[Bookmark Page]
[Bookmark Page]
Udo Schüklenk, Monash University, Centre for Human Bioethics, Australia
KARL KRAUS
It might be possible to criticize ethicists of AIDS at only one point, rather than at several. We might simply have chosen to accept the facts purported by many ethicists, but challenged their reasoning about these facts. Or we might have challenged the facts, but allowed counterfactually that if their facts had been correct, so would their conclusions. But to challenge the ethicists at only one point would attribute to them a degree of good faith which we do not believe they have shown. It is not merely that they have made honest mistakes either of fact, or of reasoning but rather that they have simply started with a conclusion, then invented or highly-selectively sought whatever facts and arguments would support this conclusion. This conclusion is that the so-called general public those not initially identified as at-risk groups will develop AIDS in vast proportions. A corollary of this conclusion is that proportionately vast social attention and funds must be paid to AIDS in this general public. The convergence of ethicists around this conclusion is not an accidental or irrational event, but rather reflects a social logic. A story of universal devastation of society is a story which exerts an understandably widespread fascination. Quite simply, the ethicists of AIDS have found they have more audience-appeal in discussing a topic (even if fictional) of widespread fascination than they do in discussing one met with relative indifference.
The three sections of this paper analyze, in turn, the social logic behind two empirical claims made by AIDS-ethicists, and then the argumentative structure used by these ethicists in general. Section one disputes the widespread exaggeration of the risks that heterosexuals, as such, face from AIDS. We show how ethicists have used and fueled this exaggeration. Section two disputes the similar exaggeration of the risks to women particularly the risks via sexual activity. In this case, the focus shifts partially from simple mistatement of the facts, to selective attention to these cases, in vast disproportion with the actual risks. Again, AIDS-ethicists have contributed to and utilized this overattention. In the final section, we discuss the kinds of rhetorical strategies AIDS-ethicists have had to adopt to maintain their sensationalistic appeal.
MICHAEL FUMENTO
If AIDS is a sexually transmitted syndrome, as seems likely whether or not HIV plays the lately questioned role usually attributed to it, then, undoubtedly heterosexual transmisions do occur. From a public health standpoint, however, the crucial question is of the degree of such transmission, both within the syndrome as a whole, and in comparison to other diseases facing these same heterosexuals. We claim that this incidence has not been particularly significant certainly not what would normally be called epidemic and we have no indication that it will become epidemic, at least in so-called First World countries. We do not comment on the situation in so-called Third World countries, because reliable epidemiological surveys about AIDS in these countries do not exist at the moment, and we refuse to join any ungrounded speculations on that subject.
Notwithstanding our above appraisal, Melbourne's The Age reported in 1985[1]: "Tens of thousands of Australians have been exposed to the deadly AIDS virus." Ansett, one of the two largest domestic airlines in Australia, announced about the same time their refusal to carry persons with AIDS.[2] That same year, the US magazine Life headlined its issue "Now, No One is Safe From AIDS." Professor David Penington, former chairman of the Australian National AIDS Task Force, sent a letter on 24 October 1986 to all physicians in the state of Victoria, claiming that "AIDS is no longer (and never really was) a disease confined to homosexuals." At the same time the Health Department Victoria reported that 98% of all AIDS cases in this state were among gay men. In March 1987 The Age reported that AIDS was hitting our children. Where? "AIDS is now spreading in schools." The Herald Sun predicted "Millions of AIDS cases to come" in the US in the same month. The Goldcoast Sun[3] promised its readers in 1987: "Because of its severe medical and social implications the Sun will keep the public informed with a weekly feature on the latest developments of a disease which, at present, has all the hallmarks of another Black Plague in Europe." The New York Times[4] proclaimed in a headline that, "AIDS may dwarf the plague." US Surgeon General C. Everett Koop declared AIDS to be "the biggest threat this nation has ever faced." Who could offer more?
Meanwhile we have come to know, as Michael Fumento has explicated dramatically in his persuasive analyses on this topic[5]: heterosexual AIDS is virtually "a myth". During the past decade, no epidemiological data have been provided which could have supported the claim of a looming, widespread heterosexual AIDS epidemic in the countries of the so-called First World. Has this prevented the public media from creating the threat of such an epidemic in their reporting? As everyone is well aware, it has not. The majority of customers of daily newspapers, as well as magazines, and radio and TV programs, are heterosexual, and the public interest in the health problems of gay men or injecting drug users (IDUs) is not as great as in those of the so-called general public. Comparisons between AIDS and the Black Plague in Europe, on the other hand, guarantee large newspaper sales and interested viewers of TV programs. Bioethicists naïvely analysed ethical problems which were expected to come in the wake of the predicted heterosexual AIDS epidemic. And indeed there has been a pandemic of AIDS related publications by bioethicists. As a 1990 review article in the Journal of Medical Ethics reveals: "Examination of the quantitative increase of articles over these years shows that, while references to AIDS and/or HIV infection increased by about one third per year, the number of papers treating ethical problems linked to AIDS doubled each year."[6]
One representative article was published by two Finnish bioethicists in 1987 in the international, refereed journal Bioethics. [7] In its introduction the article replies to a paper the philosopher Richard Mohr published in the same journal.[8] Mohr argued that AIDS will remain nearly exclusively a gay problem in the so-called First World. The Häyrys' article, with its attention-grabbing headline AIDS NOW, argues that "AIDS will seriously threaten the heterosexual population in 3 5 years' time in the Western countries if the spread of HIV cannot be controlled by then".[9] However, 6 years after the prediction was made: There have been no significant changes in the sexual behavior of the heterosexual population in the so-called Western world.[10] The 1980s epidemic of syphilis among young black people in the USA, both males and females, would not have occurred if 'safe sex' were practised. The German Federal Centre for Health Education discovered that, "only 4 to 23 per cent of all respondents in a representative sample of Germans ... always use condoms. Between 11 and 17 per cent of those who had several partners said they always used condoms."[11] However, this has not produced a significant increase in the incidence of AIDS cases in the heterosexual part of this group. The spread of the virus has not been controlled anywhere in the world, presuming its main mode of transmission is unsafe sexual behavior. iii) AIDS is still a syndrome predominantly restricted to the same risk-groups as it has been since its initial diagnosis.
How did the Häyrys try to support the "claim about AIDS being everybody's problem"?[12] They refer to speculations like the following: "It is now estimated that 30-40% of those infected will develop AIDS."[13] "In 1986 there were globally already 34,448 registered cases, and 100,000 estimated victims of AIDS".[14] "At a meeting [sic!] of AIDS researchers in New York, October 1986, the estimation was that the portion of those with HIV who had been infected through heterosexual intercourse had grown from one to two percent during the previous six months."[15] We could continue forever with the "estimations" the Finnish philosophers quote in their paper. However, who would seriously use speculations of this kind as the basis for an analysis of ethical implications? (Incidentally, we might add, these "estimations" turned out to be wrong, and Mohr's argument proved to be correct). Particularly egregious are the frequent references to an unspecified "meeting of AIDS researchers in New York". This unknown conference and its unknown participants became "experts" in this same article.[16] We are at the end of the second decade of a presumably mainly sexually transmitted deadly disease, and all we have had in 10 years are approximately 3,000 cases in Australia, with its population of 18 million, and approximately 9,000 cases in Germany, with an 80 million population. This will change, however; the numbers will become significantly higher in future. The US CDC introduced a new AIDS case definition, effective on January 1, 1993, which doubled the number of AIDS cases in New York overnight. An analysis of the implications of this new definition for San Francisco comes to the conclusion that "the number of person eligible for an AIDS diagnosis will probably more than double."[17]
The Häyrys, on their way to Armageddon, catch themselves in an exaggeration, when they write "those infected today may or may not develop AIDS, but if they do not have themselves tested to learn about their infection, they may pass it on to their sex partners who pass it on to their sex partners, and soon virtually everyone will have it. Exaggeration? Perhaps."[18] Although these "may"s are quite devoid of literal content, they are quite rich in the insinuation of disaster. The Häyrys' method thereby is to write nonsense at some length and then acknowledge it. The question remains: Why did they write it in the first place? They did so because others would consider their exaggeration to be nonsense, if they hadn't been lulled by the acknowledgement of the "exaggeration." They continue writing: "Today AIDS is everybody's concern because of its frightening potentialities."[19] Potentialities, of course, which our authors invented and pretended to verify with mysterious "estimations." A similarly vacuous statement is made by US bioethicist Timothy Murphy, who wrote that "despite better medical treatment the number of HIV-related deaths continues to increase".[20] Apart from the fact that these deaths were AIDS-related, rather than HIV-related, as Murphy proclaims, the hidden truth behind this seemingly unproblematic statement is that it is the tautologous result of the manner of counting AIDS deaths. AIDS is the only disease which is generally counted cumulatively. If there have been 250,000 AIDS deaths to date (in the US, for example), but next year one person dies of AIDS, the ravages of a disease which has killed 250,001 persons would be reported in the papers, and of course Prof. Murphy would find this an indication that the AIDS epidemic is still out of control, since still more people have died of it in total than had in the last year.
Even while a begrudging admission of the non-epidemic of heterosexually transmitted AIDS has been made in much of the scientific establishment, border skirmishes continue to be fought in the attempt to maintain evidence of widespread heterosexual spread. For example, the US National Research Council, a private research institution which is part of the National Academy of Sciences of the USA concludes that AIDS will remain largely confined to the initial groups at risk. Indeed the study concludes that AIDS will have little impact on the lives of the average American.[21] Subsequently public health educators have claimed that their educational campaigns have led to behavioural changes in the general population which explain why AIDS is not reaching epidemic proportions amongst heterosexual persons who have no sexual contacts with the classical risk groups.[22] However, the fact of the matter is, as Chapman put it so ingeniously: "There is heartening evidence that (this claim) is correct where it applies to high-risk groups like gay men, injecting drug users and sex workers in Australia, but little reason to agree with him regarding the general population."[23] For instance sexually transmitted diseases have dramatically increased in the US in adolescents, but there has been no AIDS epidemic in the heterosexual part of this population.[24,25] This example, and the above mentioned survey of the German Federal Centre for Health Education give evidence for our claim that the AIDS education campaigns directed at the general population were a complete failure. Unsafe sexual behaviour such as this, however, has not led to AIDS epidemics in these segments of the population. Gordon T. Stewart[26] shows that projections of AIDS amongst British heterosexuals have been univocally in excess of actual rates, in most cases by as much as five times. Stewart's numeric point is acknowledged in an editorial in the same issue.[27] This, however, occurs only in the context of a continued search for new arguments for heterosexual panic, as we discuss below.
A skirmish over the search for motivations for heterosexual panic is created by a recent article in The Lancet[28] which attempts to demonstrate a rate of female-to-male HIV transmission in Thailand over an order of magnitude higher than in comparable US studies, discussed below. This study of 21-year old military conscripts is unconvincing because of its unlikely assertion that "sex with nonprostitute women, sex with men, injecting drug use, blood transfusion, and tattooing did not appear to contribute to risk." [29] The authors observe that "reporting of sex with prostitutes by the young men was not stigmatised and was reasonably accurate," but omit the obvious fact that homosexual sex with men and injecting drug use are strongly stigmatized in Thailand, as elsewhere. What immediately seems more likely than that HIV is greatly more transmissible heterosexually in Thailand than elsewhere is that many of these young Thai men in fact became infected by other routes; when their rate of infection is assumed to have occurred in prostitute contacts, an artifactually high likelihood of transmission results. For the study to have reported no correlation at all between HIV-seropositivity and male-male sexual contact or injecting drug use suggests that wide misreporting contributes significantly to the high numeric estimates of female-to-male HIV transmission.
Priscilla Alexander, former consultant with the World Health Organization, Global Programme on AIDS, and former co-director of COYOTE, the San Francisco-based prostitutes' rights organization, is convinced that AIDS in Thailand was first, and continues to be, primarily an epidemic among injecting drug users.[30] The same can be said for other South-East Asian countries, such as Malaysia, where the national health ministry reports for a period between 1985 and March 1993 that 4410 out of 5459 persons with an HIV+ test result were IDU.[31] If there is any accuracy to Ms. Alexander's evaluation of the widespread IDU AIDS risk in Thailand, The Lancet article most certainly fails to identify underreporting of injecting drug use amongst the cohort studied and most likely of male-male sexual contacts also.
An editorial in The Lancet[33] asserts that "Women are the fastest growing group with HIV infection in the USA". It is difficult to fathom what this claim is based upon, since estimates of the prevalence of HIV infection are notoriously unreliable; being, if anything, constantly revised downwards. New York Times medical staff writer Lawrence K. Altman[34] reports that the newest CDC estimates show HIV infection occur in approximately 600,000 to 800,000 Americans, down from previous CDC estimates of 1 million in 1990. This 1 million itself represents a reduction from earlier CDC estimates of 1.5 million.[35]
If we look at the figures for AIDS diagnoses, we see that although women show a percentage growth rate higher than other broad categories of people with AIDS, they still represent a small proportion of the increase in numbers of people with AIDS in the latest reporting period. A November 1993 CDC[36] report shows, for example, a change in new AIDS cases amongst male IDUs from 8,621 in October 1991-September 1992 to 19,142 in October 1992-September 1993. This is an increase of 10,521 AIDS cases, most of them due to the extended 1993 surveillance definition. Female IDUs go from 2,815 to 6,891 new AIDS cases in the same interval, an increase of 4,076. Combined, this is an increase of 14,597 cases amongst IDUs of both sexes. In contrast, adult/adolescent women as a whole go from 6,153 to 14,792 cases, an increase of only 8,639 during the same interval. While this increase amongst women is still, perhaps, cause for alarm, it is numerically less than the increase amongst male IDUs, let alone IDUs in general. Even men who have sex with men went from 24,334 cases to 46,025 cases in the intervals mentioned, an increase of 21,691; although this increase is purely an artifact of the changed 1993 surveillance definition, which reflects an underlying net decrease under constant definition.
This claim about women being the "fastest growing group", whether of the HIV-infected or of AIDS patients, is misleading and alarmist to the lay reader. Wording that obscures the distinction between proportional rate of growth and absolute increase is often made by writers stressing the size or urgency of the problem among women. For example, Suki Ports[37] states (inaccurately), "the fastest growing numbers of AIDS cases are among women." Others merely insinuate patterns that don't exist without outright misstatement. A Panos Institute[38] book informs us, "where HIV has so far spread mainly among gay (homosexual) men and injecting drug users women now account for just over 10% of AIDS cases." Ignoring the slight inaccuracy of the percentage for 1990, one should observe that a contrast is drawn between hitherto spread "mainly among gays and IDUs" and the current 10% amongst women. Even leaving aside the fact that most of those 10% of female cases are IDUs themselves, 90% continues to constitute "mainly" by anyone's definition. Nothing has changed according to the Panos Institute statement, and yet that very fact is used to indicate an imminent epidemic amongst women. Furthermore, it continues to be the case that many times more men are newly diagnosed with AIDS each year than are women (hence the actual increase in cumulative AIDS cases is greater amongst men than amongst women). Compared to the 6,153 women in October 1991-September 1992 and 14,792 in October 1992-September 1993 who were diagnosed with AIDS, 36,833 and 81,707 men were diagnosed in the respective intervals.[39] In Australia, where the reported incidence of HIV infection figures appears to reflect actual incidence more closely than in the US, the percentage increases over the same period among women are higher than among men, but the numerical increases are still less than those among men by an order of magnitude.[40]
The reasons why billions of dollars are spent on AIDS research are twofold: 1) Efficient AIDS lobby groups produced the necessary public pressure to generate more money for AIDS research. 2) Researchers, not really acting altruistically, undertook AIDS projects predicated, in the absence of any scientific basis for it, on a dramatic increase in the incidence of (heterosexual) AIDS cases; and argued that these cases would legitimize the money spent. AIDS is still a predominantly male disease in all so-called First World countries, restricted to virtually the same limited risk-groups as ever.[41] Nevertheless, the amount of money and public resources spent in the last ten years for the fight against AIDS is unique. No other disease in history, killing relatively few people, has generated such a large amount of research money, so much public attention and incidentally so many new professional journals in all sciences, as AIDS has done.[42]
It was only a matter of time until someone discovered that it was somehow unfair to exclude women from these billions of dollars for AIDS research, education and prevention. The officially published statistics, however, can't provide much of a case for spending huge amounts of taxpayers' money on womens' AIDS projects, let alone on lesbian womens' AIDS projects.[43] AIDS is not an equal opportunity killer, and we have no indications that it will evolve into one. Political calculations, not epidemiological warning signs, led the New York City Gay Men's Health Crisis to implement a "Lesbian AIDS Project" presumably to avert feminist arguments about the male-dominated Gay Men's Health Crisis. The newly appointed coordinator immediately started producing "lesbian safe sex kits, which will include a range of relevant products gloves, cots, condoms, dental dams, lube and literature". The next project is said to be a "comic book illustrated by gay and lesbian cartoonists". Over the last decade there have been only two case reports of apparent female-to-female transmission of HIV.[44] Reviews of AIDS cases in the USA in women who reported having sex only with other women found that all had a history of injecting drug use or receipt of blood transfusions.[45]
The lack of actual woman-to-women transmission of HIV/AIDS has not prevented feminist medical ethicists from criticizing mainstream AIDS education for not addressing this problem. Nora Kizer Bell laments "that reliable safe sex information for lesbians is neither widely distributed nor widely known to be available."[46] Bell is mistaken about this. Every book we can find mentioning "women" and "AIDS" in the title has sections on AIDS in lesbians, with an inevitable section on lesbian transmission of AIDS. The book AIDS: The Women[47] predates Bell's proclamation by four years, and contains a chapter entitled All That Rubber, All That Talk: Lesbians and Safer Sex[48] whose tone clearly assumes safe sex knowledge to be ubiquitious amongst lesbians. Women & AIDS[49] makes the same assumption, while praising the virtues of dental dams. Lesbian magazines such as On Our Backs also provide instructional material, and moral guidance, on safer sex.[50] Our personal experience has shown largely locally produced materials urging the use of dental dams and other safe sex equipment in gay and lesbian bookstores (and similar lesbian-oriented establishments) worldwide; and we have found almost all lesbians of our acquaintance to be quite familiar, at least intellectually, with safe sex practices although few feel these measures are worth personally conforming to. Given the non-existent to minuscule risks of HIV/AIDS transmission in lesbian sex, we find these judgements generally more rational than those of bioethicists like Bell.
Christine Overall, a distinguished Canadian philosopher with a remarkable record of publications in practical ethics, made one of many unsuccessful attempts to make the case for AIDS and women. [51] Bear in mind that the situation regarding AIDS in Canada is not all that different from that in Australia. Australia has a male-to-female ratio of 35 to 1. As of January 1991, about a year after the time we assume Overall's article to have been written, 4,647 persons (mostly gay men and injecting drug users) had contracted or died from AIDS in Canada. Of these, 175 approximately 3,76% are women, the vast majority of whom belong to the risk group of injecting drug use.[52] Such is not really a good argument for the significance of "the heterosexual politics of HIV infection," as Overall's article headline proclaims of issue. She therefore purports that these figures "may well under-represent the number of female Canadians with "full-blown" AIDS, since the full spectrum of AIDS-related diseases in women often goes unrecognized as such".[53]
In the USA, the nation with the largest number of AIDS cases[54], adult and adolescent women have made up 40,702 of the cumulative 334,344 AIDS cases; in other words 12% of cases as of November 1993.[55] Pediatric AIDS cases are approximately evenly divided between the sexes, as one would expect. However, these cases account for only 4,906 of all cumulative cases, and hence do not significantly affect the percentages.[56] However, within these forty thousand cases, the cases of heterosexual transmission have been exaggerated and are far disproportionately discussed in the popular press and by bioethicists. Overall's title is one example amongst many. Many books and articles contain similar language on heterosexual AIDS in women. [57]. Heterosexual transmission makes up a minority of female AIDS cases, with injecting drug use constituting the majority of transmissions. For the most recent reported interval from October 1992 to September 1993, 6,891 female cases with injecting drug use as mode of transmission were reported, while 5,545 were reported with heterosexual contact as the risk-category.[58] Of the heterosexually transmitted female AIDS cases, where the risk category of the male partner was identified, the vast majority of the partners were IDUs. Of the 5,545 cases of female AIDS cases, allegedly transmitted heterosexually in the most recent annual reporting interval, 2,474 were partners of IDUs. Only 423 were partners of bisexual men, while 2,131 were partners of HIV-infected persons with unspecified risks.[59] We have no reason to believe that the breakdown of the actual risk-categories of thosepartners with unspecified risk is significantly different than those of partners with reported risks. In light of the argument made below that there is substantial overreporting of heterosexual risk category in men, we suspect that many of the female reports of heterosexual risk-category are misreports. For all the same reasons that other people lie to doctors about stigmatized activities, such as male male sex, women with AIDS lie about use of injected drugs. For example, in an interview, New York public health official Rand Stoneburner stated, "of 63 men [as of January 1989] who reported prostitute contact but denied other exposure, 42 were later found to have a history of contact with homosexual men or had engaged in intravenous drug abuse." Outside of New York City, thorough repeat interviews and contact tracing, which would reveal such initial misreports, are not performed.[60] Therefore, most likely, a substantial number of the reported cases of heterosexual transmission in the partners of injecting drug users, in particular, are themselves injecting drug users.
Additional suggestion of misreporting IDU AIDS risks as heterosexual contact with IDUs is contained in the very fact that the majority of reported heterosexual transmissions are from IDUs. While men who have sex with men compose over twice as many AIDS cases as men who use injected drugs, they appear to be about six times less likely to transmit AIDS to women (see above discussion)[61]. A cumulative 183,344 men who have sex with men have developed AIDS in the USA, while a cumulative 80,713 injecting drug users have developed AIDS. Some of these 80,713 IDUs are women, however. The CDC document does not provide directly cumulative numbers of IDU female AIDS cases, but from October 1992 through September 1993, there were 6,891 female IDU AIDS cases and 19,142 male IDU AIDS cases. The cumulative 80,713 IDU AIDS are likely to break down in a ratio similar to this 1:3 ratio, i.e. there should be approximately sixty thousand male IDU AIDS cases cumulatively.[62] In a rough way, this would suggest either A) HIV/AIDS is more transmissible by IDUs than by bisexual men; B) No more than 1/12th of men who have sex with men also have sex with women; or C) There is underreporting of non-heterosexual risk amongst partners of IDUs. In the absence of a plausible biochemical explanation, we reject A); B) contradicts familiar sexological surveys from Kinsey on.[63] Kinsey [64], for example, shows only 2.9% out of 19.8% of 25-year-old men who have some homosexual history are exclusively homosexual. The remaining 16.9% of all men, or 85% of men with some homosexual contacts, have some heterosexual contacts as well. This study shows a similar pattern in other age groups, with 30- and 35-year-old men with some homosexual history being exclusively homosexual at an even lower rate than 25-year-old men (but 20-, 40- and 45-year-old men having somewhat higher ratios). Kinsey's exact numbers have been disputed, but all reputable quantitative sexologists have found that a significant proportion of "men who have sex with men" also have sex with women[65].
Our conclusion, therefore, is that there is underreporting of non-heterosexual risk amongst partners of IDUs. None of this argues that women are at less of an overall risk than CDC data suggest; we merely suggest that the AIDS risk to women is not in significant part the risk of heterosexual intercourse so widely publicized popularly and professionally.
The case that someone, at least, is misreporting their heterosexual transmission category can be pretty clearly shown from the CDC data themselves. However, the data only inherently demonstrate the overreporting of male "heterosexual" cases. The CDC reports 3,328 AIDS case resulting from female to male sexual transmission during October 1992 through September 1993. During the same interval, 5,545 male-to-female-transmitted AIDS cases are reported.[66] If one notices the HIV-seroconversion partner studies which have been done, which show much greater sexual transmission efficiency of HIV from men to women than vice versa, then one simply has to reject these female-to-male cases as overreporting (or conclude that there is a large underreporting of heterosexual risk in female AIDS cases, which we reject above). Studies by Padian[67] and Peterman[68] show a sexual transmission efficiency from males to females from three to twenty times greater than that from females to males. The larger Padian study shows only a 1% transmission efficiency from female to male, after a mean of 388 sexual contacts; to the contrary, an efficiency of 20% occurs from male to female in the same group. The Peterman study shows a less extreme discrepancy of 8% and 18% however, the 8% female-to-male transmission of HIV represented only two cases. In any event, an uncritical reading of CDC numbers would indicate that the 1/8th of AIDS cases who are women heterosexually transmit AIDS 3/5 as often with a 1% to 8% transmission efficiency as do the 7/8ths of AIDS cases who are men with a 18% to 20% transmission efficiency. Even allowing that a substantial number of men suffering AIDS are exclusively homosexual (even all those with homosexual risk-category!) the numbers just don't add up. The only possible assumption in this case is of substantial overreporting of heterosexual contact as exclusive risk in men with AIDS. This is supported, admittedly anecdotally, by the published 'confessions' of a gay African-American with AIDS. He wrote: "You would not believe all the questions I had to answer. At first the doctors came as a team to ask me about my sexual past. Later on, they came one by one to ask me the same question. My story remained consistent. I lied, because I am a closet homosexual. I was not about ready to reveal the truth to strangers."[69]
Even if all of the 3,328 men and 5,545 women with AIDS who report heterosexual contact as sole risk for AIDS during the most recent annual interval are making accurate reports, it is important to notice that these numbers would contribute only in small measure to the overall health risks facing heterosexuals. These 8,873 new cases from October 1992 through September 1993, most reported under the greatly expanded 1993 AIDS surveillance definition[70], correspond to somewhat fewer than this number of AIDS deaths, probably about 5,000 per year. This approximate 5,000 may be put in perspective by comparison with the annual 496,000 American cancer deaths, 734,000 heart-disease deaths, 146,000 stroke deaths, or 43,500 automobile fatalities[71]. The usual rejoinder to such perspectivizing is that "even one death is too many," which we cannot disagree with. However, one would like to say the same of the 12,200 fatal falls, 4,600 drownings, 4,200 fire deaths, or 2,900 suffocation deaths[72], none of which receive daily newspaper headlines or massive research funding, or are subjects of articles by bioethicists.
There is another reason to think twice about whether to adopt a proposal such as Guinan and Hardy's idea that "it is important to educate all women about their risk of sexually acquired AIDS and to encourage risk-reducing behavior."[73] The vast majority of women are simply not at risk for HIV/AIDS. In times of scarce health care resources it could be argued that it is an irresponsible waste of such monies in order to keep women who aren't at risk of contracting this disease informed about AIDS in the first place. Apart from these monetary costs, there are also psychological costs attached to it. Millions of women who aren't at risk of AIDS will inevitably, each time they have sexual encounters, think of AIDS. Anxiety, depression, hundreds of thousands of unnecessary HIV-tests, and broken relationships are the results of such campaigns. Chapman correctly questions the appropriateness of such campaigns: "Is a government program of scaring people especially when there is little basis for them to be scared something that public health should see as a relatively benign means to a more important end? Or is the intrusion of this concern into every sexual encounter some form of state-sanctioned mass neurosis? Is it not worth asking seriously about the social and emotional costs involved in public health efforts attempting to have all sexually active people become sufficiently anxious about acquiring HIV to insist on condoms in every sexual encounter?"[74] Another unfortunate effect of this disproportionate anxiety about AIDS is that it has the potential to swamp people's awareness of other risks associated with sexual activity. When faced with a distant risk of a horrific outcome (a fatal disease), people tend to resort to denial: they shut their eyes and jump. This disables them from considering the much less dramatic but statistically more prevalent infections, such as herpes or wart virus, or indeed the risk of pregnancy.
Our point to stress here is that there are not enough reported female AIDS patients who have contracted these diseases through heterosexual contact to legitimize the time (and resources) spent on writing Overall's article; hence Overall claims that the too-low-to-be-true numbers underrepresent the real number of cases. This implies, unrealistically, that Overall has better numbers than the health care system of a Western country like Canada. We question that her belief that there are many unreported female AIDS cases can be true, since medical scientists all over the world have now been paying close heed for ten years for the first signs of a heterosexual epidemic. As a matter of fact, as we have pointed out earlier, the heterosexual AIDS epidemic has effectively been called off by epidemiologists and health authorities of most Western countries. However, we have no way to disprove the a priori assumption of underreporting, made by those who do not accept the officially published numbers. By postulating an unobserved, and unobservable, empirical reality, Overall makes her arguments quite unfalsifiable.
Elsewhere in her article Overall writes that "many writers have pointed out that the real social concern about HIV infection did not materialize until its potential `spread to heterosexuals' was recognized. What is less often pointed out is that concern for the `spread to heterosexuals' has mostly been manifested in concern for the spread to heterosexual men, not heterosexual women."[75] It is amazing that Overall, in the absence of a heterosexual AIDS epidemic in the past or signs of one for the future, has only the one ethical problem: that women couldn't get their fair share of this non-existent epidemic?
Under the subheading "AIDS and Social Inequality" Overall criticizes at some length the above-mentioned article, "Gays, AIDS and State Coercion", written by the gay philosopher Richard Mohr. We must stress the point that Mohr's article analyzes the situation of gay men in the age of AIDS; and that this article about gay men is written by a gay philosopher. When Mohr writes "each person on his own without state coercion can get the protection from the disease that he wants through his own actions", or when he writes "the person who gets AIDS through sexual contact . . . actively participates in the very action that harms him", Overall adds in her quotations emphasis to the personal pronouns, and adds a "sic" when Mohr writes that a gay man harms him(self).[76] It seems, however, parsimonious to us that an ethical analysis of the specific situation of gay men in the age of AIDS, written by a gay male philosopher doesn't refer to "a lesbian/straight woman harming herself", because this is not what the paper is about. It appears very strange when a feminist philosopher such as Overall criticizes a gay man writing about gay men for not using women in his examples and argumentation. She writes "Richard Mohr rather contemptuously dismisses ethical concerns about the effect on women of respect for confidentiality" ignoring, that Richard Mohr's argument and analysis are directed specifically at the situation of gay men.[77]
First Murphy establishes a tone of (empty) indignation with claims such as: "Surely an infectious, communicable, lethal disease ought to receive priority over diseases that can currently be medically managed in a way that permits people to live into old age (italics added)."[80] Beyond a failure to establish why such priority is demanded. This sets up the bogey of a contrast with generally manageable conditions like hypoglycemia or hypertension, for example. Who after all, can fail to acknowledge that AIDS should be more highly funded than research into hypoglycemia?
This is not, however, at all the contrast Fumento has in mind; but rather of AIDS with cancer or heart-disease which are, in fact, quite often unmanageable and lethal. If the argument is to be made that AIDS deserves enormously greater proportional funds than other diseases, more need be said than a hollow insinuation of the harmlessness of other diseases. Another line of argument which might be implicit in Murphy is that most persons with AIDS suffer this disease at a relatively young age, and they are going to loose more quality adjusted life years than will the typically much older heart disease patient. Hence, it might be concluded that relatively-few young people with AIDS will loose, overall, more quality adjusted life years than relatively-many older people with heart problems. However, even if we would accept this argument, and think deaths at early ages are particularly bad, we should notice that 127,000 heart-disease deaths occur in those 25-64 years old annually in the US, and 156,000 such cancer deaths.[81] Even young heterosexuals face many more serious mortality risks than AIDS In addition to greater absolute risk, to an even greater extent they face more serious risks relative to the proportional funding different diseases receive. The degree of disproportionality in disease funding is striking. For each AIDS death reported in the USA in 1990, the government spent $53,745 in research and education. That's more than 15 times the $3,241 spent per cancer death and about 58 times the $922 per death parceled out to researchers fighting heart disease.[82] Since 1990, the US AIDS budget has approximately doubled[83].
Murphy next attempts to move the issue of appropriate levels of AIDS funding to another irrelevant issue of blame and guilt. Against the argument made by none of his mentioned sources, Murphy takes pains to show that we should not reduce AIDS funding on the basis of sufferers' blameworthiness: "Perhaps it is the seemingly voluntary nature of infection that invites the notion that enough has been done for HIV-related conditions." [84] Murphy first turns here to the usual innocents with AIDS hemophiliacs, infants, health-care workers, and artificially inseminated women thereby implicitly accepting and creating the very scheme of blameworthiness versus innocence which none of his sources utilize. Next Murphy attempts to show that the "guilty" are not really so guilty because "as regards the enticements of sex and drugs, people are weak." [85] Finally Murphy invents an excuse for gay-male promiscuity in that since society has failed "to offer gay men any clear or supportive pathway to self-esteem or any incentives to the rewards of durable relationships, society has effictively forced some gay men into promiscuous behavior."[86] All of these attempts to draw our heartstrings (and purse-strings) with stories of the innocent, or of those discovered to be innocent deep down, completely dodge the argument made by Fumento, and by us herein. Even the choice of the word promiscuous, which is as much a term of morality as epidemiology, tends to cloud the issues. At any rate, infants are not innocent, and promiscuous gay men are not guilty; and neither is the reverse true. An obsession with guilt and innocence is just meaningless. We are not interested in this context whether gay men behave promiscuously because of societal compulsion, or just because they want to or whether they actually do so at all. We are interested in the rational and just distribution of medical funds in a society willing and able to fund medical research to a certain finite (albeit somewhat elastic) extent. Murphy refuses to address this question directly or honestly, instead trying to paint those suggesting lower relative allocations for AIDS with relying on the blameworthiness of its sufferers.
The fiery and misleading rhetoric continues throughout Murphy's article, as straw men are set up to be shot down. Again indignantly, Murphy proclaims, "it is important to remember that AIDS is no privilege. A diagnosis of AIDS amounts to a virtually unlimited onslaught."[87] Yes, fine. Does Murphy then believe that suffering cancer or a stroke are privileges? Disease is an unfortunate event of life, whatever its cause and incidence but there's no simple or automatic argument from the seriousness of one disease to its proper funding priority over other equally dreadful, but more common, diseases. Elsewhere Murphy chimes, "there have been many dire prophesies about the toll of the epidemic, predictions that millions to billions would die. Is it possible that critics can say that AIDS has gotten more than its share because it has not yet killed enough people?"[88] Critics of relative allocations for AIDS are thereby insinuated to wish AIDS upon huge numbers to justify the funding levels. Obviously, this is not the wish of the critics Murphy addresses. What we want is an evaluation of resource allocation unclouded by the hysteria and empty rhetoric of both the popular and biomedical/scientific press. Critics of allocation priorities do not necessarily maintain that AIDS funding should be decreased, but we do recognize that an increase of fundings for other diseases to proportionality would fundamentally change the position of medicine in modern economies. For example, according to figures indicated herein, bringing the funding for heart-disease and cancer up to that current for AIDS in the USA would involve spending approximately $180 billion dollars annually on research and education for these diseases.[89]