Reframing the HIV/AIDS debate in developing countries IV: does ethics have anything to offer?
Dealing with HIV/AIDS is one of the major ethical challenges facing the world today. It is suggested that an expanded discourse on ethics, divided into three levels, can help give a fuller understanding of all aspects of the HIV/AIDS pandemic. The levels are: (1) micro level (doctor-patient relationship); (2) meso level (civic and public health ethics); and (3) macro level (ethics of international relationships). At the micro level, the four principles of respect for autonomy, beneficence, non-maleficence and justice apply to HIV patients, as to any other. However, the overwhelming demand for medical care, and the lack of doctor availability in developing countries seriously limits their application. At the meso level, the Tavistock principles give a framework for health systems. The principles are: rights to health and health care; balancing resources among competing needs; comprehensiveness; cooperation among patients, clinicians and managers; focus on improvement, safety and openness. In this context, rights are respected by not discriminating on the basis of sex, geography, tribe or race. A balance has to be struck between treatment and prevention. Comprehensiveness means not ignoring palliative care and health improvement strategies. Cooperation requires 'the reciprocity and interdependence that characterise community'. The remaining principles are self-explanatory, but frequently ignored in health planning. At a macro level, there is a need for ethical discourse about issues like increasing inequality between rich and poor countries; the use of economic levers by developed countries to the disadvantage of developing countries; the international debt crisis; the tiny health care spend (US5-10 dollars per capita per annum) in Africa; and other problems like refugee and migrant labour movements. These factors fuel global instability and the HIV/AIDS pandemic, as well as contributing to the threat of terrorism and environmental degradation. We need to look at how the values of Western democracy can be revised to address these problems. For example, scientific knowledge should be made available to all who can benefit from it; individualism should be put into the context of the common good; and free market forces need to be modified to reflect the fact that we live in a world that is increasingly interdependent.
Gillies
J
J
Department of Public Health, NHS Borders, Newstead, Melrose, Scotland, UK. john.gillies@borders.scot.nhs.uk