and practice, as well as individual decision making. They are not screening for the purpose of clinical care. The anonymisation is a procedural research tool, which enables the studies to be done in a way that does not undermine consent or individual autonomy. The ethical standards and duties expected of professionals are thus, in this specific regard, those that relate to the conduct of clinical research. That research is evidently designed to improve the quality of clinical care as a result of the information and insight gained. The duty of care is to apply the results of properly conducted and valid research in order to improve clinical practice on behalf of the individuals receiving care, in this case the mother and unborn child. The research conducted, in this case by a particular form of screening procedure, is not the same as a screening procedure done for clinical purposes to identify individuals who could benefit from an intervention. The ethical debate must therefore focus on the purpose in applying the procedure, not on the procedure itself, regardless of intent.Secondly, it is vital to distinguish, in debating such …. (shrink)

Guest Editors' introductionFor this special issue of the Journal of Medical Ethics we have assembled articles that reflect some of the newer issues or fresh perspectives. There is a mix of approaches including forward looks, present dilemmas and reflections on the past, now that sufficient time has elapsed to allow a considered view. We are most grateful to our wide range of contributors for their thoughtful analyses of several key areas of contemporary debate. Our own contributions include the following editorials (...) in which each of us has considered, from his own perspective, the impact of AIDS on medical ethics, a case study and a lexicon that allows brief probing of some topics.The impact of aids on medical ethics -1ANTHONY J PINCHINGMedical ethics has been matured through being tested and refined through the multifaceted challenge of AIDS. As with the society and social values from which its moral framework is derived, so medical ethics has been subjected to intense scrutiny by the emergence of this new disease. Few areas of ethical discourse have been untouched. This infection is so intensely private in its transmission, the disease so isolating and so personally devastating in its impact, it readily distinguishes the reality of what people are and do, from the rhetoric of what others may feel they should be and do. AIDS has forced us to recognise that respecting individual rights is a critical safeguard for the health of the community, as well as for the person. These issues are well illustrated by the interweaving issues of patient empowerment, respect for confidentiality, and patient advocacy and activism.EMPOWERMENTPhysicians in this field have been struck by the way in which people affected have wanted to be involved in decision making. While this has often been ascribed to their social groups, it probably was more a reflection of their younger age and a generation change …. (shrink)