- Pinit Ratanakul, Ph.D. Director, College of Religious Studies, Mahidol University, Salaya Campus, Puthamoltol 4, Norkornpathom 73170, THAILAND Email: firstname.lastname@example.org
The bioethical problems raised by HIV/AIDS are complex with no definite conclusion that convinces everybody. Yet practical decision-making is urgently needed. In the paper I will discuss firstly some of the major bioethical issues concerning this pandemic and secondly the work of Thai Buddhist monks, who, while these bioethical issues are still being debated, with no conclusive arguments on either side, have found alternative solutions in the Buddhist ethic of compassion and translate it into meaningful action. This translation of the Buddhist ethic into action, which can be undertaken by all people of good will, may be regarded as a practical solution to these bioethical problems, related to HIV/AIDS pandemic.
HIV/AIDS has been a deadly disease in Thailand since the eighties. Though the rate of new AIDS infection has slowed down because of highly successful public awareness campaigns, the country still has AIDS epidemic. The estimated number of HIV inflicted sufferers is 1,040,000 with 128,000 full-blown AIDS victims (Daily New, April 2002). The majority are young people in the productive age group of 20-39 years with 27.2% between 25-29, 25.1% between 30-34, 15.3% between 35-39 and 10.5% between 20.24. The death rates are expected to be spinal as more and more of those infected with HIV develop and succumb to AIDS.
The main problems AIDS sufferers have been facing are the lack of adequate health care provided by the government and the hostile attitude health care personnel and the general public have towards them. Accordingly, AIDS patients find it difficult to procure treatment at hospitals, and are often shunned away by their families and friends. Besides, when their infection is discovered, their employers usually dismiss them. Such experience of discrimination and rejection make these sufferers very sad, some becoming depressed to the point of wanting to end their lives, or some reacting aggressively by intentionally seeking to spread the deadly virus. In the context of bioethics these problems are the issues of allocation of resources, discrimination, confidentiality and justice.
The just allocation of resources is a major presupposition for an adequate care of people living with HIV/AIDS and for an effective prevention of the spread of the infection. In Thailand only a small portion of the government budget is allocated for the treatment and care of AIDS patients and for the prevention of HIV transmission. This raises question about distributive justice. Justice requires the most care for those in greatest need. This means, in practice, that a larger portion of available resources should be allocated to hospitals enabling them to establish programmes to alleviate the suffering of AIDS patients and to prevent the further spread of the infection.
Discrimination against people living with HIV/AIDS has become an important factor preventing effective means against the further spread of the pandemic. Discrimination makes the whole community more vulnerable to the spread of HIV including the discriminators themselves and those who are discriminated. This discrimination is a result of individual and social stigma, which is caused by inappropriate fear of contamination and by traditional social and religious negative response to sexual transgression. In the situation of stigmatization, discrimination and prejudice, will not only makes it impossible for people to cooperate in the prevention of the factors leading to the spread of the pandemic, but also violates all the important ethical principles which are widely referred to in ethical studies today i.e. respect for persons, beneficence and non-maleficence, and justice. The respect for persons demands that all people are respected in the same way and nobody can be ostracized because of disease. The principle of beneficence/non-maleficence are violated because discrimination causes harm to both HIV/AIDS patients and the discriminators. Justice demands that people are treated equally and fairly so that they receive the care and attention which is attributed to all people.
Particularly the discriminating attitude of health care professionals against HIV/AIDS patients is not ethically and medically justified. Access to health care is a right for all persons including those who are infected with HIV. On the medical ground there are very few health care professionals who are HIV positive and who could be proven to have contacted the infection through the performance of their professional duties. In general health care professionals are not considered at greater risk than other people. This is the reason why international medical association demands that people infected with HIV should be treated in the same way as other patients and that the refusal of treatment is considered as a violation of the rules of professor conduct.
The ethical principle of confidentiality requires that information which persons want to keep to themselves or to a person whom they trust (doctor, councilor) is kept secretly and is not to be disclosed to others. The relationship between doctors and patients is based on mutual trust with special obligations demanded from health care professionals. Disrespect for the principle of confidentiality may drive people infected with HIV underground, if they have reasons to doubt whether their infection could be disclosed to others. This would impair the creative doctor-patient relationship and violates the principle of autonomy, which demands strict confidentiality and prohibits the disclosure of this information to a third party.
However, adhering to the principle of autonomy may be, in some cases, in conflict with the principles of beneficence/non-maleficence which demands that necessary information should be provided to protect the life of others enabling them to avoid a serious infection. The principle of autonomy and the principles of beneficence/non-maleficence need to be balanced and each particular case has to be treated with caution and great sensitivity. Every attempt has to be made to help the patient to disclose the information to his/her partner involuntarily. Much more important is the need to ensure that confidentiality is not violated heedlessly or carelessly.
Shunned off by families and friends AIDS sufferers turn to the temples as the last resort. After all, the rural poor already know Buddhist monks for their compassionate services. Out of compassion the monks, instead of turning their backs on these sufferers, try their best to find various ways and means to help them, for example, by turning the temples into a kind of hospices to accommodate them and by providing them with herbal treatment combined with religious practices. At one temple in their relationship with the patients the monk makes himself accessible to them nearly all times, seven days a week, and do not require any ceremony at all.
Such a warm and non-discriminating attitude is a typical expression of the Buddhist compassion with all the monks working with HIV/AIDS sufferers share in common. Although the temples are not hospices in the full sense (i.e. are not staffed with professional health care providers such as doctors, nurses, psychologists, and social workers) the monks' warm attitude and real concern for their welfare make the temple a sanctuary for AIDS sufferers.
The work of these monks is a translation of the Buddhist ethic of compassion into a meaningful action to alleviate the suffering of AIDS victims. This ethical ideal of compassion is the basis of all the most important bio-ethical principles, namely, respect for persons, beneficence, non-maleficence and justice. The bioethical principles of beneficence/non-maleficence are prima-facie duties, which are morally binding. The Buddhist compassion goes beyond duty or beyond the moral rule of beneficence. In their untiring efforts to help AIDS patients the compassionate monks are doing more out of compassion. "I am very tried," says one of these monks, "and my health is in deterioration. At times while treating patients I have to rush to my lodging to throw up because of over-work and exhaustion". "But I have great sympathy for these sufferers who have no other place to go. Of course, I treat them free of charge. I do not want them to feel obligated to give something back to the temple in return. But some relatives like to donate some money to the temple. This enables me to buy more herbs from villagers and to help more patients. The temple has very limited space. I like to advise people to take the medicine home and to come back only if there is no improvement. Apart from treatment I encourage all patients to have hope instead of despair, otherwise their conditions will become worse. It is not important for me at all to know how they got AIDS and whether they are good people or not. All I know is that they are in great suffering, and I am very glad to be helpful to them".
The translation of the Buddhist compassion into action to alleviate the suffering of AIDS victims may be regarded as a Thai Buddhist alterative solution to the bioethical issues related to HIV/AIDS epidemic. This Buddhist ethical ideal is inclusive of those basic bioethical principles. Due to their compassion the monks never ostracize HIV/AIDS inflicted people (respect for persons) and treat them equally (justice) with love and care (beneficence) helping them to have meaningful lives to the final days (non- maleficence) and to let go off lives peacefully.
HIV/AIDS epidemic is still a hard fact in our society. Our concern with it through the organization of conferences/workshops to debate/discuss medico-moral questions related to this epidemic is itself an act of compassion. The reflection on these issues is important. It may provide moral guidance in dealing with the pandemic. However, genuine compassion, as demonstrated by the monks, means compassionate services to suffering humanity. When divorced from action ethical ideals such as compassion is nothing.