In several of our previous comments we addressed issues of justice and equity as it relates to the urgency to treat all HIV-infected individuals regardless of their clinical status or laboratory tests. If this were universally applied, I would argue that the HIV epidemic worldwide could be brought under control by decreasing HIV transmission from infected to uninfected individuals. However in order to “treat all” a critical issue must be addressed. How can all HIV-infected individuals be treated if millions of individuals are either unaware that they are being exposed to HIV through their sexual contacts or if they are already HIV infected but have not been told that they were exposed to an HIV infection? Contact tracing is the solution. Historically, contact tracing was and is, except for HIV, foundational for controlling infectious disease epidemics.
The current tension regarding the use of contact tracing is a consequence of differences in philosophies relating to the relative weight of “autonomy” versus the concept of “do no harm” and the “duty to inform of harm.”
Moral and political philosophies that might be invoked to provide insight into the “rightness” of contact tracing range from views of libertarianism that support complete autonomy and confidentiality regardless of the consequences to utilitarian views that insist that pubic good may outweigh individual rights under some circumstances. For example, Rawles suggests that, “From the standpoint of justice as fairness it is not true that the conscientious judgments of each person ought absolutely to be respected; nor is it true that individuals are completely free to form their moral convictions.” (A Theory of Justice. Belknap Press. Harvard University Press. Cambridge, Massachusetts 1999)
Discomfort with an extreme theory of autonomy was also expressed in “Human Dignity and Bioethics” (Essays Commissioned by the President’s Council on Bioethics. www.bioethics.gov ):
“… the growing sense that the prevalence of autonomy in bioethics and beyond, in American culture and society, reflects an incomplete and inadequate — even a distorted — grasp of humanity and thus of what is at stake in many of the controversies provoked by the advance of biomedicine and biotechnology.”
“The dignity of the human person — construed not, or not primarily, as the assertion of the rights of the autonomous but as the obligation to protect those whose autonomy is very limited — is such a point of reference.
“Childress and Beauchamp are inclined to ground a privacy right in respect for autonomy; yet they recognize that this cannot account for all circumstances in which we would think such a right existed.”
Issues of autonomy arising from Immanuel Kant and extended by John Stuart Mill are often invoked to support the claim that the right to confidentiality is absolute and the conclusion that contact tracing is therefore unjustifiable in relation to HIV. However, Mill also stated that liberty can only be enjoyed, “…without impediment from our fellow creatures, so long as what we do does not harm them.” (The Political Philosopher. Random House. NY. 1949)
John Locke also stated, “To understand political power aright, and derive it from its original, we must consider what state all men are naturally in, and that is a state of perfect freedom to order their actions and disposed of their possessions in persons as they think fit, within the bounds of the law of nature, without asking lead, or depending upon the will of any other man. But Locke also qualified his views of liberty, “But though this be a state of liberty, yet it is not a state license, no man in that state have an uncontrollable liberty to dispose of his person or possessions, yet he has not liberty to destroy himself, or so much as any creature in his possession.”
At this junction in the HIV epidemic, with lifesaving treatment available for all those who are infected, and with full knowledge of how HIV is transmitted and how HIV transmission can be prevented, the duty to inform and prevent harm must take precedent over individual autonomy under these circumstances. Transmission of an ultimately fatal infection such as HIV should not be protected by philosophies which insist on absolute autonomy.