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AIDS, POLICY AND BIOETHICS:
A NEW
BIOETHICAL FRAMEWORK
FOR CHINA'S HIV/AIDS
PREVENTION
YAN GUANG WANG PhD, Professor
Department of Ethics & Center for Applied Ethics,
Institute of Philosophy, Chinese Academy of Social
Sciences
1.
POSSIBILITY FOR CHINA TO BECOME A
COUNTRY
WITH A HIGH RATE OF HIV INFECTION
The first case of HIV infection was reported in China in June
1985. At the end of October, 2006, there were 183,733 reported
cases of HIV-positive and AIDS patients all over the country.
Experts estimated that the number of HIV-positive
people has reached more than 600,000.
Even though the numbers of HIV infection seem to be
quite low considering China's population of 1.3 billion,
we have reason to assume that it is very probable
that China will become a country with a high HIV
infection rate.
The reasons are as follows:
Reforms in China's economic structure have
given rise to population mobility on an
unprecedented scale.
The mobile population, which is estimated to
reach more than 100 million, lives far away
from their homes, are without traditional
cultural and moral constraints and can easily
develop high-risk behavior, all of which
makes it highly likely that they will be infected
with HIV and spread HIV.
With economic reforms and social
dislocations, a proliferation of all kinds
of high-risk behavior has emerged, such
as unprotected intravenous drug use,
prostitution and homosexual activity,
fostering the spread of HIV infection.
Other STDs which facilitate HIV
infection have spread over the country
rapidly. Premarital and extramarital sex,
casual sex, and multiple sex partners
have increased in the younger
generation, again facilitating the spread
of HIV infection.
Being faced with the danger of becoming a country
with a high HIV infection rate, there are some
misleading conceptions of HIV/AIDS which have run
counter to the countermeasures of effectively
preventing and controlling the spread of HIV infection.
within the situation that the majority of Chinese do not
know how to protect themselves against HIV infection,
some public and healthy workers have even said that
"AIDS is the punishment for promiscuity".
As a result, HIV-positive and AIDS patients and also
uninfected persons in high-risk groups suffer from
discrimination and stigma.
Another important problem in China's HIV prevention
is that the laws of prohibiting prostitution and drug
use have made many prostitutes and intravenous
drug users go underground, and they thus have no
chance of receiving HIV education for changing their
unsafe activities.
HIV infection is an epidemic so special that the
conventional
public
health
measures,
the
conventional public health approach is not sufficient
to prevent or control the HIV epidemic.
The problems in China's HIV prevention
policy and law show that an adequate
bioethical framework to evaluate the action
taken by policy and law-makers on controlling
the HIV epidemic must be formulated.
It is indispensable for shaping an effective
and supportive ethical and legal climate for
HIV prevention in China and addressing the
ethical issues.
2. FORMULATING A NEW
BIOETHICAL FRAMEWORK
Now which bioethical framework ought to
govern China's HIV prevention policy? The
basic bioethical framework we use to
evaluate actions in bioethics consists of
principles
such
as
Nonmaleficence,
Beneficence, Respect for autonomy, and
Justice. It seems that these principles are not
fully suitable for HIV/AIDS prevention.
The basic bioethical framework, when
applied in the ordinary medical context, is
based on a presumption that all patients
have equal social and moral status, but
when it is used in the HIV epidemic, we
encounter problems.
In the HIV epidemic, some special social
groups, such as AIDS patients, HIV
positives, drug users, prostitutes and
homosexuals are involved.
It is very difficult for the public to presume that HIV
/AIDS people have equal social and moral status.
The public often thinks that they got the disease
through immoral or illegal behavior, so they deserve
punishment.
The public often regards homosexuals, drug users
and prostitutes as perverse, abnormal, impermissible
or even disgusting, so their rights are often infringed
upon.
How can these persons, be treated by the principles
of nonmaleficence, beneficence, respect for
autonomy and justice?
I suggest an improved bioethical framework that
consists of the principles of tolerance, beneficence,
autonomy and care.
In my new bioethical framework the principles of
tolerance and care should play a central role.
The principle of tolerance is located in the first order
of this bioethical framework. It generates other
principles and facilitates dealing with the moral and
policy issues in biomedicine, especially how to treat
HIV/AIDS-related special population problems.
3. PRINCIPLE OF TOLERANCE
The principle of tolerance means that members of a
moral community should
a) permit members of other communities to do what
they themselves think wrong or do not want to do,
Some populations, such as homosexuals, have a
different lifestyle or set of moral views.
b) permit members of other communities to have a
lifestyle they themselves do not want, and
c) forgive the mistakes of others.
The principle of tolerance is presumed on the basis
that the differences or disagreements between
different moral communities exist at all times,
and that members of different moral communities
have to live together as neighbors or co-workers and
seek common ground while retaining their differences
The principle of tolerance will shape a more
supportive network in society. For HIV/AIDS
prevention, such a supportive network is very
important.
To tolerate others, one must first respect them.
The natural law can justify respect for others.
It argues that human nature demands that
humanity respect each other.
The factor of human nature or the person's
character, which is different from other
animals, is self-consciousness, rationality and
higher intelligence. The common nature of
humanity makes humanity respect each other.
Kant also justified respect for others. He
argued that because humans are the
only rational agents, they must be
respected.
Rawls's theory of justice explicates
justice as fairness, understand as
norms of cooperation agreed to by free
and equal persons.
His theory is based on this perspective, He
claimed that rational agents agents would
choose social allocations to meet certain
needs.
Social policy would guarantee a safety net or
minimum floor below which citizens would not
be allowed to fall. Based on this perspective,
Rawls further discusses how to treat the
marginalized population.
Norman Daniels extends Rawls's theory. He
considers When the public uses the principle of "fair
equality of opportunity", they are often thinking about
some properties, such as race, health, IQ, national
origin, and social status.
This thinking leads to rules such as "To each
according to gender" or "To each according to social
status". Just this thinking forms a widely accepted
reason for permitting different treatment of some
persons.
Norman Daniels argues that some properties, such
as IQ and health, are not the responsibility of the
people who own them, so they should have fair
opportunity to be treated justly.
some philosophers argue that some properties
should not be taken as a justification for
discrimination, because the persons who have these
properties (for example, the homosexual's sexual
preference, the drug user's addiction, and the HIVpositive's disease) are not responsible for them.
From the point of view of tolerance, such HIV-positive
and AIDS patients do not bear all the responsibility
for their behavior. AIDS is a special disease, which
can be contracted in many ways.
In China, some people might be infected by casual
sex, having no other way to satisfy sexual desire.
Some young people might be infected by premarital
and extramarital sex because of the traditional
culture's objection to premarital and extramarital sex
as well as to making condoms available to young,
unmarried people.
Some homosexuals, drug users, and
prostitutes might be infected as a result of
having multiple partners because the
repressive
climate
made
them
go
underground where no HIV education and
prevention was available.
Even though someone may be infected by
unhealthy sex, we have to forgive them, try to
understand them, give them a chance and
help them correct their mistakes.
4. PRINCIPLE OF CARE
The principle of care is located in the last
order of this bioethical framework.
It improves on the principles of
nonmalficence, beneficence and respect for
autonomy and helps to solve the issues
within the basic bioethical framework,
especially about how to solve special issues
that HIV/AIDS-related population is involved
in.
The principles of nonmaleficence and beneficence
are based on utilitarianism and Kantianism.
When applied in an ordinary medical context, this
principle is relatively unproblematic, because the
conflict between patients and other related persons
and society is not so serious.
However, the HIV/AIDS epidemic is not the same as
ordinary diseases. It is a fatal disease with no many
effective therapeutic drugs. It is an infectious disease,
which can be communicated by HIV-positive
individuals who live without symptoms.
On one hand, HIV infection-causing private acts can
have social consequences. If we do not control the
behavior of HIV/AIDS people, the disease will
produce devastating effects on society.
On the other hand, HIV-positive people can live more
than ten years without symptoms, and ought to have
any rights (such as the right to marriage, work, or
education). But when they get married, they might
infect their partner through sex action.
So the possible conflicts between society, HIV/AIDS
individuals and other related people are much larger
than ordinary diseases.
To solve these serious conflicts between persons or
between a person and society, utilitarians have said
that by giving equal weight to the interests each
affected party, we can get the best overall result.
However, in practice this is equal to permitting the
interests of the majority to override the rights of
minorities. For the interests of others, HIV/AIDSaffected people might have to give up the right to
marriage or having a family.
Kantianism is also inadequate. Kantianism is
an obligation-based theory.
But Kant has a problem with conflicting
obligations. Sometimes we cannot at the
same time fulfill obligations to two persons.
Kant's categorical imperative is both obscure
and difficult to render functional in the moral
life.
To improve the basic framework and solve the
HIV/AIDS related balancing problems, I add a
principle called the principle of care.
The meaning of the principle care is that from the
starting point of caring, one analyses ethical
affairs depending on the context and the
relationship between parties,
and tries to arrive at a conclusion that
encourages each party to care for the interests of
others so as to make the conflict smaller.
Ethics of care shares some premises with
Western communitarian ethics, including
some objections to central features of
liberalism, an emphasis on traits valued in
intimate personal relationships,
such as sympathy, compassion, fidelity,
discernment, and love, and a minimization of
Kantian universal rules and utilitarian
calculations.
The origin of the ethic of care is feminist perspectives.
Caring distinguishes between caring about and
caring for. "Caring about' something can distance the
agent from the object of caring and involves
impersonality, cause, institution etc.
"Caring for" focuses on emotions, feelings, and
attitudes. Central to the ethics of care are the notions
of receptivity, relatedness, and responsiveness.
Ethical caring is simply the relation in which we meet
another morally. Motivated by the ideal of caring in
which we are partners in human relationships,
we are guided not by ethical principles but by the
strength of the caring. In this point, morality is viewed
in terms of responsibilities of care deriving from
attachments to others,
and empathic association is also stressed as the
emotional relation with others. Ethical judgment is
based on a very strong sense of being responsible.
Another important feature of the ethics of
care is its contextual approach to ethical
problems.
Ethics of care stresses approaching ethical
dilemmas in a contextualized, narrative way
that looks for resolution in particular details
and that involves personalized and socialized
contexts.
In this way the affairs of ethics can be better
understood.
The principle of care is a new way of
reasoning ethically.
It does not stress isolated autonomy,
avoiding direct conflicts between
individual and individual,
and focusing on how to be beneficent
within the relationship and context.
When we apply the principle of care to
solve the problems facing HIV/AIDS
persons, the ethical issues are sometimes
changed to relationship issues.
Relationship issues do not involve
deciding who wins various right struggles.
There can be more than one conclusion to
a rights struggle.
For example, from the perspective of caring,
we can care both for HIV/AIDS persons and
their sex partners by giving rights to marriage
and reproduction to both,
but whether they can get married or not
depends on their relationship, their health,
and their related network and so on. In this
way, we can know how to assign rights and
who ought to receive the rights.
Some feminists have argued that utilitarianism,
Kantianism, Rawls's justice theory and so on can be
called "ethics of justice" compared to "ethics of care".
to promote the "ethics of care" and reject the "ethics
of justice" .
I disagree with this opinion. In practice, caring should
sometimes be principle-guided. In caring, at times our
actions may be too partial and in need of correction
by impartial principles.
The ethics of care can be viewed as a supplement to
the ethics of justice in balancing conflicts of rights or
interests, and the ethics of justice is a rational
addition to the ethics of care.
Even though there are some incompatibilities in the
foundational theories between the principles of
beneficence, autonomy, tolerance and care,
there are no inconsistencies between principlism and
contextualism.
5. CONCLUSION
The new bioethical framework that consists of the
principles of tolerance, beneficence, autonomy
and care emphasizes principle and experience,
right and responsibility, reason and passion, and
individual and community.
Even though the compatibility between old
principles and new principles or between the
ethics of care and the ethics of justice is still not
very clear in the field of bioethics,
I hope this new bioethical framework can be
useful and can improved by further inquiry and
application.