10—
No Time for an AIDS Backlash

Writing in Time, columnist Charles Krauthammer described the May 1990 protests by AIDS activists at the National Institutes of Health as a misdirected demonstration: "The idea that American government or American society has been inattentive or unresponsive to AIDS is quite simply absurd." On the contrary, he continued, "AIDS has become the most privileged disease in America" since Congress continues to allocate an enormous amount of money for research and for the treatment of people with HIV infections and disease.^[1] Except for cancer, HIV disease now receives more research funding than any other illness in the United States, a priority Krauthammer maintains is out of proportion to its significance since AIDS kills fewer people each year than many other diseases. The "privilege" of PWAs Krauthammer also extends to access to certain experimental drugs, access unavailable to others.

Chicago Tribune columnist Mike Royko also challenged the view that there is government indifference to AIDS: "That might have been true at one time. But it no longer is. Vast sums are being spent on AIDS research. Far more per victim than on cancer, heart disease, and other diseases that kill far more people."^[2] In his view the Gran Fury poster showing interracial and different- and same-sex couples kissing (see figure 4) had more to do with the "promotion" of homosexuality than with the prevention of disease. Views of this kind would not only put homoeroticism back in the closet, they would also assign AIDS a lesser standing in the social and medical priorities of the nation.

The sentiment that gay men with AIDS were being treated as a privileged class surfaced as early as 1983 even prior to the identification of its viral origins.^[3] What is new now is the increasing prominence of this view in public discourse and its justifications. In The Myth of Heterosexual AIDS political writer Michael Fumento mounts a full-scale defense of the proposition that the AIDS epidemic has achieved national and medical priority all out of proportion to its dangers, especially since the disease will make few inroads against white, middle-class heterosexuals. Fumento writes in self-conscious sound bytes: "Other than fairly spectacular rare occurrences, such as shark attacks and maulings by wild animals, it is difficult to name any broad category of death that will take fewer lives than heterosexually transmitted AIDS."^[4] Or: "Most heterosexuals will continue to have more to fear from bathtub drowning than from AIDS."^[5] He also says that the mass mailing of the surgeon general's report on AIDS to every household "makes every bit as much sense as sending a booklet warning against the dangers of frostbite to every home in the nation, from Key West, Florida, to San Diego, California."^[6] Because there is no looming heterosexual epidemic and because the nation has neglected other medical priorities by siphoning off talent and money for AIDS research, Fumento concludes that "the ratio of AIDS research and development spending to federal patient costs is vastly out of proportion to other deadly diseases." Fumento also believes that the priority assigned to AIDS will endanger the lives of other people: "The blunt fact is that people will die of these other diseases because of the overemphasis on AIDS. We will never know their names, and those names will never be sewn into a giant quilt. We will never know their exact numbers. But they will die nonetheless."^[7]

Not only the priority of AIDS on the national agenda but also the tactics used to put it there and keep it there have found their critics. Krauthammer concedes that the gains made by AIDS activists are a tribute to their passion and commitment, but he believes that such gains have been won by deceptive strategies. He charges that the "homosexual community," to advance its own interests, first claimed that AIDS was everyone's problem because everyone was at risk and its solution required universal social urgency. As it became clear that people would not fall at random to the disease, he says activists changed their tactics and began to prey on social guilt: how dare a society let its gay men, needle-users, their partners, and their children sicken and die? But this

guilt is unwarranted, Krauthammer believes, since for the most part HIV disease is the self-incurred consequence of ignoring clear warnings.

Also objecting to activist tactics, the New York Times criticized the ACT UP disruption that made it impossible for the secretary of health and human services to be heard during his remarks at the 1990 international AIDS conference in San Francisco.^[8] "It is hard," the editors of that paper of record wrote, "to think of a surer way for people with AIDS to alienate their best supporters." They characterized the action as a pointless breakdown in sense and civility, adding that "ACT UP's members had no justification for turning a research conference into a political circus," especially since (in the standard refrain) society has not turned its back on people with AIDS but has committed extravagant effort and resources to the epidemic. The disruption, moreover, was deemed all out of proportion to the matters protested: immigration restrictions for people with HIV infection and President Bush's absence from the conference by reason of an event important to the reelection of North Carolina senator Jesse Helms.

In a different vein, English professor Bruce Fleming suggests in The Nation that Americans have come to hype AIDS because of a distorted sense of what it means to be sick and dying.^[9] Westerners in general, he says, assume that the absence of disease is the normal state of human affairs; disease thereby becomes a divergence to be named, isolated, and eliminated. Thus there can be the fury and anger he found in a presentation at a Modern Language Association convention, an AIDS address full of discussions of Susan Sontag and Harvey Fierstein and laments about the lost golden age of free sex. Accepting sickness and death as an integral part of life, he thinks, would free us from the frenetic feeling that AIDS and all disease is unfair treatment amenable to moral and medical control—control that in any case is impossible to achieve.

Priority and Tactics

The criticisms mentioned above have some important messages—remembering people sick and dying with other conditions, keeping priorities and discourse rational, recalling the inevitable mortality of human beings as an antidote to their hubris—but I see little reason to shift the priority now devoted to the HIV epidemic, to smear the tactics that have

made that priority possible, or to alter the view that sickness and dying with HIV disease are evils to be resisted.

Fumento makes the most direct claim that people are dying from neglect because the nation has chosen to worry about people with HIV. He argues that AIDS needs to be put into perspective, but he offers not a word about what priority an infectious, communicable lethal disease should receive as against, for example, diabetes or certain heart conditions, which are noninfectious and noncommunicable and can be successfully managed by medicine throughout life and which are also "preventable" by the kinds of behavior long known to extend health and life.^[10] In fact, Fumento says nothing at all about how priorities ought to be set. Surely an infectious communicable, lethal disease affecting large numbers of people ought to receive priority over diseases that can currently be medically managed in a way that permits people to live into old age, a prospect not currently enjoyed by people with HIV disease. Whether funding should be allocated according to the number of persons affected by a particular disease is problematic, for such allocation would effectively orphan certain diseases altogether. Moreover, many of the diseases that do now kill people in numbers greater than AIDS have a long history of funding, and the expenditures made on behalf of AIDS research and treatment should be measured against that history, not solely against the individual lines of current annual budget allocations. In some ways, AIDS is only now catching up with comparable past expenditures.

Perhaps the seeming voluntary nature of infection invites the notion that enough has been done for those with HIV. Does the perception that HIV could be eliminated as a health worry if people simply avoided the sex and drug techniques implicated in infection drive public antipathy toward public expenditures for health care and research? It seems, according to this logic, that AIDS can be prevented even if not cured; by extension its costs should be equally preventable as well, especially since sex and drug use are under individual control. But HIV disease is not simply a matter of individual failure to heed clear warnings. Many cases of AIDS were contracted before any public identification of the syndrome itself. Even after the identification of the syndrome, there was no clear identification of its cause or how it might be avoided. Early in the epidemic there were no widespread efforts to protect blood used in transfusions, even when certain screening tests were available.^[11] Even after the discovery of the presumptive viral cause and the development of blood-screening tests, educational efforts to reach persons most at risk

were inadequate and in any case no one knew what forms of education were capable of effecting behavioral change. What educational programs there were have failed, then and now, to reach drug-users, their sexual partners, and persons in rural areas. Some persons were infected, of course, by means altogether beyond their control: by rape, by transfusion, by Factor VIII used in the control of hemophilia, through birth to an infected mother, by accidental needle infection from providing health care or using drugs, through artificial insemination, and so on. Because of ambiguities and delays (culpable or not) in biomedicine, education, and public policy, it is not evident for the majority of people with AIDS that there were "clear warnings" that went unheeded.

In any case, we must remember that the existence of such warnings now does not mean that they can be retrospectively applied to all persons in the past or that there will not continue to be people who fall outside the protection of educational umbrellas because of geography, chance, or accident. Over thirteen years have passed since the Centers for Disease Control first reported the occurrence of rare diseases in gay men and drug-using persons. Since that time another cohort of gay men and drug-users has come along, persons who may not have been educated about the dangers of HIV, young persons who will not yet have the maturity of judgment in sexual and drug matters, persons who may not have access to clean needles or drug rehabilitation programs, who may not have the personal and social skills necessary to avoid risk altogether. In some cases there may be cultural and social barriers to protection from risk as well, such as resistance to condom use, a reluctance grounded in the variable meanings of condom use.^[12] We must remember too that in matters of sex and drugs, people are weak and not always capable of protecting themselves, even from the risks they know and fear. It is not surprising then that a considerable portion of all human illness is self-incurred, brought about through an individual's life choices. This is to vary the principle of the double-effect: what is chosen is not illness but sex, food, alcohol, drugs, and so on. The aftermath of these choices, unchosen if inevitable, may be illness. So considered, AIDS does not stand apart from, for example, the heart disease that is both the consequence of behavior amenable to choice and about which there is plentiful public warning. It would be idiosyncratic and therefore prejudicial to single out AIDS as undeserving of public attention and research unless one also made the equivalent claims about other diseases whose antecedents are in avoidable risk. A comparison of AIDS with other "avoidable" diseases might even show less sympathy for diseases like diet-related heart disease

or smoking-related emphysema. These latter diseases can sometimes be seen as the result of thousands and thousands of badly made eating and smoking choices while an HIV infection can result from a single lapse in unprotected sex. To the extent that the avoidability of disease is thought relevant to judging its merit for social investment, it would seem in the example given that AIDS is less avoidable insofar as it involved only a single mistake whereas the other conditions had vastly more opportunities for avoidance and correction.

Where critics see misplaced privilege in the priority and attention AIDS has won they might instead see a paradigm for other successes. Should the priority accorded to AIDS research and care be seen as an indictment of the wiles of AIDS activists or should the rise of AIDS research and treatment be required study in schools of public health? AIDS activists are not trying to bleed the nation dry (though some would fundamentally redesign it), and neither are they blind to the nation's other needs. They are merely trying to ensure that government and medicine work together to achieve important goals. If other disease research is being neglected, the question is not whether activists have bullied the Congress or the American Medical Association into questionable priorities. The relevant question is why other health-care research services cannot be delivered with the urgency and high profile that the HIV epidemic has received. In this sense the HIV epidemic is an opportunity for critical thinking about the nature of health care in the United States: is it the nature of the disease itself or the design of the health-care system that makes the HIV epidemic so formidable? Is it the communicability of the disease itself or social attitudes toward sexuality and drug use that make prevention so difficult?

But all this talk of the priority given to the HIV epidemic can be misleading. AIDS is no privilege for anyone. A diagnosis of AIDS amounts to a virtually unlimited onslaught against an individual's physical, emotional, familial, and economic resources. In addition, there is the burden of stigmatization, given that the disease has been interpreted as a punishment or deserved consequence of immoral behavior. A 1988 report, for example, showed that, depending on the social category of the respondent, some 8 to 60 percent of persons surveyed considered AIDS to be God's punishment for immoral sexual behavior.^[13] A minority of Americans is prepared to tolerate considerable discrimination against people with an HIV-related condition.^[14] Varying but significant numbers of persons surveyed report that they would refuse to work alongside people with AIDS, would take their children out of school if a child with

AIDS were in attendance, would favor the right of landlords to evict people with AIDS, and so on. Perhaps the most telling results of a survey reveal that the majority of respondents believed health professionals should be warned if patients have an HIV infection; a third of these would allow physicians to decline treating such patients.^[15]

This last observation would be benign by itself except that medical students and faculty are also expressing apprehension about working with people with AIDS and there is some evidence that some medical professionals are choosing specialties and geographies that will keep them at a distance from such patients.^[16] Some physicians have even taken to the pages of the New York Times to announce that they will refuse to treat any patients with an HIV infection.^[17] Nursing recruitment has become difficult for hospitals that care for large numbers of people with HIV. There are still places in the United States where hospital food trays are left at the doors of people with AIDS because the nutrition staff will not go into the rooms.

All the money thus far spent in the HIV epidemic has not by itself ensured adequate medical care for all people with HIV. This is especially true for the homeless who have HIV-related disease.^[18] Neither have the dollars spent on HIV research produced any medical panacea. Improved treatment has proved important for many people but not for all, and there are still many unresolved questions about the long-term ability of key HIV therapies to extend the lives of all people with HIV infection or to guarantee a good quality of life.^[19] Zidovudine notwithstanding, as Larry Kramer has pointed out, there continues to be one HIV-related death every twelve minutes in the United States.^[20] Is it therefore surprising that ACT UP now chants, "One billion dollars . . . one drug . . . big deal"?

As sociologists Charles Perrow and Mauro F. Guillén point out in The AIDS Disaster, it is hard to "prove" that funding for AIDS research has been inadequate. But as they also point out a broad array of highly credible reports have each drawn attention to government and philanthropic failures to respond to the epidemic.^[21] These reports have come from the Office of Technology Assessment, the Congressional Research Service, the General Accounting Office, the Institute of Medicine, the Presidential Commission on the Human Immunodeficiency Virus Epidemic, and the National Commission on AIDS. Whatever funding has occurred, it is hard to see that one can object to the amounts per se that yet need to be spent since the money called for, for example, by the presidential commission or the Institute of Medicine^[22] is not an invented figure pulled out of the air as a way of keeping scientists and bureaucrats

in fat salaries. The figures represent estimates made in good faith about the extent of funding needed. Early estimates calculated that billions would be required, and that estimation has not changed merely because headlines have moved on to other subjects. They should not change merely because the American public has decided that the money thus far spent has surpassed its interest in the diseases of gay men and drug-users.

Costs and Compensation

Perhaps some in American society question the amount of money spent on behalf of AIDS research and treatment because they are unfamiliar with the amounts of money that are already spent for biomedical research and treatment. The research carried out by the National Institutes of Health has always been enormously expensive, as has been the provision of medical benefits to veterans, the elderly, and the poor. The federal funding of dialysis for end-stage renal disease alone, for example, provides life-saving therapy for only some seventy thousand people yet its costs have been measured in the billions since Congress decided to pick up the bill for such services.^[23] If this kind of funding is any precedent, neither high cost nor small number of affected persons serve as a convincing rationale for limiting the funding now accorded to AIDS research and treatment.

Budget requests based on what should be done are one thing, of course, and budgets actually produced in government legislative process are another. The question at issue in discussions about the "privilege" of AIDS is the question of what priority should be assigned to AIDS funding given all the other funding needs that face the nation. Richard D. Mohr has argued that AIDS funding exerts a moral claim insofar as the disease is associated with gay men, for in many of its most significant aspects the HIV epidemic among gay men is the consequence of prejudicial social attitudes and arrangements.^[24] Because rituals, laws, educational systems, and prevailing opinion in the U.S. fail to offer gay men any clear or supportive pathway to self-esteem or any incentives to the rewards of durable relationships, society has effectively forced some gay men into promiscuous behavior. Neither does society permit gay men the opportunity to form families that could shoulder at least part of the care their sick need. Philosopher Patricia Illingworth has fleshed out this argument and extended it to drug-users as well.^[25]

These are powerful arguments; it is hard to think of any public rituals in family life, education, the media, religion, or the law that dignify the love of one man for another or that support any abiding union there. Some cities now recognize domestic partner relations between gay men and between lesbians, as do some employers. But these arrangements are exceptions rather than the rule, and none of these existed during the early years of the epidemic. Promiscuity is sometimes used as the basis for an argument that gay men bring AIDS on themselves. But whose promiscuity is it anyway in a culture that does not offer public incentive or support to gay men for anything but socially invisible sexual relations? How can AIDS be blamed on gay men who pursue what social options are open to them? It is also hard to argue that society has protected its needle-users when it clearly cannot prevent drug use or offer successful drug rehabilitation programs. American society's enthusiasm for wars on drugs has not been effectively translated into action capable of helping any but a fortunate few stop their drug use. Needle-exchange programs have been rejected out of fear that such action will appear to condone drug use—a fear that is odd given the de facto acceptance of drug use by people at every level of American culture, including members of Congress, Supreme Court justice nominees, and presidents, as recent events have shown.

Isolated from the mainstream, and left to their own devices, many gay men, drug-users, their sexual partners, and their children find themselves at the mercy of an indifferent virus as they try to lead what lives they can. Diseases rarely "just happen." More often than not, society's economic structure and moral values permit them to happen, make them inevitable. Philosopher and bioethicist Robert M. Veatch has observed that fairness permits inequality of outcome where opportunities have been equal, but he has noted in health care "persons who are truly not equal in their opportunity because of their social or psychological conditions." Fairness does not apply "to those who are forced into their health-risky behavior because of social oppression or stress in the mode of production."^[26] Because many of the persons who have contracted HIV have done so under prejudicial social arrangements, there is a significant argument that priority for HIV research and care is required as compensation.

But compensation alone does not constitute the sole moral imperative for society's obligation. Moral philosophy also avails itself of the supererogatory, those burdens we undertake beyond the call of formal obligation. The society worth praising, the society worth having is the one

that finds ways to care and to research, even though there is no formal obligation to do so and for no other reason than empathy for its citizens who are ill and dying. The care of those who contracted HIV infection through blood transfusions or of women whose HIV was a result of a husband's sexual activity outside of marriage are examples of such responses. The morally admirable society would do what it could to protect such persons from infection and care for them when they are sick whether society specifically owed them this concern and care or not.

Because of its contributions to basic research in immunology and virology and because of its importance for the care of a great number of afflicted persons, AIDS research is as important as any other research being conducted in the United States today. Delaying this research will not only impede therapy and vaccine development but will also subject the eventual costs to inflation; AIDS research will only get more expensive the longer it is delayed. Delay also increases the number of people who will be potentially at risk of HIV infection. We should remember that in the history of the planet only one disease, smallpox, has ever been entirely eliminated;^[27] every other disease known to humanity continues to take a toll. Bubonic plague, for example, is no stranger to the contemporary world.^[28] HIV disease is a problem for our time and it will be a problem for future generations. It is not a disease at which one can throw a fixed sum of money before moving on. Even when fully effective vaccines and treatment become available, some people will fail to benefit from them by reason of social deprivation, geography, choice, or chance. HIV disease needs to be treated as a disease that is here to stay, not one that has already used its share of the limelight, the public coffers, and the public's indulgence.

Critics of AIDS activists's disruptions of traffic and speech seem to believe that quiet discourse argued in mannerly fashion by legislators consulting with medical boards is enough to ensure that the nation will set appropriate medical priorities. But this view of rationally framed public policy is not entirely true to history. There are few important social reforms that did not require the abandonment of polite discourse and the disruption of business as usual. Government and policy in this country have often been as much a product of protests, strikes, and civil disobedience as of reasoned debate. It is wrong to pretend that civil disobedience and social disruption are not part and parcel of this nation's political techniques, and it is wrong to blame AIDS activists for using them as others have. Perhaps we have forgotten that the United States

owes its very origin to acts of rebellion that the New York Times might have found easy to condemn as breakdowns in sense and civility.

Without protests, moreover, one wonders how the battle against AIDS would have ever been launched.^[29] In the early years of the epidemic the sickness and death of small numbers of gay men did not lend itself to the advocacy of important legislators and medical commissions. In some respects this state of affairs continues to this day. Most of the many recommendations of the 1988 Presidential Commission Report on the Human Immunodeficiency Virus Epidemic, for example, have done little but collect dust. If recommendations from a group with the stature of a presidential commission cannot spur action on important goals, what other recourse is there than the tried and true methods of protest which are as much a part of American democracy as its parliamentary rules of order?^[30] It is a shame that critics see conspiracy, irrationality, and impropriety behind AIDS activism when they might see a standard of urgency and passion by which to evaluate and improve the entire health-care system in the United States.

In the context of broad health-care needs, the acceptance of dying that Bruce Fleming has urged seems an invitation to quietism. If disease and dying are inevitable, what incentive is there ever to resist? Granted, some Americans may have lost their sense of mortality, but I wonder what is to be gained in respect to biomedical priorities by restoring it. On the contrary, it may be the very perception of disease as "excrescence" that functions as the spur to its control and eradication. I see no point in glorifying disease and dying; the lessons they teach are easily learned and do not require advanced instruction. There is a point at which sickness and dying cease to offer insights into the human condition or opportunities for strength and become instead unbearable, unredeemable absurdity. To his credit Fleming does say that hesitation by the U.S. government to carry out necessary HIV research would be criminal. The change in the perception of death he counsels would thus hardly make any practical difference to the responsibility of government and medicine to resist the epidemic with all the resources it can muster.

The sentiment nevertheless grows that AIDS is getting more than its share of media attention, resources, and social indulgence. But there has been no diminution in the status of the epidemic to warrant a change in the scope or intensity of research and treatment programs. HIV remains a lethal, communicable virus. Despite better medical management, the number of HIV-related deaths continues to increase. More and more hospital resources have to be directed to the care of people with

HIV. What then accounts for the sentiment that AIDS is getting more than its share? From the onset of the epidemic there have been desperate prophecies about the toll of the epidemic and facile predictions that millions to billions would die.^[31] Is it possible that critics say that AIDS has received more than its share because it has not yet killed enough people? Is the same indifference that first kept the epidemic at the margins of national attention now inspiring the claim that enough has been done? The sentiment against AIDS research and funding has been primarily argued in the popular press, not in professional journals of medicine, bioethics, or public policy. Can it be that this sentiment therefore belongs to those who do not know the epidemic at first hand, who are tired of gay men and drug-users in public view, who by their very distance from the epidemic can make the easy judgment that it is time to move on?

Setting Priorities

The question of how biomedical research and treatment priorities should be decided for HIV disease is extremely difficult. I offer the following discussion primarily to underline the need for sustained reflection on this problem but also to claim priority for HIV treatment and research, though that priority is neither unconditional nor exclusive.

It is truly difficult to demonstrate with any kind of fully convincing precision why certain biomedical research and treatment programs should have moral priority over others among the many worthy claimants for government dollars. The difficulty is compounded when the benefit of such research and treatment programs (for instance, for PWAs) is uncertain. Utilitarian counsels for promoting the greatest happiness for the greatest number of individuals prove an unreliable guide here because they are capable of subjugating the interests of some persons to a "greater" social good and because it is often unclear which among competing allocations will in fact promote the greatest happiness for the greatest number. For example, how might it be demonstrated that treatment and research for people with lung cancer would increase the greatest happiness of the greatest number in ways that treatment and research for people with AIDS did not? Moreover, certain diseases might be orphaned altogether under a utilitarian approach. Certain diseases,

progeria, for example, strike only miniscule numbers of individuals. How could persons with progeria lay claim to any kind of biomedical priority according to this standard? Would not its claims be swamped by competition from the sheer numbers of persons suffering from other conditions, even less debilitating and less life-shortening conditions?

Meritocratic approaches to the treatment and research of diseases invite the invidious application of highly questionable standards about the worth of individuals. These approaches also suffer from the difficulties of establishing a morally convincing criterion of worth. How, for example, should a newborn with AIDS be judged as deserving or undeserving of treatment? After all, he or she has not yet "proved" any social worth. As another example, a man with AIDS may have served ably in the U.S. Congress. Might he not be said to deserve some support in recognition of that service, even if there were "immoralities" involved in his contracting an HIV infection? Meritocratic allocations of biomedical resources have proved offensive in the past, as in the case of renal dialysis,^[32] and there is good reason to be suspicious of them as they are used in both the dispersal and denial of resources. The underlying question is whether meritocratic allocations advance a moral agenda at the expense of the vulnerable or at the expense of the diversity of "worthwhile" human life.

The meritocratic standard of allocation is especially problematic for PWAs. Many people hold PWAs responsible for their condition and judge them undeserving of social support. Strict libertarians too recognize no obligation on their part to "subsidize" the health care of PWAs; they might wish to contribute to charities to help treat and research HIV infection and disease, but they feel no obligation to do so. The former view ignores the way most persons are infected with HIV, that is, in ways that do not "deserve" the range of illness and disease that follow. Even if one grants for the sake of the argument that homosexuality and drug use are morally culpable, do they deserve either punishment as severe as AIDS or abandonment by the biomedical community? Is there any measure of proportionality in such a "punishment."^[33] Moreover, biomedical research operates in ways that in a sense make these kinds of questions irrelevant. It would be a mistake to fail to research HIV pathogenesis merely because people sick with it "deserved" their infection and disease. Research, especially insofar as it may be expected to contribute to basic knowledge in immunology, virology, and neurology among other fields, does not gain by closing doors on research areas because the subjects are "unworthy." A libertarian willingness to con-

tribute to biomedical support, as mentioned above, is wholly altruistic and not the enactment of a duty. While some individuals may be able to support their health-care needs insofar as biomedicine can treat their conditions, many people cannot. And most people certainly cannot afford to, by themselves or in conjunction with the donations of others, produce the biomedical research and experimentation necessary to discover treatments for conditions now untreatable. The health of a society in general and its biomedical progress can therefore prove ill-served by assuming that individuals only have obligations to themselves.

Because meritocratic approaches fail to be morally compelling guides, the allocation of resources for research and treatment could be governed by a presumption of equality in a population. Equality is an assumption necessary for the possibility of moral judgments themselves (otherwise people are merely forces antagonistic to one another), and equality is a powerful constitutional feature of U.S. political history. But a commitment to equality will not by itself solve scarcity problems. Indeed, depending on what one means by equality, such a commitment may aggravate research and treatment problems. If all persons with all diseases were treated as financial equals in terms of the health-care dollars available for treatment and research, individual health care would be seriously jeopardized and research programs crippled by a strictly egalitarian division of resources. But perhaps by equality we mean proportionality. The government would then expend its health-care dollars and research funds proportionate to the prevalence (or sometimes maybe even incidence) of a particular disability. Certainly there is an intuitive appeal to such a notion in that each group of people with a particular disease or disability knows in advance that allocation decisions are made proportionate to the gravity of the disease in the overall population. This kind of parity avoids the appearance that some diseases are treated preferentially while others are neglected. There is much to recommend this kind of approach, although again it cannot be and should not be expected to be the sole criterion by which allocation decisions are made. Such an approach would still need to consider, for example, the social significance of the disease or disability and take into account the likelihood of, for example, research success.

Philosopher Albert R. Jonsen has rightly noted that the traditions of medical ethics are often ill equipped to make decisions about larger social policies that affect distribution of health-care resources. The traditional emphases on patient protection, professional competence, and even altruism in the manner of the Good Samaritan cannot provide an un-

equivocal model for the rationing that is the irreducible consequence of finite human, material, and economic resources.^[34] Seen in this light, the question of priorities for PWAs is not only a question that results from the emergence of a new disease syndrome but a question that becomes difficult because of the very limitations of the traditions of medical and social ethics, especially when these are strained by novel disease syndromes and the increasing costs of medical technology. We may then wonder whether questions challenging the priority given to HIV research and treatment aren't merely idiosyncratic, raised as they are about AIDS when they might also be raised about a whole range of other research and treatment priorities. And if they are idiosyncratic, might not their driving force be less disinterested analysis of social policy than homophobia, social disapproval of drug use, and contempt for the poor? Why, in other words, did questions about the general failings of social and medical ethics in establishing a convincing scheme of prioritization emerge with respect to HIV/AIDS when they might have equally well emerged with respect to resources allocated to, for example, veterans' health care unrelated to military injury or to subsidized renal dialysis?

As to the larger questions of how social policies ought to be arranged in respect of health-care resources, Jonsen observes: "Justice in health care has no actual patients: it seeks a principle of distribution that will, in anticipation of actual need, count some persons as worthy of attention and count others out."^[35] And yet Jonsen is skeptical that such a principle can be identified. He rejects the notion of triage because the origin of that notion—returning soldiers to battlefield quickly—plays no role in contemporary thinking about the purposes of medicine.^[36] He doubts, moreover, that any satisfying principle of rationing can be devised, not because—in the words of philosopher Alasdair MacIntyre—there is no neutral, independent standard of justice but because—in the words of ethicist Paul Ramsey—larger questions of social and medical priorities are "incorrigible to moral reasoning."^[37]

There are many reasons to concur with the view that biomedical priorities are intractable to any simple moral ordering. For whatever values they might espouse, decision-making bodies such as legislatures and professional organizations are often driven by nonmoral considerations. Legislatures and professional groups are often large and lumbering institutions whose policies emerge for reasons as varied as the accidents of individual leadership, the force of social opinion, advice of legal counsel, administrative policies, economic considerations, or symbolic values. What is more important, the openness of human moral life

to competing visions and standards does not even suggest the desirability of a single, unifying principle ordering all biomedical research and treatment in one lexical pattern. Biomedical research and treatment policies will always provoke uncertainty, an uncertainty that will sometimes frustrate those looking for help and funding but an uncertainty that will also preserve the flexibility of research and treatment and protect them from the rigidities of any single moral view about which sick people deserve help and which do not.

The use of moral philosophies to determine biomedical priorities in research and treatment is additionally problematic because such theories were not developed to address these kinds of questions. Even natural law traditions, which have always recognized the importance of maintaining health, do not easily lend themselves to questions of resource allocation. The question of biomedical priorities is complicated by nonmoral factors as well, especially when one takes research objectives into account. The progress of science cannot always be mapped or programmed in advance. Even well-plotted, well-financed research can fail to produce effective therapies. By contrast, important breakthroughs can take place in unforeseen, even accidental circumstances. There are therefore no guarantees that monetary priority will in fact lead to effective therapies or vaccines, let alone outright cures. The likelihood of success ought to be a factor in determining how money gets spent in both research and treatment, but it cannot be the sole criterion if one wants to leave the door open for those serendipitous events that play an important role in biomedical advance and if one acknowledges that even promising leads fail. The "spin-off" effects of research can also be expected to influence funding decisions since research can achieve many important secondary gains. Characterizing and ranking the relative importance of such possible gains in assigning moral priorities to competing research and therapy programs, however, poses questions of immense difficulty, especially when one starts to measure expected future benefits against the needs of living, suffering persons.

In spite of all these general difficulties in establishing priorities for biomedical research and treatment, I believe there are nevertheless several rationales for giving HIV/AIDS research and treatment high priority in funding. First, HIV is a communicable, lethal infection; it is not a self-limiting condition of only those now infected. It can be expected to appear in the children, sexual partners, and needle-sharers of those already infected for the foreseeable future. Second, given the wide prevalence and increasing incidence of HIV among persons who have claims

to being socially mistreated, a claim of "compensatory damages" is certainly relevant in setting priorities.

John Rawls's contractarian account of justice as fairness is also relevant to the discussion here, especially his effort to identify the way in which society ought to be organized in favor of the most disadvantaged persons.^[38] Rawls believes that conclusions about the social distribution of benefits can be drawn from a hypothetical circumstance he calls the original position. In the original position hypothetical persons are charged with identifying the broad principles governing social organization and access to resources and advantages. To ensure that their choices are fair he imposes on them a "veil of ignorance" that keeps them from knowing what role they would have in the society they are organizing. They must therefore try to secure advantages for all possible roles they might have once the veil of ignorance is lifted. Health and health care are important goods, but it is unclear in Rawls's account whether they are to be counted among the "primary goods" around which his governing principles are organized; they may nevertheless be profitably analyzed in the context of his general theory. On the one hand, people in the original position will recognize that they might be seriously ill or disabled when the veil of ignorance is lifted; they should thus wish to secure health-care entitlements from the society they are organizing. On the other hand, those same people will recognize that they might be persons who live in the full bloom of health and who have no significant need of health care; they will thus also want to protect themselves from having to pay for the health care of others. To use an example involving PWAs, people in the original position would understand that AIDS is a profoundly disabling condition often necessitating significant medical assistance. They would also understand that once the veil of ignorance is lifted, they might be gay men or drug-users at high risk of HIV infection or PWAs. From this perspective, a program of national health coverage for all medical needs might appear attractive. Yet these same persons would also recognize that they might be straight, non-drug-using individuals whose lives would not involve them in any significant HIV risk. Indeed, they might be blessed with a robust genetic endowment resistant to many kinds of disease. It would not be to the advantage of such a person to advocate the kind of costly nationally sponsored health care favored from the perspective of, say, poor drug-users with HIV infections. What kind of resolution is possible between positions so antithetical in what they would require of health care support? Because social disadvantages can be more damaging to people than social ad-

vantages can be rewarding, Rawls concludes that people in the original position would agree that the general construction of society ought to operate in a way that benefited the least advantaged. In this way, society could offset the disadvantages of, for example, poverty and ill health without unduly burdening others. It does not follow that all health-care needs would be met through favoring the most disadvantaged, but it does follow that the disadvantaged should have to be taken into consideration in the distribution of all society's resources.

It seems eminently reasonable to say that PWAs belong in the category of society's least advantaged persons. AIDS is a disabling array of disorders that puts one at significant risk of early death, and treatments are at the moment not only experimental in nature but are often beyond the economic and geographical reach of those who need them. While there has been advance in clearing away social hostility toward PWAs, still, as noted above, they often receive substandard treatment and social disapproval. It does not follow from this account that PWAs should be the first among those to benefit from a socially subsidized medical system. But it does follow that health-care resources ought to be apportioned in a way that devotes priority to those persons whose disorders most profoundly disadvantage them.

Another argument from the original position might recognize the duty to be charitable. This duty could make up the difference between what a society is morally obligated to provide by way of therapy and health care and the actual care and research people will in fact need. Thus persons who find themselves in full health outside the original position—indeed all members of society—would have some responsibility to meet the health needs of others as a matter of charity, whether through tax dollars, participation in biomedical research, organ donation, or other actions. This charitable duty would be an imperfect duty—it would belong to the individual person to exercise in accordance with his or her conscience, and no other person could demand the exercise of that duty. Nevertheless, a generalized, imperfect duty of charity which could be exercised in regard to the health care of others seems a reasonable outcome of the decision-making of Rawls's original position. The treatment of PWAs or biomedical research in regard to HIV would only have priority in fulfilling this duty to the extent that people with HIV were in fact among the most disadvantaged; charity exercised on their behalf would certainly meet any obligations imposed by a duty of charity. Since neither the provision of a minimal level of health care nor the recognition of a limited duty of charity would guarantee provision of all health-care

treatment and research needs for PWAs, this position underscores too the importance of individual responsibility—to the extent possible—in pursuing therapy and promoting the kind of research necessary for one's individual disabilities. And this conclusion would extend to all forms of disability and disease.

The case for HIV/AIDS as a centerpiece for contemporary biomedical research and treatment allocations may be summarized in the following way. A Rawlsian moral consensus directs social and economic institutions to arrange themselves in order to benefit the least advantaged, and PWAs suffer the serious disadvantages of a communicable and lethal condition, putting them in that class of persons. A duty of charity may also be said to exist from a Rawlsian perspective, a duty that while not obligated exclusively to PWAs would certainly be met by efforts on their behalf. Notions that HIV/AIDS is a sanction for immoral behavior are unconvincing given that equivalent immoralities are not similarly punished. Even if HIV/AIDS were a divine punishment, there is no obvious justification for human contribution to that punishment or to its continuation.^[39] There is also some sense in which AIDS treatment and research and treatment are owed to gay men, drug-users, and the poor as a kind of compensatory damage for social injustice or neglect contributing to the likelihood of their infection and lack of social protection, for example, the health insurance available to others. A whole range of other human disease is "self-incurred," so to view AIDS as undeserving of consideration on that account is merely and objectionably idiosyncratic. The arguments for such a priority for HIV/AIDS are not unconditional. Should advances in treatment diminish the illness of PWAs, their claim to priority in future research might be diminished against the competing claims of those with illnesses that have no equivalent therapy. Should the nation go to war, to use another example, biomedical funds might justly be withdrawn to finance that purpose. Should another novel, lethal syndrome appear or some nuclear disaster occur, such problems might also assume priority over the funding of HIV research and treatment. For these reasons it is better to see the arguments here not as establishing immutable duties to provide research and treatment for people with HIV/AIDS but as prima facie obligations. Perhaps it would be better still to see these arguments not as commitments required by the logic of moral duty but as counsels of supererogation.

The arrangement of biomedical priorities is and always will be guided by both moral values and pragmatic considerations. In addition, it will

always be an awkward, ad hoc process. Nevertheless, there are reasons to maintain a priority for AIDS in research and treatment even if the often alarmist views about the eventual numbers of people expected to have AIDS prove unfounded. Perhaps one way to see the importance of HIV research is to consider what it would mean to diminish concern in this area. If HIV research and therapy are relegated to a lesser rank in the nation's priorities, it will be gay men, needle-users, their sexual partners, and their children who will continue to pay the price of neglect, and the epidemic may again become the shadow killer it was in the beginning. In view of the people who are still sick, who are dying, who bear the costs of this epidemic, it is too early and too shameful to say that enough has been done. It is certainly too early for a backlash.