There are some circumstances in which the transmission of the AIDS virus is particularly dramatic, for example when innocent subjects like children, bom from seropositive mothers, contract the infection "vertically". The AIDS virus can be transmitted from an infected mother to the child in three ways: (i) in the uterus through the transplacental passage of the virus; (ii) during childbirth because of the exposure to infected blood and vaginal secretions; (iii) after birth through breast-feeding. The percentage of maternal-fetal transmission in the uterus and during childbirth is 15-20% and for breast-feeding 14%. 1234 If the mother contracts the infection afler delivery this risk of transmission increases to 29%. If the child contracts the infection while he is still in the uterus or during delivery he will run a very high risk of developing the disease with an unfavourable prognosis after a short period.
Faced with the present impossibility of curing the disease, the only way to reduce the incidence in infants is prevention. But it is not possible to talk about responsible prevention of the infection in children when systematic abortion is considered in the case of pregnant women who are seropositive. What kind of prevention is it that is pitiless towards the sick person, eliminating him instead of his disease? Furthermore, since at present it is not possible to carry out a prenatal diagnosis of AIDS, because before birth it is not possible to check whether the infection is apparent or real, there is a risk of killing 4 out of 5 healthy fetuses.
In the light of ontologically founded personalistic model, which is explained in the encyclical Humanae Vifae, as in all Catholic teaching, we have to consider that even though physical life does not include all the riches of the person, it is the fundamental value and as such should be respected and protected from the time of conception:
"Therefore we base our words on the first principles of a human and Christian doctrine of marriage when we are obliged once more to declare that a direct interruption of the generative process already begun and, above all, direct abortion, even for therapeutic reasons, are to be absolutely excluded as lawful means of controlling the birth of children" (Humanae Vitoe, n.l4). 5
In this sense the correct concept of prevention has to be the elimination of the causes that are responsible for the appearance of the disease, not of the diseased subjects.
Before dealing with the problem of the prevention of HIV infection from the mother to the child, I would like to explain the ontologically founded personalistic model that I will be referring to, and compare it with two other ethical models which are widespread today6.
According to the liberal-radical model, the reference "value" is freedom, so everything that is freely desired, freely accepted and that does not affect the freedom of others is allowed. However, it is a question of reduced freedom: it is only freedom for those who can use and express it; it is a constrained, limited freedom, not aimed towards a plan for life. As far as the HIV infection is concemed, according to the supporters of this ethical model, since sexual freedom is not only ethically allowed but actually a right, prevention should mainly aim to inform people about the hygenic health regulations (for example, the use of the condom) in order to assure "free and safe sex". I will not stop to disprove this ethical model which would require a criticism of the anthropological foundations of the conception of sexuality, human life and freedom generally. It is certain, however, that as far as the facts are concemed, this kind of philosophy would also be "epidemiologically" dangerous, as we shall see.
The criteria of reference for the pragmatic-utilitarian model is what is useful, understood as the achievement of the maximum pleasure, the minimum pain and the maximum freedom for the greatest amount of people. If society requires, and rightly so, that the spread of HIV infection be controlled, but at the same time it can be seen that the individuals are not able to abstain from behaviour that is "at risk", it is considered useful to propose "safe sex" with the use of the condom. And even it this does not solve the problem of prevention 100%, as we shall see in the next paragraph, it is still considered useful to have at least partly solved the problem. This is a question of a wrong position, first of all because it generates false certanties and encourages disordered sexual behaviour, and secondly because it does not allow for the vision of all the good of man and all of man in every man.
The personalistic model has as its reference value the person considered as a whole; his freedom and responsibility, his social value, and his relatic,nship with other living beings all result from this value. We have defined this personalism ontologically founded, in that the person is not only considered biologically but in the whole of his nature, that is of his essence, which is that of an individuality in which the spirit and the body are united in such a way that the spirit is made flesh and manifests in the body and it pervades, forms and gives life to corporeity.
According to this model the person is the point of reference and source of society, he is the objective value that transcends the rest of the cosmos. And this is the value that the whole ethical debate should refer to. Consequently when one talks about the prevention of HIV infection, the aim is not only to avoid infection, but a model of life is proposed, which aims for the promotion and protection of the whole good of the person. In other words one wants to help the person discover the whole horizon of his greatness, of his destination, of the fullness of life that he is called to, and the whole objective truth that concems him. Hiding the purpose that we are called for and the true and authentic paths of growth would be a betrayal and an act of a lack of trust with respect to our neighhbour and God.
Therefore an ideal of sexuality for the value of the family and of conjugal faithfulness is proposed. This is a series of values that lead towards overcoming the temptation of drugs by respecting life, corporeity and positive creativity made up of a social commitment and respect for society. It is without a doubt the most difficult path, but if you want to help someone climb a mountain, you have to be sympathetic with him in his moments of tiredness and support him when the going is rough. You may have to tie him at the waist at a risky moment but you cannot trick him by saying that the mountain does not exist or that the path is easy or that the mountain is lower than it is. The mountain cannot be made lower to help those who have trouble climbing it.
The real prevention of HIV infection is carried out through responsible procreation in relation to the various situations that can occur, that is, through the careful evaluation of what could be consequences of conception in certain circumstances. The concept of responsible procreation has often been mentioned and explained by the Catholic Magisterum teaching, and responsible procreation is carried out in various ways:
"If first we consider it in relation to the biological processes involved, responsible parenthood is to be understood as the knowledge and observance of their specific functions. Human intelligence discovers in the faculty of procreating life, the biological laws which involve human personality.
"If, on the otherhand, we examine the innate drives and emotions of man,responsible parenthood expresses the domination which reason and will must exert over them. But if we then auend to relevant physical, economic, psychological and social conditions, those are cc,nsidered to exercise responsible parenthood who prudently and generously decide to have a large family, or who, for serious reasons and with due respect to the moral law, choose to have no more children for the time being or even for an indeterminate period.
"Responsible parenthood, moreover, in the terms in which we use the phrase, retains a further and deeper significance of paramount importance which refers to the objective moral order instituted by God, the order of which a right conscience is the true interpreter. As a consequence the commitment to responsible parenthood requires that the husband and wife, keeping a right order of priorities,recognize their own duties towards God, themselves, their families and human society" (Humanae Vitae, n. 10) (5).
And even before Humanae Vitae, we read in the Pastoral Constitution Caudium et Spes (n. 50) that the choice whether to procreate or not has to be taken by "evaluating the conditions of one's life in terms of one's time and the actual state of one's life, as much from a material as from a spiritual point of view; and finally by protecting the scale of values regarding the good of the family, society and the Church itself'7.
But responsible procreation, as it has already been mentioned inHumanae Vitnen. 10, also involves respect for oneself and c,ne's partner, in the reciprocal recognition of being a person: consequently the spouse who gives the other spouse the burden of programming the births, by imposing contraceptive choices or abortions and putimg health and life at risk, does not recognize its full dignity:
"For men rightly observe that to force the use of marriage on one's partner without regard to his or her condition or personal and reasonable wishes in the matter, is no true act of love, and therefore offends the moral order in its particular application to the intimate relationship of husband and wife" (Humanae Vitae, n.l3) (5).
With regard to the subject we are discussing, there are basically two situations that can arise: there can either be a couple in which only one of the spouses is infected ("serodiscordant" couple) or a couple in which both the spouses have signs of the disease or are carriers ("seroconcordant" couple).
In the case in which only one of the spouses is infected, apart from the problem of avoiding the conception of a subject who could be infected by the HIV virus, the healthy spouse also needs to avoid bemg infected, even though one should bear in mind that the risk of a woman transmitting the infection to a man is very low, whereas in the opposite case the risk is very high. The only proposal made from a purely medical-epidemiological pomt of view in order to prevent the healthy spouse from being infected is, as we have seen, the use of the condom, in the conviction that it can guarantee so-cailed "safe sex". Studies carried out on human subjects, however, have shown that the risk of contracting the HIV infection despite the use of the condom can reach 15-16% and this data cannot be ignored and should be given by doctors to couples so as not to create a false sense of security 8910.
From a moral point of view the use of the condom as a means to avoid infection has been compared to the use of substances that are indicated to cure certain diseases (e.g. oestroprogestins) and that can have a secondary contraceptive effect. As it is known, the Catholic teaching considers the use of these substances ethically acceptable:
"But the Church in no way regards as unlawful therapeutic means considered necessary to cure organic diseases, even though they also have a contraceptive effect, and this is foreseen, provided that this contraceptive effect is not directly intended for any motive whatsoever." (Humanae Vitae, n.l5) (5).
The condom, however, is not a therapeutic means but only preventative (and not even completely effective); moreover the prevention of procreation is directly desired in that procreation and infection are closely connected. So what form of prevention should be used? The safest choice from a scientific and moral pomt of view which respects human dignity is that of abstaining from sexual intercourse: it is a choice that should be seen by the seropositive spouse as an act of love with respect to the healthy spouse because conjugal love cannot bring death to the loved person; it is a choice that involves sacrifice and heroism, required in other circumstances in married life: "All of us, including married couples, reminds John Paul II, are called to saintliness, and this is a vocation that can also require heroism. This should not beforgotten." 11 On a pastoral level this fact itself involves the need for great understanding and compassion with respect to those who are not able to experience this high tribute to unselfish love.
The second case to consider is that of a couple in which both spouses are seropositive and, at first sight, it would not appear that there is any problem of infection of the healthy spouse, in that they are both already infected. Therefore it is a question of clearly pointing out to the couple the risks of conception and the scientifically valid and ethically acceptable means to avoid it. Nevertheless, it is only the couple, and nobody else, as it has already been said, who has to responsibly decide whether to transmit life within the marriage. There are various factors within this responsibility among which is the risk of transmitting the infection to the child and also the possibility that, considering the parent's condition, the child may become an orphan in a short time. In these circumstances, we feel that giving up a possible pregnancy, until scientific knowledge is more detailed, is a really responsible act of paternity-maternity. This choice would not be in contrast with the aims of matrimony and can also be proposed for other kinds of diseases.
If the couple responsibly decides not to procreate they face the problem of which means to use in order to avoid conception. In the iight of the teaching of Humanae Vitae and of an overall and total vision of man and his actions, contraception is not ethically acceptable:
"Therefore we base our words on the first principles of a human and Christian doctrine of marriage (that is the inseparable connection between the unitive significance and the procreative significance which are both inherent to the marriage act)...excluded is any action, which either before, at the moment of, or after sexual intercourse, is specifically intended to prevent procreation, whether as an end or as a means." (Humanae Vitae, n. 14). (5)
The fallibility inherent in every contraceptive technique also has to be mentioned: it is a fallibility that should be taken into consideration and which it would be seriously illicit to obviate with abortion. Therefore one could point out the natural birth control methods and from a theoretical point of view this choice could be ethically acceptable:
"If therefore there are reasonable grounds for spacing births, arising from the physical or psychological condition of husband or wife,or from external circumstances, the Church teaches that then married people may take advantage of the natural cycles immanent in the reproductive system and use their marriage at precisely those times that are infertile, and in this way control birth,a way which does not in the least offend the moral principles which we have just explained" (Humanae Vitae, n.16) (5).
Nevertheless, from a strictly scientific point of view, the literature indicates that repeated contact with the HIV virus, as in sexual intercourse with seropositive subjects, seems to favor the evolution of seropositivity alone towards AIDS. Therefore even the couples in whom both spouses are seropositive, despite the fact that sexual intercourse may be limited to the infertile periods, risk a rapid progression towards AIDS. Consequently also in this second case the safest method of prevention would be to abstain from sexual intercourse: this choice would not only be felt as a moral "constriction" but also as scientifically safer.
It is obvious in both cases, the 'serodiscordant" couple and the "seroconcordant" couple, that if the woman is already pregnant, the most dramatic result, an abortion, should be avoided. This will be possible by promoting in the couple and in the relatives, a culture of welcome for the newborn life, even if sick or potentially sick, in the light of an indisputable truth, that the fetus is a human individual from its conception, a personal human being. And this right always exists, even in the very painful and dramatic situation of a fetus with a malformation or infected by an infectious disease with a fatal outcome.
Therefore the responsibility that is required of Christian couples is a responsibility that does not deny life and does not mortify it, but loves it and protects it, even at the cost of a personal sacrifice that can certainly be placed at a level of extraordinary virtue. This is what is required when a couple decides to abstain from sexual intercourse in order to responsibly prevent infection or the evolution of the infection towards the disease. But Christian spouses are not left alone by God in front of this difficult choice: "The Spirit, given to believers, reminds John Paul II, writes the law of God in our hearts so that this is not only commanded from outside, but is also and above all given within. To believe that there are situations in which it is not possible for the spouses to be faithful to all the requirements of the truth of conjugal love means forgetting this event of grace that characterizes the New Alliance: the grace of the Holy Spirit makes possible that which for man, left with only his own strength, is not possible". (11, p.564)
1 Dunn, D.T. et al. (1992). Risk of human immunodeficiency virus type-1 transmission through breastfeeding, Lancet (340) :585. [Back]
2 European Collaborative Study (1992). Risk factors for mother-to-child transmission of HIV-1. Lancet (339): 1007. [Back]
3 Fischl, M. et al. (1988). Heterosexual transmission of HIV: relationship of sexual practices to seroconversion. IV. International Conference on AIDS, Stockoholm, 12-16 June 1988. [Back]
4 Moreno, J.D., and Minkoff, H. (1992). Human immunodeficiency virus infection during pregnancy. Clinical Obstetrics and Gynecology 35(4): 813. [Back]
5 Paul Vl (1970). Encyclical Humanae Vitae. [Catholic Truth Society: London.] About the argument in n. 14, see Sgreccia, E. (1990): Aids and responsible procreation. Dolentium Hominum (13): 271. [Back]
6 Sgreccia, E. (I991). "Manuale di Bioetica. I. Fondamenti ed Etica Biomedica." [Vita e Pensiero: Milan]. [Back]
7 Concilio Vaticano II, Costituzione Pastorale Gaudium et Spes. In "Enchiridion Vaticanum" 1, 1962/1965, Dehoniane, Bologna,1981, pp.770-965. [Back]
8 Hearst, H., and Hulley, S. (1988). Preventing the heterosexual spread of AIDS. Are we giving our patient the best advice? Journal of the American Medical Association 259: 2428-32. [Back]
9 Rietmejer, C. A.M.(1988). Condoms as physical and chemical barriers against human immunodeficiency virus. Journal of the American Medical Association 259: 1851. [Back]
10 Feldblum, P. J., and Fortney, J. A. (1988). Condoms, spermicides, and the transmission of human immunodeficiency virus: a review of the literature. American Journal of Public Health 78: 52. [Back]
11 Giovanni Paolo II (1983). Discorso ai partecipanti ad un semlnario sulla procreazione responsabile, 17 novembre 1983. In "Insegnamenti di Giovanni Paolo II." Vol. VI/2. Libreria Ed. Vaticana, Citta del Vaticano, 1984, p.564. [Back]