HIV/AIDS and bioethics: historical perspective, personal retrospective.

Problems posed by HIV/AIDS differ from those of past epidemics by virtue of unique properties of the causative agent, dramatic societal changes of the late 20th century, and the transition of medical practice from a professional ethic to a technology-dependent business ethic. HIV/AIDS struck during the coming-of-age of molecular biology and also of bioethics, and the epidemic stimulated the growth of both disciplines. The number of articles published about AIDS and ethics (as identified by a MEDLINE search) peaked in 1990, just before the peak incidence of AIDS in the United States. The character of ethical dialogue has now shifted from familiar moral quandaries such as civil liberty versus public welfare to concerns about vaccine trials and public policy toward the developing world. Physicians and other health care workers who were involved from the onset endured something of an emotional roller coaster. Their compassion-based work ethic was to a large extent replaced by a competence-based work ethic after the introduction in 1996 of highly active antiretroviral therapy. The abundant recent literature on "professionalism" in medicine makes scant mention of AIDS/HIV. The disruptive effect of AIDS/HIV on society would have been substantially greater had relevant technology such as the ability to isolate retroviruses and potent therapy against tuberculosis not been in place. This sobering consideration, along with such recent events as the use of bioterrorism against civilian populations, suggests new relevance for Potter's definition of "bioethics" as a science of survival in which the biology of ecosystems must be taken into account.