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Arthur Caplan, Ph.D.
Director, Center for Bioethics, University of Pennsylvania
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YES
One of the main arguments against mandatory testing for HIV has been that because AIDS is a fatal disease, one gains nothing by testing for it and risks much. A positive test can be a risk to job and insurance plus a host of devastating social calamities.
We now have new drugs, such as protease inhibitors, that are able to stop HIV growth in cells. Three-drug regimens can keep the immune systems of recently infected asymptomatic patients relatively intact. If this success can be sustained, AIDS will begin to be viewed as a chronic illness, not an imminent death sentence.
If early therapy is important, so is identifying people who are HIV-positive. This weakens the case against routine mandatory testing. If we can save lives by mandatory testing, we have a moral imperative to do so.
A good place to start would be prehospital admissions. Mandatory blood tests are already required. Adding HIV testing would not be hard.
Those who are positive would be put on a drug regimen to reduce the further spread of the virus; spouses or significant others would be alerted to the need to get tested; if the patient is pregnant, both mother and child could get treated; and universal precautions would be more carefully adhered to.
When we find a medicine, or combination of medicines, that can kill HIV, then the civil rights and AIDS activists-as well as politicians-who have opposed testing will have a moral duty to advocate screening all Americans in a quick and cost-efficient manner.
We are not at this point yet. However, there is enough evidence to suggest that it is a greater possibility than it was just a few years ago. We must begin thinking now about changing our views toward mandatory testing.
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Elizabeth V. Getter, M.D.
Co-Chair, New York County District Branch AIDS Committee, American Psychiatric Association; Director, Psychiatry, AIDS Day Treatment Program, Village Center For Care, New York
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NO
Many illnesses, including communicable, life-threatening, and treatable ones, could be included in a routine admission workup, but it’s not cost-effective to do so.
Instead, routine preadmission bloodwork is reflective of the general health of a person’s body. Specific illnesses are test-
ed for in response to complaints, symptom profile, history, and physical exam. So why would we want to single out AIDS, an emotionally laden diagnosis that bears great prejudice and stigma?
Some would paternalistically impose early diagnosis and treatment of this illness on the public. Yet there is still no known cure, despite the hope inspired by protease inhibitors combined with other drugs.
The protease inhibitors are far from perfect. At best they are difficult to take, requiring com-
plex regimens of diet and dosing time. There are often significant side effects and negative interac-
tions with other medicines. And if a person doesn’t use these drugs correctly, the virus may develop resistance to the medication and the person might forever lose any beneficial effects.
A negative ELISA for HIV is not definitive for three to six months. And a positive doesn’t necessarily mean an end to unsafe behaviors. Education about safer sex practices, condoms, clean needles, or needle-exchange programs would more effectively allow and encourage the public to protect themselves than the knowledge of a positive result.
It is more cost-effective and health promoting for a practition-
er to develop a trusting rapport with a patient and complete a thorough history than to blindly test anyone presenting to a hospital for HIV.
Testing is available, but where no routine public risk is posed, people have a right to know or to not know about their health and to make their own treatment choices.
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