This article appears in the February 2001edition of the Catholic Medical Quarterly

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Book Reviews

1. Catholic Ethicists on HIV / Aids prevention

2. Catholic Bioethics and the Gift of Life



Edited by James F. Keenan, SJ, with Lisa Sowle Cahill and Kevin Kelly.
Continuum. New York and London, pp346,  $24.95.

Aids has never been prevalent in this country except in homosexual and bisexual men and their partners, arid in some drug addicts. Persons in these risk groups have now learnt the lesson that it is mainly a self inflicted disease almost entirely avoidable by desisting from recognised risks in the chosen life styles and behaviour of those groups. For those who do not or cannot desist, medication is beneficial but not curative and often has serious side effects. Aids in Africa is a different story: it is spreading uncontrollably in the Sub-Sahara. Its prevalence in that region appears to depend on cultural attitudes which do not accept its proven cause. The bizarre position of the South African President, Thabo Mbeki and his Minister of Health, Dr. Mantor Tshabalala Msimang. denying that HIV causes AIDS, is baffling.

A story from a farm in Zambia illustrates the cultural difficulties in the region, recounted in the Spectator by Colin Bostock-Smith (30 September 2000). James, a worker on the farm died recently. The mother of his wife has decided that according to tribal custom, the wife must now be cleansed. This means she must sleep with the elder brother of her dead husband as otherwise she, will never be able to marry again. One of two things will then happen. Either she has got AIDS already, in which case she�ll give it to her brother, or. he has got AIDS and will give it to her. Either way, it�s AIDS and more AIDS. This is but one of many problems associated with the current situation in Africa.

These essays deal with AIDS from a global view point although Africa, understandably, dominates. In a powerful introduction James Keenan SJ and Jon Fuller SJ, look at progress at the end of the first generation of HIV prevention in moral theology and medicine. They point out that Catholic moral ists can respond to the pandemic, not only by serving those who are HIV infected, but also by working to prevent the spread of the disease. As currently: the main method of prevention is the distribution of the condom, they quote various documents from the American episcopate that in the event, of a person being unable to live a chaste life and if it is obvious that a person will not act without bringing harm to others" then the health care professional could recommend the use of prophylactics. Naturally this provoked widespread opposition from other Bishops and Archbishops who registered a double concern: firstly, the solution could be construed as approving or promoting illicit sexual activity and therefore could compromise Catholic teaching and confuse the faithful; and secondly, condoms do not work effectively enough. The editors views are that recommending condoms in a time of AIDS is not an endorsement of contraception, but rather prophylaxis. They support the argument that Humanae Vitae is not undermined at all when one acknowledges the moral legitimacy of using prophylactics in a marriage where one spouse is HIV positive.

Regarding the second objection, that the condom is ineffective, they refer surprisingly to studies conducted over the past four years that condoms are very effective. A study reported in the New England Journal of Medicine showed that, in 124 couples in which only one partner was HIV positive, consistent use over a period of two years demonstrated not one transmission. Such a study goes against the studies reported in this journal from the WHO.

It also ignores many of the experiences detailed by other contributors to these essays. Stuart Bate, Lecturer at St. Joseph�s College in Cedara, South Africa, in his contribution that the AIDS Training and Information Centres in Durban, points out that "throwing condoms at the AIDS problem will not solve it. We have learned this from fifteen years in ATIC and now in the diocesan AIDS programme". In his view they promote precisely the sort of promiscuity and irresponsibility in human relationships which has led to where we are now.

From Haiti, in 1990, a large project in the rural areas was undertaken to identify several factors enhancing rates of AIDS transmission, including poverty and gender inequality. The dominant ideology at the time was education and condom promotion. The use of condoms was actively encouraged even in the parishes. The central message was "Panther condoms: Its cool !" Community dialogue about AIDS was enhanced and the number of adolescents receiving formal sex education went up from nil to thousands. The unfortunate outcome was that the level of AIDS did not decrease. Paul Farmer, an associate professor at the Harvard Medical School, reporting on the project, concludes that poverty and social inequality are the motor forces behind AIDS transmission.

In Uganda, although the AIDS Commission promotes the use of condoms, President Museveni in his active discussions on the problem prefers to advocate abstinence from unsafe sex and commitment to loving faithfully in marriage.

One hopeful feature on the African scene is the establishment of TASO (The AIDS Support Organisation) with the motto of 'living positively with AIDS and dying with dignity.� With a philosophy of compassionate care, mutual support and elimination of any trace of discrimination, it operates on a strong faith in a loving God, creator of all. Its activities include sensitisation and advocacy; training counsellors at various levels of society; giving counselling to people infected and affected by AIDS; providing medical services; and carrying out social welfare services. It is having a great effect in Uganda.

Are we then to approve the spread of the condom culture from the developed world in an attempt to overcome or change the existing cultures of the developing world? As many of the contributors observe, this could only be realised when African communities learn that some of their marriage institutions and sexual rituals diminish rather than promote the life of the community because they are agents of death. An information campaign satisfied with advertising condoms treats only the symptoms and ignores the deeper causes.

Mgr. Suaudeau, an official in the Pontifical Council for the Family, says that condom use "could not be proposed as a model of humanisation and development ." According to the Washington - based Catholic News Service (CNS), there is lively debate among Vatican theologians on whether and how the use of a condom to prevent the spread of AIDS can be permitted. Those who spoke to CNS said that condoms could be tolerated on a case-by-case basis but could never be advocated as a policy to fight AIDS.

Father Kevin Kelly in his concluding essay asks "granted the scientifically established capacity of good quality condoms, properly used, to diminish considerably the risk of HIV infection, would not condom use be more accurately described, from a moral perspective, as life preserving rather than life threatening, prolife rather than antilife?" But given the widely recognised inefficiency of condoms in the prevention of conception and sexually transmitted diseases, it is difficult to contemplate an act of loving intercourse in which the uninfected partner may be left with almost certain terminal disease.

1. Jon Fuller, "AIDS Prevention: A Challenge to the Catholic Medical Tradition," America 175 (28 December 1996): 13-20.

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William E. May
Our Sunday Visitor, Huntington, Illinois, 2000, pp.340.

For many years, we have been waiting for a compact, comprehensive textbook on Catholic bioethics. Some texts are very long, or deal with a restricted subject matter, or provide a general overview rather than entering into detail on such vexed questions as 'rescuing� frozen embryos. Catholic Bioethics and the Gift of Human Life, which goes into just this kind of detail is therefore very welcome.

It is not, of course, perfect: to begin with, the style and tone are uneven. The book is attractive for its warmth and enthusiasm; however, there are various infelicities of expression. May is generous to his friends and severe to his enemies: phrases such as 'woeful ignorance�, however well-founded in fact, should perhaps have been avoided. Typographical errors and errors in quotations are also not unknown. Having said this, the book, while some times over hasty, is a lively and useful introduction to a highly troubled field.

May begins with a resume of key Church documents dealing with bioethieal issues: Evangelium Vitae, Donum Vitae, the Declaration on Procured Abortion and the Declaration on Euthanasia. In the second chapter, May looks at moral assessment of human acts in general. He makes the point that human acts are not physical events, but 'the out ward expression of a person�s choices� : choices which themselves determine the very being of a person. May�s philosophical approach is very much of the school of Germain Grisez and John Finnis, though he does part company with these authors on such questions as direct killing. Those with reservations on the Grisez/Finnis approach will find that May leaves various problems with it unresolved. For example, opponents of the view of contracep tion as immoral simply as a 'choice against life� will regret May�s failure to distinguish consistently between impeding procreation in relation to chosen sexual behaviour and avoiding procreation (intentionally) by avoiding sex at fertile times, without withholding one�s fertility from any sexual act in which one engages. Rather than being 'anti-life� in any general sense, contraception is 'non-marital� : involving a failure to give oneself completely to one�s spouse (though admittedly, this account needs some adaptation where the sterilizing act is per formed by third parties irrespective of the wishes of the couple).

Only by marriage, May argues, do couples 'capaci tate� themselves to act in truly marital ways which are worthy of generating life. In a chapter on marriage and procreation, May evaluates various forms of assisted conception, and also looks at the question of what can be done for IVF embryos whose mothers cannot or will not gestate them. May�s approach to this question is arguably somewhat too permissive (he believes that embryos may be gestated by those who do not plan to adopt them after birth), while his approach to assisted conception is arguably somewhat too restrictive. To equate the removal from the woman�s body and reintroduction of sperm with the removal and reintroduction of ova seems mistaken. Ova, unlike sperm, do not normally owe their presence at the site of conception to intercourse, but make their own journey towards that site: a journey which can therefore be bypassed with far fewer qualms than the journey of the sperm. Still, it is encouraging to see May reject such techniques as GIFT and TOTS, where the marital act cannot be said to cause, even partially, the progress of the sperm towards the ovum.

The chapter on abortion is generally helpful though it could, perhaps, have included mention of the effect of abortion on women, and discussion of cooperation. May asks, in relation to abortion to save the mother�s life, what constitutes 'direct abortion�. Is any abortion where the aim is to remove the child from its mother�s body a 'direct abortion�, or is an abortion 'direct� only where the aim is to cause the child�s death? May is surely right to reject craniotomy, as a procedure which fatally attacks the body of the foetus. However, craniotomy does not necessarily involve, as he suggests, intending death itself, as well as the change to the foetal body which brings death about. An analysis of such an intervention as lethal mutilation, rather than intentional killing might have been useful here and in a subsequent chapter on organ donation.

In the chapter on organ donation and brain death (which follows chapters on human experimentation and euthanasia), May rejects the concept of 'whole brain death� under the influence of the findings of the neurologist Alan Shewmon. In so doing, May joins a series of bioethicists who formerly accepted this concept and are now unhappy with it. Like many of the other issues dealt with in the book, this issue is certainly contentious; however, if nothing else, May�s discussion of these questions will facilitate debate. As a whole, the book is very much needed: a valuable resource in a field where Catholic material is sadly all too scarce.

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