Margaret P. Battin, Leslie P. Francis, J.A. Jacobson and Charles B. Smith. 2009. The patient as victim and vector: Ethics and infectious disease

New York: Oxford University Press, ISBN 019533583X

At the conclusion of Plagues and Peoples (1977) his magisterial account of epidemics and their impact on history, William McNeil wrote,

Ingenuity, knowledge and organization alter but cannot cancel humanity’s vulnerability to invasion by parasitic forms of life. Infectious disease which antedated the emergence of humankind will last as long as humanity itself, and will surely remain, as it has been hitherto one of the fundamental parameters and determinants of human history.

Published in the mid-1970s, these observations may have appeared overdrawn to readers in the United States and other economically advanced societies. I cited these words in the last chapter of Private acts, social consequences: AIDS and the politics of public health (1989) because McNeill, from the vantage point of just a decade after Plagues and Peoples appeared so prescient. Ten years of AIDS had changed the world and our understandings profoundly. The change was underscored by the observation of Deborah Cotton, an infectious disease physician who was among the first generation of clinicians to respond to AIDS. When she had started her training in 1978 she noted, “everyone was saying it’s over. It’s done. There were editorials saying ‘what are we going to do with these infectious disease doctors? They’re going to culture each other. There’s nothing. We’ve conquered this’”. We had become a post- infectious disease society. Diseases of “lifestyle”, chronic infections, would shape our future. Johns Knowles’ classic essay “The Responsibility of the Individual” published in Daedalus, the Lalonde Report in Canada and Healthy People in the US all drove home the same point.

And so it is not surprising that when contemporary bioethics began to take form in the 1960s and 1970s questions posed by infectious disease were all but absent. Less the consequence of ideological blinders, this lacuna reflected the dominant thinking in medicine and even in public health. What little there was of even the first glimpses of an ethics of public health focused on the issues posed by the new paradigm.

And then there was AIDS. Bioethicists drawn to this new challenge at a time when its global dimensions were not even a specter on the horizon brought with them the conceptual apparatus that had served them well in considering issues of research and the clinical encounter. While the autonomy-focused bioethical frame was very useful at a moment when concerns about coercion, stigma, and privacy and confidentiality were central, it became increasingly obvious—at least to some—that something more robust would be essential if an ethics of epidemic disease were to provide for a meaningful encounter with the real world of public health. That initial insight became all the more obvious in the early 1990s with the resurgence of concern about tuberculosis.

What began to emerge was a number forays into the ethics of infectious disease as part of the broader project of efforts to articulate an ethics of public health. But nothing until now approached the scope and depth of the Patient as victim and vector by Margaret Battin, Leslie Francis, Jay Jacobson, and Charles Smith. This new book, the collective effort of philosophers and physicians, well serves as both a statement to the field of bioethics and as a valuable text for students in medicine, public health and bioethics. It is accessibly - and sometimes elegantly - written, cogent and provocative.

Battin and her colleagues begin with an insight that is both biological and socio-cultural.

Human beings all live together with each other in a web of potential and actual disease...Even when they are not currently overtly ill and not aware of the possibly of matter how people try, they cannot avoid the fact not just that they are at risk of infection from others but that they in turn pose risks to others and thus perhaps to others far distant from themselves (80).

We are thus “way-station selves” embedded in biological networks that have ineluctable ethical consequences. From this starting point it is not a long way to the framework that informs the Patient as victim and vector: “ethical problems in infectious disease should be analyzed, and clinical practice and research agendas and public policies developed, that always take into account the possibility that a person with communicable infectious disease is both victim and vector” (7). More, this perspective serves as a foundation for their claim that much of bioethics and American ideology is too limited, cabined in a way that limits moral theory and its application to the world of “flesh and blood human beings”.

With care and unusual modesty Margaret Battin and her colleagues turn to a range of topics central to the practice of public health: surveillance, required testing, mandated immunization and the imposition of constraints in light of infectious disease. SARS, tuberculosis and the threat of pandemic flu receive sustained attention. In speaking of the burdens borne by those who may even be the legitimate subject of imposed constraint they display both care and humanity: “there will remain the recognition that victims have had important moral interests overridden despite the justifiability of the choices made”.

There are matters that I wish had been given more attention—the insights of history and social demography, so classically discussed by Thomas McKeown, that patterns of infectious disease have changed more as a consequence of profound changes in the social environment than because of anything done by clinicians or public health officials. I was also troubled by what at times seemed a too easy assumption that our contemporary ethical perspectives can serve to judge history. But even here the authors display unusual candor in their discussion.

At the end of the day, quibbles aside, this is a very fine volume. Perhaps most important it demonstrates again and again that formulaic responses to the threat of infectious disease are inadequate to the challenges they pose. It is a remarkable, and I think lamentable fact, that in recent years the still-nascent discussion of public health in general and of epidemic disease more specifically, has all but been supplanted by the language of human rights. Human rights efforts can and have had important, morally significant outcomes, especially in the face of outrageous assault on human dignity. But too frequently the terms of human rights have been too blunt an instrument for engaging the extraordinarily difficult challenges of infectious disease. That, Battin and her colleagues have made abundantly clear. To watch the authors probe and struggle with the moral dilemmas we all face is more than worth the price of admission.

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Correspondence to Ronald Bayer.

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Bayer, R. Margaret P. Battin, Leslie P. Francis, J.A. Jacobson and Charles B. Smith. 2009. The patient as victim and vector: Ethics and infectious disease . Bioethical Inquiry 6, 249–250 (2009).

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