EDITORIAL
Is Our AIDS Policy Ethical? EZEKIEL J. EMANUEL, M.Sc., and LINDA L. EMANUEL, M.D., Ph.D.
o one can doubt the enormity of the acquired immune deficiency syndrome (AIDS) epidemic. By 199 1, it is estimated that in the United States almost 270,000 people will have contracted AIDS [I]. Since the prospects for a vaccine or a cure are several years away [2], the only interventions with any potential for effectiveness are public health measures to stem the transmission of human immunodeficiency virus (HIV). With sexual contact accounting for 78 percent of all AIDS cases in the United States [ 1,3], the effort is focussed on the use of condoms in “safe sex.” Within the last few months, the campaign for “safe sex” has greatly accelerated. The Surgeon General and influential members of Congress have strongly advocated an intense education program on AIDS and “safe sexual” behavior [4]. Many universities have begun selling condoms on campus and educating students on their use to promote “safe sex” [5]. Concomitantly, the media have portrayed the condom as a “safeguard” against AIDS [6] and have stated that “using condoms is excellent protection against” AIDS [7]. Within the least few months, a handful of local television stations and members of the print media started accepting condom advertisements [5]. Indeed, this campaign’s message is best captured by an AIDS center that distributed condoms in packages identifying them as “lifeguards” [8]. We question the ethics of this campaign. There are only three studies on the prevention of AIDS transmission by condom use. One group found that HIV could not pass through condoms with 15 cycles of aspiration and expulsion by a syringe barrel [9]. The experiment has been criticized in part because the diameter of the syringe was small and might not have mimicked the stretch or tension associated with sexual relations [lo]. A second retrospective study of 376 prostitutes in Zaire found that the eight prostitutes who reported that more than half of their
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customers used condoms were all seronegative for HIV, whereas among the 288 prostitutes who did not use condoms 26 percent were seropositive [ ill. The significance of this study is vitiated by the reliability of the reporting methods, the size of the sample frequently using condoms, and the absence of any data on the prevalence of HIV infections among the customers. The third is a prospective study among 45 heterosexual couples in which one partner had AIDS [ 121, which revealed that among partners who continued to have unprotected sex, 12 of 14 of the spouses converted to seropositivity; of the eight couples who completely abstained from sexual relations, none converted; and of the 10 couples who used condoms, one spouse became seropositive. Two additional couples who claimed to use condoms were seropositive before the study began, These studies are small: only 20 persons used condoms in more than half their sexual encounters. They lack confirmation; they are limited in scope, since the effectiveness of condoms in homosexual relations was untested. But most importantly, whether the result of misuse, breaks, leaks, erratic use, or transmission by secretions other than semen, the studies do suggest that some spouses of AIDS-infected partners became HIV-infected despite the use of condoms. These data suggest that condoms are safer than unprotected sex, but they do not ensure “safe sex.” Indeed, they suggest the entire concept of “safe sex” is a misnomer. The message of the current “safe sex” campaign is untrue and therefore unethical. People may be resistant to information they would prefer not knowing, but this is no excuse for deceiving them into thinking condoms are, to quote a Congressman, “life-saving” [4]. Further, those individuals who do heed the public health warnings are lulled into a false sense of security because they believe that by using condoms they can avoid HIV infection and
From the Department of Government, Harvard University Cambridge, Massachusetts. Requests for reprints should be addressed to Dr. Linda L. Emanuel, Department of Medicine, Massachusetts General Hospital, Fruit Street, Boston, Massachusetts. Manuscript submitted April 28, 1987, and accepted May 28. 1987.
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EDITORIAL-EMANUEL
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REFERENCES
AIDS. If a physician were to provide his patients medical information like that being propagated in the “safe sex” campaign, he would be violating the tenets of informed consent. Furthermore, the “safe sex” campaign may also be counter-productive. The rate of AIDS transmission not only depends upon the likelihood of transmitting HIV during sexual relations, but also on the frequency of sexual contacts with infected persons. If people are led to believe that condoms eliminate HIV transmission, they may not reduce the frequency of sexual relations; they may also take less care to find partners who are not infected by HIV. Finally, people may no longer consider abstinence, since they are told that sexual relations with condoms are “safe” [ 131. No one doubts that encouraging the use of condoms is an essential part of the effort to reduce HIV transmission. The content of this educational campaign must be carefully designed. It may well fail if people use condoms in the belief that they can eliminate their risk of contracting HIV but do not simultaneously alter the promiscuity or frequency of their sexual contacts. Furthermore, it is ethically impermissible to use distorted slogans, partial information, and exaggerated claims; we cannot offer people false security in the hope of persuading them to act more prudently.
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Peterman TA, Curran JW: Sexual transmission of human immunodeficiency virus. JAMA 1966; 256: 2222-2226. Institute of Medicine and National Academy of Sciences: Confronting AIDS: directions for public health, health care and research. Washington, DC: National Academy Press, 1986. Curran JW, Morgan WM, Hardy AM, Jaffe HW, Darrow WW, Dowdle WR: The epidemiology of AIDS: current status and future prospects. Science 1965; 229: 1352-1357. Koop urges TV condom ads to fight AIDS. New York Times, February 11, 1967; Al. Condoms, AIDS and morals: new concern alters debate. New York Times, February 12, 1967; Al. Ads that shatter an old taboo. Time, February 2, 1987; 63. AIDS: at the dawn of fear. U.S. News & World Report, January 12, 1967; 60-69. Fear of sex. Newsweek, November 24, 1966; 30-39. Conant M, Hardy D, Sernatinger J, Spicer D, Levy JA: Condoms prevent transmission of AIDS associated retrovirus. JAMA 1966; 255: 1706. Minuk GY, Bohme CE, Bowen TJ, Hoar DI, Cassol S: Letter. JAMA 1966; 256: 1443. Mann J, Quinn TC, Piot P, et al: Condom use and HIV infection among prostitutes in Zaire. N Engl J Med 1967; 316: 345. Fischl MA, Dickinson GM, Scott GB, et al: Evaluation of heterosexual partners, children, and household contacts of adults with AIDS. JAMA 1987; 257: 640-644. McKusick L, Horstman W, Coates TJ: AIDS and sexual behavior reported by gay men in San Francisco. Am J Public Health 1965; 75: 493-496.