Running head: PUBLIC HEALTH ETHICS REFLECTION PAPER
Public Health Ethics Reflection Paper
Crystal J. Bendele
Ferris State University
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Abstract
Health policy and ethical issues surrounded the topic of the HIV infection in the early 1980s.
Before much was known about this deadly disease, ethical issues regarding the rights of
heterosexuals and homosexuals broke out in a rampage. As health policymakers struggled to
make ethical decisions based on CDC recommendations to control the potential harm caused
from this epidemic, it was difficult for particular social groups not to feel discriminated against.
This paper explores a major issue in health policy that was identified in the movie, And the Band
Played On. It identifies with an ethical framework best suited for implementing policy during a
crucial time in history as the HIV virus emerged and became an epidemic.
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Public Health Ethics Reflection Paper
The ethical issue chosen to explore and link with health policy deals with controlling the
AIDS epidemic without discriminating against gays or infringing on others’ rights (Walters,
1988). While watching the movie, And the Band Played On, the health policy issue identified
was the attempt of the CDC to control the epidemic and prevent further spread of the disease.
The fact that little was known about the disease and initially there was not any proof that the
disease was spread through sexual contact made it difficult to implement health policies that
public health officials believed would help prevent the spread of the disease and protect the
population. Because this disease was initially believed to be a disease among men who have
sexual relations with other men, ethical issues surrounding the disease and the stigma of the hosts
were many. The focus here reflects on the earliest days of the HIV infection and AIDS and the
collision of health policies and ethical issues surrounding the disease.
Past Challenges with the AIDS Epidemic
In the 1980s, public health officials were forced to confront the challenge of the AIDS
epidemic (Bayer, 1991). Little information was known about this disease that was killing
members of a specific population. The CDC worked to identify the disease and mode of
transmission, but, nothing was for certain in the early days. They did however, believe that the
disease was spread through sexual activities between men. One of the health policies identified
because of their studies included closing of bathhouses in an attempt to prevent the spread of this
disease. The attempt to prevent the spread of what we now know as HIV resulted in closing the
cities’ bathhouses. Because sexual encounters happened onsite at bathhouses and the CDC
believed the infection was spread sexually, bathhouses posed a significant danger to public
health. According to Kelley, an even more significant concern regarding the bathhouses was not
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just that sexual encounters occurred but the number of sexual encounters with multiple partners
in which an infected person could engage (1992). Because the disease was linked to homosexual
men and believed to be sexually transmitted, the CDC had a valid argument that closing
bathhouses could potentially prevent the spread of the disease. However, this gesture would not
prevent men from participating in sexual acts with other men. It would however, hopefully
decrease the number of partners and decrease the incidence (Kelley, 1992). This suggestion left
homosexuals feeling discriminated against and tension was built between public health and
individuals’ rights.
Ethical Aspect and Public Health
Kelley stated that bioethical issues to be considered from a public health aspect include:
a public versus individual health, public versus individual rights, and seriousness of disease
issues (1992). Issues that must be weighed include benefits versus harm of policies, rights or
freedom of those affected by the policies and distribution of the outcomes within the population
(Kelley, 1992). There was no question that the government had the power to close bathhouses
for the sake of public health, but, was this the morally right thing to do? This becomes an ethical
issue in that it may not respect the rights of all parties at stake. However, the Rights Approach to
this ethical dilemma may not be the best choice when people’s lives are at risk. Perhaps, using
the Utilitarian Approach would be the best choice of framework in which to base the decision on
whether or not to close the bathhouses. The argument here is that if men choose to participate in
sexual activity with other men they will find another place other than a bathhouse. However,
closing the bathhouses might have reduced the rate of spread of infection. On the side of public
health, since the belief of the CDC was that the disease was transmitted sexually and most cases
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were among homosexual men the correct action was to close the bathhouses. This was the best
decision for the greater good of this high risk population.
From an ethical standpoint, implementing a policy to close bathhouses did not cause
harm to men that frequented them. Harm was prevented because multiple sexual partners
increase the risk of infection and closing bathhouses affected the source of partners (Frankena,
1973). Frankena recognized that psychological harm may have been caused due to disruption of
social networks (1993). The issue was ethnically problematic however, the outcome was
supposed to decrease physical harm even though there may be sufferers of psychological harm.
In the absence of vaccine, effective treatment, or cure, it became evident almost immediately that
the only weapon against AIDS was a preventive measure: education (Silverman & Silverman,
1985).
Education as an Alternative
A principle function of public health agencies has always been to inform the community
about disease and to promote health, placing much of the responsibility on individuals to act in
the light of facts presented (Silverman & Silverman, 1985). Silverman & Silverman also stated
that the task of formulating appropriate recommendations for behavior to reduce the risk of
contracting AIDS was hampered by initial confusion about the exact mechanism of transmission
and what constituted safe sexual practices (1985). The recommendations from the CDC to close
the bathhouses may have been the most rapid measure for the greater good of the at risk
population. However, according to Kelley, education programs would have been a less
restrictive alternative than closing the bathhouses (1992). Leroy Walters later argued that
imaginative public health education would be moral education in the sense that it helped the
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hearer see clearly the possible effects of his or her behavior on others (1988). This argument
could be beneficial, however, after the identification of the virus and the certainty of it being a
sexually transmitted disease. Ethically, Walters suggests, promotion of legal prohibition of
discrimination against people who engage in private homosexual acts (1988). To reduce the
fears about being stigmatized would encourage homosexual and bisexual males to disclose their
patterns of sexual activities and could lead to discussions of risk reducing practice (Walters,
1988). At the time, because little was known about the virus, a discrimination free environment
for homosexuals may have provided information for a more rapid identification of the virus and
transmission routes. This information would have provided possible insight into measures that
could prevent disease. The incidence rate may have been decreased had gays not felt stigmatized
and discriminated against and allowed to express their position from the beginning. However, on
the defense of the gays, it may be difficult to open up and discuss a topic with such high
stigmatism.
Blood Donation Stance
A second public health issue that was tied to an ethical dilemma identified in the movie
included the prevention of blood donations from the at risk population. Once the virus was
identified in blood, vulnerable populations such as hemophiliacs were at risk if health policies
were not in place to protect them. Homosexuals argued that because this was initially identified
as a gay disease, they were being discriminated against. The ethical argument is placing the
entire population at risk of death by not applying a policy to prevent high risk individuals from
donating blood. This infringed on individuals’ right to live. Once again, this issue is best
approached using the Utilitarian Approach. It can be argued that dying from an unknown disease
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that is spread through blood products is less harmful than dealing with emotional effects suffered
from discrimination.
Ethical Framework
When implementing health policies, it is crucial to utilize an ethical framework from
which to draw ideas. According to Santa Clara University, after recognizing the ethical issue by
asking the question, ‘could this decision or situation be damaging to someone’ (2009). They also
recommended obtaining all of the facts prior to making decisions. Perhaps, this is why there was
difficulty in implementing health policies regarding closure of bathhouses. It was initially
difficult to prove that the disease was spread sexually. That made it difficult for the at risk
population to accept. The ethical issues presented by AIDS as a public health event will be
pondered by health professionals, bioethicists, and sociologists for years to come (Silverman &
Silverman, 1985). The ethical standpoint from which the conclusion is drawn is that at the time
of the first recognition of the disease, public health officials made the correct decision for the
greater good of the population.
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References
Bayer, R. (1991). Public health policy and the aids epidemic-an end to hiv exceptionalism. The
New England Journal of Medicine, 324.
Frankena, W. (1973). Ethics. Englewood Cliffs, NJ: Prentice Hall.
Kelley, J. (1992). Community health and ethical theory: implications for holistic nursing.
Journal of Holistic Nursing, 10(3), doi: 10.1177/089801019201000307
Sandford, M., & Pillsbury, S. (Producers), & Spottiswoode, R. (Director). (2010). And The Band
Played On [Motion picture]. USA: Warner Brothers.
Silverman, M.F., & Silverman, D.B. (1985). AIDS and the Threat to Public Health. The hastings
center report. Retrieved November 24, 2010, from http://www.jstor.org/pss/3561393
Velasquez, M., Moberg, D., Meyer, M.J., Shanks, T., & McLean, M.R. (1988). A framework for
thinking ethically. Informally published manuscript, Markkula Center for Applied Ethics,
Santa Clara University, Santa Clara, California. Retrieved from
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239(4840), doi: 10.1126/science.3340846