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AIDS and the Foundations of Health Care

The AIDS (acquired immune deficiency syndrome) epidemic can be viewed from several vantage points. One can look at the reaction of the political and health care systems with a focus on why the response to AIDS was so sluggish. Randy Shilts's (1987) And the Band Played On takes this path. Or, one can examine the impact of AIDS on political, economic, and health care systems. This challenge is the focus of AIDS and the Health Care System. Lawrence Gostin's introduction makes two critical and related points. First, the AIDS epidemic forces us to concentrate on "foundational" issues, which cover virtually all aspects of the health care system: ethics, right to know, pharmaceutical research and approval, and cost of and access to services. At the same time, Gostin points out that hysteria surrounding AIDS has decreased and the perception of the epidemic's urgency has likewise diminished. He notes that AIDS is increasingly perceived as a chronic disease, such as cancer, which by definition lacks the urgency of a pandemic. If Gostin is correct, then the challenges posed by AIDS are likely to go unmet. The most important message of this book is the need to maintain the sense of urgency required for change. The ethical issues posed by AIDS are based on two points: (1) the near certainty that contracting HIV (human immunodeficiency virus) is fatal, and (2) the adverse social consequences of being identified as someone who has AIDS or is HIV-positive. The ethical problems often involve a conflict of rights. Does mandatory testing of hospital or surgical patients violate the rights of the patient? Such testing can be done routinely without the patient's permission. If a patient is indeed HIV-positive or has AIDS, do the caregivers have a right to refuse care on the grounds that they might contract the disease? Do the caregivers have aright to be informed about such patients? Should patients be informed if, during routine testing, they show up as HIV-positive? Should there be special laws protecting HIV-positive/AIDS patients against discrimination? In general, the authors endorse routine screening. Brandt, Cleary, and Gostin, in "Routine Hospital Testing for HIV: Health Policy Considerations," offer three evaluative principles for such screening tests: that they be accurate, lead to effective action, and be based on explicit consent. They point out that the informed con-