Human Immunodeficiency Virus Infections and Reproductive Health: A French Legal and Ethical Approach

ost of the points raised by Chervenak, McCullough, and Ledger apply to the French position, particularly as far as the historical and psychological aspects are concerned. We may agree with the possibility and furthermore the need to "rethink the clinical and public health ethics of HIV infection" and to accept "a more ethically balanced approach" than the "exclusive emphasis on the rights of those with HIV infection to the exclusion of their ethical obligations to others." Every issue dealing with information, persuasion, and possible termination of pregnancy is in accordance with the French approach. As far as the legal and ethical aspects are concerned, one must point out that France is a smaller country, with a society very centralized in its structure. This is particularly true for legal considerations, the origin of which is to be found in the statute law as expressed in the Civil Code of Napoleon, to ethical considerations regularly expressed by the National Consultative Committee on Ethics in Life and Health Sciences [Comit6 Consultatif National d’Ethique (CCNE)] founded in 1983, as well as to welfare considerations, through the generalized social security system, which tries to combine (with some difficulty) safety, efficiency, and justice. We shall consider three major issues, mainly the difficult problem when faced with possible conflicts of interest and rights for each member of the couple, and for the unborn child. The first point concerns the partner. The legal situation is unequivocal: the absolute necessity to keep confidentiality given any medical situation, irrespective of the possible harmful effects to the partner, forces the physician to remain silent. Respect for confidentiality is a strict obligation, established by the civil code, the penal code, and the code for public health. If broken, the risk of prosecution is high. The explanation for this situation has been put forward numerous times, and has to do with the risk of losing the patients’ trust if they suspect that confidentiality could be compromised. Of course, the risk for the partner has been taken into consideration, particularly by the French Academy of Medicine (the highest medical authority, which has the main and official duty to advise the French Government in health matters), which was in favor of an inflection of this rule in very specific circumstances and under very strict control; however, its advice was ignored. A risk for the physician in charge of both partners could be the possible suing by the noninfected partner, in the case of contamination, for failing to provide advised information. This situation has not yet arisen. However, a practical solution could be to advise practitioners to limit their care to one of the partners in such circumstances. The second point concerns the child to be. First, let us consider the problem of prenatal testing. The situation is identical to the one prevailing in the United States; i.e., the practitioner has the obligation, both moral and legal, to offer the test to the patient and to try and convince her to accept it. However, this situation is highly paradoxical and questionable, since it is an exception to the prevailing rules concerning prenatal care: for more than 50 years now prenatal care, including some blood tests, has been mandatory in France, for ev-