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HIV and AIDS—Testing, Screening, and Confidentiality
  1. Anthony J Pinching
  1. Department of Immunology St Bartholomew's & The Royal London School of Medicine & Dentistry Queen Mary, University of London

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    Edited by Rebecca Bennett and Charles A Erin, Oxford, Oxford University Press, 1999, 285 pages, £35.00.

    If I have any objection to this book, it is to the title, in that it might narrow the audience that would benefit from it. Although the title is formally quite accurate in describing the contents, it underplays the relevance of the arguments set out herein to a very broad range of clinical arenas, for which HIV/AIDS can be a notable example. This fascinating series of essays covering the topics in the subtitle and much more, shows how valuable AIDS has been as a worked example of a series of interdigitating core issues in medical ethics, as it has been in so many areas of clinical medicine, public health and public policy. Although the authors and editors underplay this wider relevance, I found myself, despite my own substantial involvement in HIV and AIDS over the past twenty years, constantly wanting to cross-refer to other clinical areas. Perhaps readers of this review, who are minded to read, or even to reread, this book might take such a perspective.

    The editors have managed, by their choice of authors, to organise a very broad range of perspectives. While the styles, compass and approach taken by the authors are quite variable, this is generally a benefit and not a problem, as it enables the reader to appreciate the diversity of views that can legitimately be taken on the same mountain. The format is not an artificially polarised debate (though there are plenty of polar views and opposing perspectives to be found), but rather a series of thoroughly reasoned perspectives, usually set out according to a clearly defined system of reasoning. The introductory chapter by the editors is a valuable guide to the issue itself and to the chapters and their perspectives (and is worth rereading at the end).

    I must applaud the authors and editors for a truly informative exploration of some very big issues in medical ethics. The breadth of the coverage is substantial, encompassing ethical and legal dimensions, and considers some central themes in health care ethics: Is the individual or society responsible for their health? Can health care workers be advocates for third party interests, as well as caring for their patients? There is a thoughtful essay on compensation and consent in relation to transfusion-associated infection, and another on whether a fiduciary relationship can be both an ethical approach and a legal concept. These chapters provide a conceptual underpinning to the more formal exploration of the very thorough coverage of testing, screening and confidentiality—in clinical and public contexts, as well as in research settings. There is a very nicely argued chapter near the end on the categories of people who might want to know the status of a person with HIV, and whether they should. It is, however, rather invidious to select out individual articles when so many are excellent. Similarly, picking out specific aspects of the debate could distort the impression of the impact of the whole, which I found to be deep as well as broad (hence I took an unconscionable time reading it for this review!)

    Of course there is plenty with which one could take issue and I could not agree with all the views set out, despite their persuasive style and scholarly tone, but that is the essence of a book of this sort. A few chapters seemed slightly remote from clinical reality, but that distance was mostly used to good effect. One chapter (purportedly giving “an American perspective”) seemed inclined to rewrite the brief history of AIDS from a rather distorted personal and distant view; this was really the only weak chapter in the book. I don't think most of my American colleagues would recognise this as a fair national perspective. I found it polemical and a barely recognisable account of what actually went on; it might better have been subtitled “the personal perspective of an American lawyer”.

    I heartily recommend this outstanding volume to anyone interested in medical ethics, whether or not their primary interest is concerned with HIV/AIDS. It explores the rich perspectives that this terrible pandemic has given us on contemporary medical ethics.

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