AIDS, POLICY AND BIOETHICS: A NEW BIOETHICAL FRAMEWORK FOR CHINA'S HIV/AIDS PREVENTION

1. AIDS, POLICY AND BIOETHICS: A NEWBIOETHICAL FRAMEWORKFOR 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

2. 1.POSSIBILITY FOR CHINA TO BECOME A COUNTRYWITH 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 reachedmore 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:

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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?

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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 HIV-positive's disease) are not responsible for them.

20. 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 becontracted 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.

21. 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.

22. 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.

23. 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.

24. 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.

25. 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/AIDS-affected people might have to give up the right to marriage or having a family.

26. 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.

27. 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.

28. 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.

29. 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.

30. 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 carederiving 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.

31. 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.

32. 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.

33. 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.

34. 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.

35. 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.

36. 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.

37. 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.