Beyond fear. Resolving ethical dilemmas regarding HIV infection.

T he human immunodeficiency virus (HIV) epidemic, by its devastating nature as an incurable, contagious disease primarily affecting young, previously healthy patients, presents care-givers with many ethical dilemmas. While the epidemic and the dilemmas it creates are novel, the ethical principles at our disposal are well established through our experience with other diseases. In this article we review six major clinical problems confronting care-givers treating HIV antibody-positive patients: (1) indications for screening, (2) confidentiality of HIV test results and the notification of third parties at risk, (3) indications for life-sustaining treatment, (4) refusal of care for seropositive patients, (5) dilemmas regarding research protocols and experimental therapies, and (6) allocation of medical resources. Bringing standard ethical principles to bear on these problems can make medical decision-making rational and consistent. Therefore, ethical principles that guide other medical decisions should also be applied in the case of HIV infection. These principles include autonomy, confidentiality, truthtelling, nonmaleficence, beneficence, and justice.’ We shall briefly review these principles before applying them to the specific case of HIV infection. The principle of autonomy, or respect for persons, allows individuals to make decisions about their bodies and their health care, even if others consider those decisions unwise . ‘ Competent , informed patients may decline tests or treatments that their physicians recommend. The legal doctrine of informed consent is based on this principle of autonomy. Effective communication is essential if patients are to be informed, autonomous participants in their own health care.2 Preserving the confidentiality of medical informa-