This article argues that the hysteria and misconceptions of the popular press
surrounding AIDS have been adopted uncritically and unreflectively by
bioethicists, who have not bothered to explore popular empirical claims in
sufficient depth. As a result of this adoption, and because ethicists attempt
to sell moral problems in a manner not much different than the way in
which the popular press attempts to sell copies, artificial and artifactual
dilemmas have been produced in professional journals. We concentrate on two
popular misconceptions surrounding AIDS the heterosexual incidence of the
syndrome, and relatedly, the incidence in women and show how these have led
to conceptual and practical errors by bioethicists.
Several conceptually distinct, but pragmatically inseperable, criticisms are
made of many professional ethicists in this paper. Unavoidably, in this
instance, these criticisms have epidemiological, ethical and political aspects.
Those medical ethicists we address have themselves premised poor ethical
reasoning upon poor epidemiology, in order to argue for sensationalistic, but
intellectually vacant, political programs. These medical ethicists have
neither dictated, nor merely received, the popular press' reporting on AIDS;
rather they have been active, but not sole, participants in shaping this
coverage. The overall result is a public terrified of AIDS, but in the context
of a widespread, almost universal, misunderstanding of the syndrome and its
distribution, with AIDS generally given a more mythical than epidemiological
significance. We take systematic obfuscation of facts and promotion of
irrationality to be failures in the professional responsibilities of
ethicists.
It might be possible to criticize ethicists of AIDS at only one point, rather
than at several. We might simply have chosen to accept the facts purported by
many ethicists, but challenged their reasoning about these facts. Or we might
have challenged the facts, but allowed counterfactually that if their facts had
been correct, so would their conclusions. But to challenge the ethicists at
only one point would attribute to them a degree of good faith which we do not
believe they have shown. It is not merely that they have made honest mistakes
either of fact, or of reasoning but rather that they have simply started with
a conclusion, then invented or highly-selectively sought whatever facts and
arguments would support this conclusion. This conclusion is that the so-called
general public those not initially identified as at-risk groups will
develop AIDS in vast proportions. A corollary of this conclusion is that
proportionately vast social attention and funds must be paid to AIDS in this
general public. The convergence of ethicists around this conclusion is not an
accidental or irrational event, but rather reflects a social logic. A
story of universal devastation of society is a story which exerts an
understandably widespread fascination. Quite simply, the ethicists of AIDS
have found they have more audience-appeal in discussing a topic (even if
fictional) of widespread fascination than they do in discussing one met with
relative indifference.
The three sections of this paper analyze, in turn, the social logic behind two
empirical claims made by AIDS-ethicists, and then the argumentative structure
used by these ethicists in general. Section one disputes the widespread
exaggeration of the risks that heterosexuals, as such, face from AIDS.
We show how ethicists have used and fueled this exaggeration. Section two
disputes the similar exaggeration of the risks to women particularly the
risks via sexual activity. In this case, the focus shifts partially from
simple mistatement of the facts, to selective attention to these cases, in vast
disproportion with the actual risks. Again, AIDS-ethicists have contributed to
and utilized this overattention. In the final section, we discuss the kinds of
rhetorical strategies AIDS-ethicists have had to adopt to maintain their
sensationalistic appeal.
Each year, the press finds something on which to hang its
heterosexual AIDS message, to demonstrate that this year the wolf
really has appeared.
Retrospectively analyzed, the public attention towards AIDS can be compared
with the ups and downs of stock market prices. The mass media when they
found an epidemiologist who was willing to speculate about future prospects for
the so-called AIDS epidemic, especially outside the classical risk groups of
gay men and injecting drug users were always willing to print every unproven
apocalyptic prediction.
If AIDS is a sexually transmitted syndrome, as seems likely whether or
not HIV plays the lately questioned role usually attributed to it, then,
undoubtedly heterosexual transmisions do occur. From a public health
standpoint, however, the crucial question is of the degree of such
transmission, both within the syndrome as a whole, and in comparison to other
diseases facing these same heterosexuals. We claim that this incidence has not
been particularly significant certainly not what would normally be called
epidemic and we have no indication that it will become epidemic, at least in
so-called First World countries. We do not comment on the situation in so-called
Third World countries, because reliable epidemiological surveys about AIDS in
these countries do not exist at the moment, and we refuse to join any
ungrounded speculations on that subject.
Meanwhile we have come to know, as Michael Fumento has explicated dramatically
in his persuasive analyses on this topic[5]:
heterosexual AIDS is virtually "a myth". During the past decade, no
epidemiological data have been provided which could have supported the claim of
a looming, widespread heterosexual AIDS epidemic in the countries of the
so-called First World. Has this prevented the public media from creating the
threat of such an epidemic in their reporting? As everyone is well aware, it
has not. The majority of customers of daily newspapers, as well as magazines,
and radio and TV programs, are heterosexual, and the public interest in the
health problems of gay men or injecting drug users (IDUs) is not as great as in
those of the so-called general public. Comparisons between AIDS and the Black
Plague in Europe, on the other hand, guarantee large newspaper sales and
interested viewers of TV programs. Bioethicists naïvely analysed ethical
problems which were expected to come in the wake of the predicted heterosexual
AIDS epidemic. And indeed there has been a pandemic of AIDS related
publications by bioethicists. As a 1990 review article in the Journal of
Medical Ethics reveals: "Examination of the quantitative increase of
articles over these years shows that, while references to AIDS and/or HIV
infection increased by about one third per year, the number of papers treating
ethical problems linked to AIDS doubled each year."[6]
One representative article was published by two Finnish bioethicists in 1987
in the international, refereed journal Bioethics.[7]
In its introduction the article replies to a paper the philosopher Richard Mohr
published in the same journal.[8] Mohr argued
that AIDS will remain nearly exclusively a gay problem in the so-called First
World. The Häyrys' article, with its attention-grabbing headline AIDS
NOW, argues that "AIDS will seriously threaten the heterosexual population
in 3 5 years' time in the Western countries if the spread of HIV cannot be
controlled by then".[9] However, 6
years after the prediction was made: There have been no significant changes in
the sexual behavior of the heterosexual population in the so-called Western
world.[10]
The 1980s epidemic of syphilis among young black people in the USA, both males
and females, would not have occurred if 'safe sex' were practised. The German
Federal Centre for Health Education discovered that, "only 4 to 23 per cent of
all respondents in a representative sample of Germans ... always use condoms.
Between 11 and 17 per cent of those who had several partners said they always
used condoms."[11] However,
this has not produced a significant increase in the incidence of AIDS cases in
the heterosexual part of this group. The spread of the virus has not been
controlled anywhere in the world, presuming its main mode of transmission is
unsafe sexual behavior. iii) AIDS is still a syndrome predominantly restricted
to the same risk-groups as it has been since its initial diagnosis.
How did the Häyrys try to support the "claim about AIDS being everybody's
problem"?[12] They refer to speculations like the following: "It is now estimated that
30-40% of those infected will develop AIDS."[13] "In 1986
there were globally already 34,448 registered cases, and 100,000
estimated victims of AIDS".[14] "At a
meeting [sic!] of AIDS researchers in New York, October 1986, the
estimation was that the portion of those with HIV who had been infected
through heterosexual intercourse had grown from one to two percent during the
previous six months."[15] We could
continue forever with the "estimations" the Finnish philosophers quote in their
paper. However, who would seriously use speculations of this kind as the basis
for an analysis of ethical implications? (Incidentally, we might add, these
"estimations" turned out to be wrong, and Mohr's argument proved to be
correct). Particularly egregious are the frequent references to an unspecified
"meeting of AIDS researchers in New York". This unknown conference and its
unknown participants became "experts" in this same article.[16] We are at
the end of the second decade of a presumably mainly sexually transmitted deadly
disease, and all we have had in 10 years are approximately 3,000 cases in
Australia, with its population of 18 million, and approximately 9,000 cases in
Germany, with an 80 million population. This will change, however; the numbers
will become significantly higher in future. The US CDC introduced a new AIDS
case definition, effective on January 1, 1993, which doubled the number of AIDS
cases in New York overnight. An analysis of the implications of this new
definition for San Francisco comes to the conclusion that "the number of person
eligible for an AIDS diagnosis will probably more than double."[17]
The Häyrys, on their way to Armageddon, catch themselves in an
exaggeration, when they write "those infected today may or may not develop
AIDS, but if they do not have themselves tested to learn about their infection,
they may pass it on to their sex partners who pass it on to their sex partners,
and soon virtually everyone will have it. Exaggeration? Perhaps."[18] Although
these "may"s are quite devoid of literal content, they are quite rich in the
insinuation of disaster. The Häyrys' method thereby is to write nonsense
at some length and then acknowledge it. The question remains: Why did they
write it in the first place? They did so because others would consider their
exaggeration to be nonsense, if they hadn't been lulled by the acknowledgement
of the "exaggeration." They continue writing: "Today AIDS is everybody's
concern because of its frightening potentialities."[19]
Potentialities, of course, which our authors invented and pretended to verify
with mysterious "estimations." A similarly vacuous statement is made by US
bioethicist Timothy Murphy, who wrote that "despite better medical treatment
the number of HIV-related deaths continues to increase".[20] Apart from
the fact that these deaths were AIDS-related, rather than HIV-related, as
Murphy proclaims, the hidden truth behind this seemingly unproblematic
statement is that it is the tautologous result of the manner of counting AIDS
deaths. AIDS is the only disease which is generally counted cumulatively. If
there have been 250,000 AIDS deaths to date (in the US, for example), but next
year one person dies of AIDS, the ravages of a disease which has killed 250,001
persons would be reported in the papers, and of course Prof. Murphy would find
this an indication that the AIDS epidemic is still out of control, since still
more people have died of it in total than had in the last year.
Even while a begrudging admission of the non-epidemic of heterosexually
transmitted AIDS has been made in much of the scientific establishment, border
skirmishes continue to be fought in the attempt to maintain evidence of
widespread heterosexual spread. For example, the US National Research Council,
a private research institution which is part of the National Academy of
Sciences of the USA concludes that AIDS will remain largely confined to the
initial groups at risk. Indeed the study concludes that AIDS will have little
impact on the lives of the average American.[21] Subsequently
public health educators have claimed that their educational campaigns have led
to behavioural changes in the general population which explain why AIDS is not
reaching epidemic proportions amongst heterosexual persons who have no sexual
contacts with the classical risk groups.[22] However,
the fact of the matter is, as Chapman put it so ingeniously: "There is
heartening evidence that (this claim) is correct where it applies to high-risk
groups like gay men, injecting drug users and sex workers in Australia, but
little reason to agree with him regarding the general population."[23] For
instance sexually transmitted diseases have dramatically increased in the US in
adolescents, but there has been no AIDS epidemic in the heterosexual part of
this population.[24,25] This
example, and the above mentioned survey of the German Federal Centre for Health
Education give evidence for our claim that the AIDS education campaigns
directed at the general population were a complete failure. Unsafe sexual
behaviour such as this, however, has not led to AIDS epidemics in these
segments of the population. Gordon T. Stewart[26] shows that
projections of AIDS amongst British heterosexuals have been univocally in
excess of actual rates, in most cases by as much as five times. Stewart's
numeric point is acknowledged in an editorial in the same issue.[27] This,
however, occurs only in the context of a continued search for new arguments for
heterosexual panic, as we discuss below.
A skirmish over the search for motivations for heterosexual panic is created
by a recent article in The Lancet[28] which
attempts to demonstrate a rate of female-to-male HIV transmission in Thailand
over an order of magnitude higher than in comparable US studies, discussed
below. This study of 21-year old military conscripts is unconvincing because
of its unlikely assertion that "sex with nonprostitute women, sex with men,
injecting drug use, blood transfusion, and tattooing did not appear to
contribute to risk."
[29] The authors
observe that "reporting of sex with prostitutes by the young men was not
stigmatised and was reasonably accurate," but omit the obvious fact that
homosexual sex with men and injecting drug use are strongly stigmatized in
Thailand, as elsewhere. What immediately seems more likely than that HIV is
greatly more transmissible heterosexually in Thailand than elsewhere is that
many of these young Thai men in fact became infected by other routes; when
their rate of infection is assumed to have occurred in prostitute contacts, an
artifactually high likelihood of transmission results. For the study to have
reported no correlation at all between HIV-seropositivity and male-male
sexual contact or injecting drug use suggests that wide misreporting
contributes significantly to the high numeric estimates of female-to-male HIV
transmission.
Priscilla Alexander, former consultant with the World Health Organization,
Global Programme on AIDS, and former co-director of COYOTE, the San Francisco-based
prostitutes' rights organization, is convinced that AIDS in Thailand was first,
and continues to be, primarily an epidemic among injecting drug users.[30] The same can
be said for other South-East Asian countries, such as Malaysia, where the
national health ministry reports for a period between 1985 and March 1993 that
4410 out of 5459 persons with an HIV+ test result were IDU.[31] If there is
any accuracy to Ms. Alexander's evaluation of the widespread IDU AIDS risk in
Thailand, The Lancet article most certainly fails to identify
underreporting of injecting drug use amongst the cohort studied and most
likely of male-male sexual contacts also.
It is not illegitimate for women to now try to do what their male peers have
gotten away with for years: grossly exaggerate the real threat of AIDS to the
major population in an attempt to support their applications for more and more
research money every year. For example, "In 1993, the US Congress approved a
record $2.5 billion spending package for AIDS prevention and research."[32] Variations
on the theme "women are the fastest growing "risk-group' for AIDS" appear
virtually everywhere, in the scientific no less than the popular press.
Sometimes these statements are literal untruths, at other times they merely
insinuate untruths in their equivocation between rates of disease and
rates-of-change in population-specific disease rates. In general, medical
professionals are no more, and are often less, precise in their assertions than
is the popular press.
If we look at the figures for AIDS diagnoses, we see that although women show
a percentage growth rate higher than other broad categories of people with
AIDS, they still represent a small proportion of the increase in numbers of
people with AIDS in the latest reporting period. A November 1993 CDC[36] report
shows, for example, a change in new AIDS cases amongst male IDUs from 8,621 in
October 1991-September 1992 to 19,142 in October 1992-September 1993. This is
an increase of 10,521 AIDS cases, most of them due to the extended 1993
surveillance definition. Female IDUs go from 2,815 to 6,891 new AIDS cases in
the same interval, an increase of 4,076. Combined, this is an increase of
14,597 cases amongst IDUs of both sexes. In contrast, adult/adolescent women
as a whole go from 6,153 to 14,792 cases, an increase of only 8,639
during the same interval. While this increase amongst women is still, perhaps,
cause for alarm, it is numerically less than the increase amongst male IDUs,
let alone IDUs in general. Even men who have sex with men went from 24,334
cases to 46,025 cases in the intervals mentioned, an increase of 21,691;
although this increase is purely an artifact of the changed 1993 surveillance
definition, which reflects an underlying net decrease under constant
definition.
This claim about women being the "fastest growing group", whether of the
HIV-infected or of AIDS patients, is misleading and alarmist to the lay reader.
Wording that obscures the distinction between proportional rate of growth and
absolute increase is often made by writers stressing the size or urgency of the
problem among women. For example, Suki Ports[37] states
(inaccurately), "the fastest growing numbers of AIDS cases are among women."
Others merely insinuate patterns that don't exist without outright
misstatement. A Panos Institute[38] book informs
us, "where HIV has so far spread mainly among gay (homosexual) men and
injecting drug users women now account for just over 10% of AIDS cases."
Ignoring the slight inaccuracy of the percentage for 1990, one should observe
that a contrast is drawn between hitherto spread "mainly among gays and IDUs"
and the current 10% amongst women. Even leaving aside the fact that most of
those 10% of female cases are IDUs themselves, 90% continues to constitute
"mainly" by anyone's definition. Nothing has changed according to the Panos
Institute statement, and yet that very fact is used to indicate an imminent
epidemic amongst women. Furthermore, it continues to be the case that many
times more men are newly diagnosed with AIDS each year than are women (hence
the actual increase in cumulative AIDS cases is greater amongst men than
amongst women). Compared to the 6,153 women in October 1991-September 1992 and
14,792 in October 1992-September 1993 who were diagnosed with AIDS, 36,833 and
81,707 men were diagnosed in the respective intervals.[39] In
Australia, where the reported incidence of HIV infection figures appears to
reflect actual incidence more closely than in the US, the percentage increases
over the same period among women are higher than among men, but the numerical
increases are still less than those among men by an order of magnitude.[40]
The reasons why billions of dollars are spent on AIDS research are twofold:
1) Efficient AIDS lobby groups produced the necessary public pressure to
generate more money for AIDS research. 2) Researchers, not really acting
altruistically, undertook AIDS projects predicated, in the absence of any
scientific basis for it, on a dramatic increase in the incidence of
(heterosexual) AIDS cases; and argued that these cases would legitimize the
money spent. AIDS is still a predominantly male disease in all so-called First
World countries, restricted to virtually the same limited risk-groups as
ever.[41]
Nevertheless, the amount of money and public resources spent in the last ten
years for the fight against AIDS is unique. No other disease in history,
killing relatively few people, has generated such a large amount of research
money, so much public attention and incidentally so many new professional
journals in all sciences, as AIDS has done.[42]
It was only a matter of time until someone discovered that it was somehow
unfair to exclude women from these billions of dollars for AIDS research,
education and prevention. The officially published statistics, however, can't
provide much of a case for spending huge amounts of taxpayers' money on womens'
AIDS projects, let alone on lesbian womens' AIDS projects.[43] AIDS is not
an equal opportunity killer, and we have no indications that it will evolve
into one. Political calculations, not epidemiological warning signs, led the
New York City Gay Men's Health Crisis to implement a "Lesbian AIDS Project"
presumably to avert feminist arguments about the male-dominated Gay Men's
Health Crisis. The newly appointed coordinator immediately started producing
"lesbian safe sex kits, which will include a range of relevant products
gloves, cots, condoms, dental dams, lube and literature". The next project is
said to be a "comic book illustrated by gay and lesbian cartoonists". Over the
last decade there have been only two case reports of apparent female-to-female
transmission of HIV.[44] Reviews of
AIDS cases in the USA in women who reported having sex only with other women
found that all had a history of injecting drug use or receipt of blood
transfusions.[45]
The lack of actual woman-to-women transmission of HIV/AIDS has not prevented
feminist medical ethicists from criticizing mainstream AIDS education for not
addressing this problem. Nora Kizer Bell laments "that reliable safe sex
information for lesbians is neither widely distributed nor widely known to be
available."[46] Bell is
mistaken about this. Every book we can find mentioning "women" and "AIDS" in
the title has sections on AIDS in lesbians, with an inevitable section on
lesbian transmission of AIDS. The book AIDS: The Women[47] predates
Bell's proclamation by four years, and contains a chapter entitled All That
Rubber, All That Talk: Lesbians and Safer Sex[48] whose tone
clearly assumes safe sex knowledge to be ubiquitious amongst lesbians.
Women & AIDS[49] makes the
same assumption, while praising the virtues of dental dams. Lesbian magazines
such as On Our Backs also provide instructional material, and moral
guidance, on safer sex.[50] Our
personal experience has shown largely locally produced materials urging the use
of dental dams and other safe sex equipment in gay and lesbian bookstores (and
similar lesbian-oriented establishments) worldwide; and we have found almost
all lesbians of our acquaintance to be quite familiar, at least intellectually,
with safe sex practices although few feel these measures are worth personally
conforming to. Given the non-existent to minuscule risks of HIV/AIDS
transmission in lesbian sex, we find these judgements generally more rational
than those of bioethicists like Bell.
Christine Overall, a distinguished Canadian philosopher with a remarkable
record of publications in practical ethics, made one of many unsuccessful
attempts to make the case for AIDS and women.
[51] Bear in mind that
the situation regarding AIDS in Canada is not all that different from
that in Australia. Australia has a male-to-female ratio of 35 to 1. As of
January 1991, about a year after the time we assume Overall's article to have
been written, 4,647 persons (mostly gay men and injecting drug users) had
contracted or died from AIDS in Canada. Of these, 175 approximately 3,76%
are women, the vast majority of whom belong to the risk group of injecting drug
use.[52] Such
is not really a good argument for the significance of "the heterosexual
politics of HIV infection," as Overall's article headline proclaims of issue.
She therefore purports that these figures "may well under-represent the number
of female Canadians with "full-blown" AIDS, since the full spectrum of
AIDS-related diseases in women often goes unrecognized as such".[53]
In the USA, the nation with the largest number of AIDS cases[54], adult and
adolescent women have made up 40,702 of the cumulative 334,344 AIDS cases; in
other words 12% of cases as of November 1993.[55] Pediatric
AIDS cases are approximately evenly divided between the sexes, as one would
expect. However, these cases account for only 4,906 of all cumulative cases,
and hence do not significantly affect the percentages.[56] However,
within these forty thousand cases, the cases of heterosexual transmission have
been exaggerated and are far disproportionately discussed in the popular press
and by bioethicists. Overall's title is one example amongst many. Many books
and articles contain similar language on heterosexual AIDS in women. [57].
Heterosexual transmission makes up a minority of female AIDS cases, with
injecting drug use constituting the majority of transmissions. For the
most recent reported interval from October 1992 to September 1993, 6,891 female
cases with injecting drug use as mode of transmission were reported, while
5,545 were reported with heterosexual contact as the risk-category.[58] Of the
heterosexually transmitted female AIDS cases, where the risk category of the
male partner was identified, the vast majority of the partners were IDUs. Of
the 5,545 cases of female AIDS cases, allegedly transmitted heterosexually in
the most recent annual reporting interval, 2,474 were partners of IDUs. Only
423 were partners of bisexual men, while 2,131 were partners of HIV-infected
persons with unspecified risks.[59]
We have no reason to believe that the breakdown of the actual risk-categories
of thosepartners with unspecified risk is significantly different than those of
partners with reported risks. In light of the argument made below that there
is substantial overreporting of heterosexual risk category in men, we
suspect that many of the female reports of heterosexual risk-category are
misreports. For all the same reasons that other people lie to doctors about
stigmatized activities, such as male male sex, women with AIDS lie about use of
injected drugs. For example, in an interview, New York public health official
Rand Stoneburner stated, "of 63 men [as of January 1989] who reported
prostitute contact but denied other exposure, 42 were later found to have a
history of contact with homosexual men or had engaged in intravenous drug
abuse." Outside of New York City, thorough repeat interviews and contact
tracing, which would reveal such initial misreports, are not performed.[60] Therefore,
most likely, a substantial number of the reported cases of heterosexual
transmission in the partners of injecting drug users, in particular, are
themselves injecting drug users.
Additional suggestion of misreporting IDU AIDS risks as heterosexual contact
with IDUs is contained in the very fact that the majority of reported
heterosexual transmissions are from IDUs. While men who have sex with men
compose over twice as many AIDS cases as men who use injected drugs, they
appear to be about six times less likely to transmit AIDS to women (see above
discussion)[61]. A
cumulative 183,344 men who have sex with men have developed AIDS in the USA,
while a cumulative 80,713 injecting drug users have developed AIDS. Some of
these 80,713 IDUs are women, however. The CDC document does not provide
directly cumulative numbers of IDU female AIDS cases, but from October 1992
through September 1993, there were 6,891 female IDU AIDS cases and 19,142 male
IDU AIDS cases. The cumulative 80,713 IDU AIDS are likely to break down in a
ratio similar to this 1:3 ratio, i.e. there should be approximately sixty
thousand male IDU AIDS cases cumulatively.[62] In a rough
way, this would suggest either A) HIV/AIDS is more transmissible by IDUs than
by bisexual men; B) No more than 1/12th of men who have sex with men also have
sex with women; or C) There is underreporting of non-heterosexual risk amongst
partners of IDUs. In the absence of a plausible biochemical explanation, we
reject A); B) contradicts familiar sexological surveys
from Kinsey on.[63] Kinsey[64], for
example, shows only 2.9% out of 19.8% of 25-year-old men who have some
homosexual history are exclusively homosexual. The remaining 16.9% of all men,
or 85% of men with some homosexual contacts, have some heterosexual contacts as
well. This study shows a similar pattern in other age groups, with 30- and
35-year-old men with some homosexual history being exclusively homosexual at an
even lower rate than 25-year-old men (but 20-, 40- and 45-year-old men having
somewhat higher ratios). Kinsey's exact numbers have been disputed, but all
reputable quantitative sexologists have found that a significant proportion of
"men who have sex with men" also have sex with women[65].
Our conclusion, therefore, is that there is underreporting of non-heterosexual
risk amongst partners of IDUs. None of this argues that women are at less of
an overall risk than CDC data suggest; we merely suggest that the AIDS risk to
women is not in significant part the risk of heterosexual intercourse so widely
publicized popularly and professionally.
Even if all of the 3,328 men and 5,545 women with AIDS who report heterosexual
contact as sole risk for AIDS during the most recent annual interval are making
accurate reports, it is important to notice that these numbers would contribute
only in small measure to the overall health risks facing heterosexuals. These
8,873 new cases from October 1992 through September 1993, most reported under
the greatly expanded 1993 AIDS surveillance definition[70], correspond
to somewhat fewer than this number of AIDS deaths, probably about 5,000 per
year. This approximate 5,000 may be put in perspective by comparison with the
annual 496,000 American cancer deaths, 734,000 heart-disease deaths, 146,000
stroke deaths, or 43,500 automobile fatalities[71]. The usual
rejoinder to such perspectivizing is that "even one death is too many," which
we cannot disagree with. However, one would like to say the same of the 12,200
fatal falls, 4,600 drownings, 4,200 fire deaths, or 2,900 suffocation deaths[72], none of
which receive daily newspaper headlines or massive research funding, or are
subjects of articles by bioethicists.
There is another reason to think twice about whether to adopt a proposal such
as Guinan and Hardy's idea that "it is important to educate all women about
their risk of sexually acquired AIDS and to encourage risk-reducing
behavior."[73]
The vast majority of women are simply not at risk for HIV/AIDS. In times of
scarce health care resources it could be argued that it is an irresponsible
waste of such monies in order to keep women who aren't at risk of contracting
this disease informed about AIDS in the first place. Apart from these monetary
costs, there are also psychological costs attached to it. Millions of women
who aren't at risk of AIDS will inevitably, each time they have sexual
encounters, think of AIDS. Anxiety, depression, hundreds of thousands of
unnecessary HIV-tests, and broken relationships are the results of such
campaigns. Chapman correctly questions the appropriateness of such campaigns:
"Is a government program of scaring people especially when there is little
basis for them to be scared something that public health should see as a
relatively benign means to a more important end? Or is the intrusion of this
concern into every sexual encounter some form of state-sanctioned mass
neurosis? Is it not worth asking seriously about the social and emotional costs
involved in public health efforts attempting to have all sexually active people
become sufficiently anxious about acquiring HIV to insist on condoms in
every sexual encounter?"[74] Another
unfortunate effect of this disproportionate anxiety about AIDS is that it has
the potential to swamp people's awareness of other risks associated with sexual
activity. When faced with a distant risk of a horrific outcome (a fatal
disease), people tend to resort to denial: they shut their eyes and jump. This
disables them from considering the much less dramatic but statistically more
prevalent infections, such as herpes or wart virus, or indeed the risk of
pregnancy.
Our point to stress here is that there are not enough reported female AIDS
patients who have contracted these diseases through heterosexual contact to
legitimize the time (and resources) spent on writing Overall's article; hence
Overall claims that the too-low-to-be-true numbers underrepresent the real
number of cases. This implies, unrealistically, that Overall has better
numbers than the health care system of a Western country like Canada. We
question that her belief that there are many unreported female AIDS cases can
be true, since medical scientists all over the world have now been paying close
heed for ten years for the first signs of a heterosexual epidemic. As a matter
of fact, as we have pointed out earlier, the heterosexual AIDS epidemic has
effectively been called off by epidemiologists and health authorities of most
Western countries. However, we have no way to disprove the a priori
assumption of underreporting, made by those who do not accept the officially
published numbers. By postulating an unobserved, and unobservable, empirical
reality, Overall makes her arguments quite unfalsifiable.
Elsewhere in her article Overall writes that "many writers have pointed out
that the real social concern about HIV infection did not materialize until its
potential `spread to heterosexuals' was recognized. What is less often pointed
out is that concern for the `spread to heterosexuals' has mostly been
manifested in concern for the spread to heterosexual men, not
heterosexual women."[75] It is
amazing that Overall, in the absence of a heterosexual AIDS epidemic in the
past or signs of one for the future, has only the one ethical problem: that
women couldn't get their fair share of this non-existent epidemic?
Under the subheading "AIDS and Social Inequality" Overall criticizes at some
length the above-mentioned article, "Gays, AIDS and State Coercion", written by
the gay philosopher Richard Mohr. We must stress the point that Mohr's article
analyzes the situation of gay men in the age of AIDS; and that this article
about gay men is written by a gay philosopher. When Mohr writes "each person
on his own without state coercion can get the protection from the disease
that he wants through his own actions", or when he writes "the person who gets
AIDS through sexual contact . . . actively participates in the very
action that harms him", Overall adds in her quotations emphasis to the personal
pronouns, and adds a "sic" when Mohr writes that a gay man harms him(self).[76] It seems,
however, parsimonious to us that an ethical analysis of the specific situation
of gay men in the age of AIDS, written by a gay male philosopher doesn't refer
to "a lesbian/straight woman harming herself", because this is not what the
paper is about. It appears very strange when a feminist philosopher such as
Overall criticizes a gay man writing about gay men for not using women in his
examples and argumentation. She writes "Richard Mohr rather contemptuously
dismisses ethical concerns about the effect on women of respect for
confidentiality" ignoring, that Richard Mohr's argument and analysis are
directed specifically at the situation of gay men.[77]
It might help if contemporary ethicists were to recall the terminology of
traditional rhetoric. The argumentum ad misericordiam made by
bioethicists discussing AIDS, in apparent efforts simply to shame us into
arbitrary conclusions through gestures to the dreadfulness of AIDS, is nowhere
better witnessed than in an article by Timothy Murphy.
[78] Murphy responds to the assertion by Fumento[79], Charles
Krauthammer and others that AIDS has been relatively overfunded compared to
other diseases with an increasingly irrelevant series of (mostly true)
assertions about the seriousness of AIDS, and with (equally unconnected) calls
for sympathy with AIDS patients.
This is not, however, at all the contrast Fumento has in mind; but rather of
AIDS with cancer or heart-disease which are, in fact, quite often unmanageable
and lethal. If the argument is to be made that AIDS deserves enormously
greater proportional funds than other diseases, more need be said than a hollow
insinuation of the harmlessness of other diseases. Another line of argument
which might be implicit in Murphy is that most persons with AIDS suffer this
disease at a relatively young age, and they are going to loose more quality
adjusted life years than will the typically much older heart disease patient.
Hence, it might be concluded that relatively-few young people with AIDS will
loose, overall, more quality adjusted life years than relatively-many older
people with heart problems. However, even if we would accept this argument,
and think deaths at early ages are particularly bad, we should notice that
127,000 heart-disease deaths occur in those 25-64 years old annually in the US,
and 156,000 such cancer deaths.[81] Even
young heterosexuals face many more serious mortality risks than AIDS In
addition to greater absolute risk, to an even greater extent they face more
serious risks relative to the proportional funding different diseases receive.
The degree of disproportionality in disease funding is striking. For each AIDS
death reported in the USA in 1990, the government spent $53,745 in research and
education. That's more than 15 times the $3,241 spent per cancer death and
about 58 times the $922 per death parceled out to researchers fighting heart
disease.[82] Since 1990, the US AIDS budget has approximately doubled[83].
Murphy next attempts to move the issue of appropriate levels of AIDS funding
to another irrelevant issue of blame and guilt. Against the argument made by
none of his mentioned sources, Murphy takes pains to show that we should not
reduce AIDS funding on the basis of sufferers' blameworthiness: "Perhaps it is
the seemingly voluntary nature of infection that invites the notion that enough
has been done for HIV-related conditions."[84] Murphy
first turns here to the usual innocents with AIDS hemophiliacs,
infants, health-care workers, and artificially inseminated women thereby
implicitly accepting and creating the very scheme of blameworthiness versus
innocence which none of his sources utilize. Next Murphy attempts to show that
the "guilty" are not really so guilty because "as regards the enticements of
sex and drugs, people are weak."[85] Finally
Murphy invents an excuse for gay-male promiscuity in that since society has
failed "to offer gay men any clear or supportive pathway to self-esteem or any
incentives to the rewards of durable relationships, society has effictively
forced some gay men into promiscuous behavior."[86] All of
these attempts to draw our heartstrings (and purse-strings) with stories of the
innocent, or of those discovered to be innocent deep down, completely dodge the
argument made by Fumento, and by us herein. Even the choice of the word
promiscuous, which is as much a term of morality as epidemiology, tends to
cloud the issues. At any rate, infants are not innocent, and promiscuous
gay men are not guilty; and neither is the reverse true. An obsession with
guilt and innocence is just meaningless. We are not interested in this context
whether gay men behave promiscuously because of societal compulsion, or just
because they want to or whether they actually do so at all. We are
interested in the rational and just distribution of medical funds in a society
willing and able to fund medical research to a certain finite (albeit somewhat
elastic) extent. Murphy refuses to address this question directly or honestly,
instead trying to paint those suggesting lower relative allocations for AIDS
with relying on the blameworthiness of its sufferers.
The fiery and misleading rhetoric continues throughout Murphy's article, as
straw men are set up to be shot down. Again indignantly, Murphy proclaims, "it
is important to remember that AIDS is no privilege. A diagnosis of AIDS
amounts to a virtually unlimited onslaught."[87] Yes, fine.
Does Murphy then believe that suffering cancer or a stroke are privileges?
Disease is an unfortunate event of life, whatever its cause and incidence but
there's no simple or automatic argument from the seriousness of one disease to
its proper funding priority over other equally dreadful, but more common,
diseases. Elsewhere Murphy chimes, "there have been many dire prophesies about
the toll of the epidemic, predictions that millions to billions would die. Is
it possible that critics can say that AIDS has gotten more than its share
because it has not yet killed enough people?"[88] Critics of
relative allocations for AIDS are thereby insinuated to wish AIDS upon huge
numbers to justify the funding levels. Obviously, this is not the wish of the
critics Murphy addresses. What we want is an evaluation of resource allocation
unclouded by the hysteria and empty rhetoric of both the popular and
biomedical/scientific press. Critics of allocation priorities do not
necessarily maintain that AIDS funding should be decreased, but we do recognize
that an increase of fundings for other diseases to proportionality would
fundamentally change the position of medicine in modern economies. For
example, according to figures indicated herein, bringing the funding for
heart-disease and cancer up to that current for AIDS in the USA would involve
spending approximately $180 billion dollars annually on research and education
for these diseases.[89]
Timothy Murphy[90] claims that
the problem with discussions of AIDS is that they have "primarily been argued
in the press or journalistic accounts and not in professional journals of
medicine, bioethics, or public policy. Could it be that this sentiment belongs
to those who do not know the epidemic at first hand?" Our analysis has shown
that Murphy's claim is diametrically opposed to the true situation, that it is
these professionals themselves who do not know basic facts about AIDS
and who are willing to accept the most idle speculation in the name of creating
ethical issues on which they may pontificate. Until bioethicists
abandon their uncritical acceptance of the most sensationalistic elements of
popular reporting around AIDS, they will remain the least qualified of
all commentators on ethical issues around AIDS. Harris and Holm agree in a
recent article "that the epidemiology and mode of infection of a given epidemic
disease will be crucial in determining the ways in which societies attempt to
cope with it."[91] Indeed,
bioethicists in the age of AIDS have contributed little more to the debate of
ethically justifiable AIDS policies than partisan papers like the above
criticised. Not surprisingly Harris and Holm realise that "in most Western
European countries and North America, strategies to contain the spread of AIDS
have emphasized civil liberties. This may be due more to the epidemiology of
the disease than to moral progress." Unfortunately these frank insights are
blurred by the fact they they subsequently add another useless speculation to
the abundance of existing speculations, with their article If Only AIDS Was
Different! By the end of 1993 these bioethicists at least realised that the
epidemiology of AIDS defining diseases didn't follow the speculations of our
most distinguished bioethicists; hence they discuss the 'what if it had behaved
as we thought it would?' question. Bioethics is too important to be left to
bioethicists of this sort!