A Commentary of The National Catholic Bioethics Center on Health Care and the Life Sciences

BENEDICT XVI ON CONDOMS AND AIDS

On a ight to Cameroon in March 2009, Pope Benedict XVI responded to a question about the AIDS epidemic in sub-Saharan Africa. In part of his reply, he stated that the AIDS epidemic cannot be overcome by the distribution of prophylactics: on the contrary, they increase it.1 This remark caused a furore around the world: The Belgian parliament voted to censure the Popes comments. Frances former Prime Minister Alain Jupp complained in an interview that the Pope was a problem. Daniel CohnBendit, a German member of the European parliament described Benedicts remarks as close to premeditated murder. And the Spanish congress shipped one million condoms to Africa in protest! Even the usually unappable Lancet became caught up in the frenzy, questioning if indeed redemption was possible for the Pope.2 Finally, a lone voice appeared on the scene to ght for justice and truth: Edward Green, the former director of the AIDS research program at Harvard University. In an article in the Washington Post on March 29, 2009, with the headline The Pope May Be Right he wrote,
In 2003, Norman Hearst and Sanny Chen of the Un iversit y of Ca l i for n ia conduc ted a condom effectiveness study for the United Nations AIDS program and found no evidence of condoms working as a primary HIV-prevention measure in Africa. UNAIDS quietly disowned the study. ... Since then, major articles in other peer-reviewed journals such as the Lancet, Science and BMJ have confirmed that condoms have not worked as a primary intervention in the population-wide epidemics of Africa.3

The risk of contracting HIV depends on the type of sexual activity that one is engaged in. It was commonly held that the chance of becoming infected with HIV in any one sexual encounter with an infected person was one in one thousand (0.1 percent). However, more recent data has challenged this assumption, and a more accurate gure might be between 0.15 percent and 2 percent for every sexual encounter.6 The Lancet published a series of articles on HIV incidence in men who have sex with men. Rebecca Baggaley, Richard White, and Marie-Claude Boily reported that the overall risk of HIV transmission through anal sex was 1.4 percent, which is roughly eighteen times greater than that which has been estimated for transmission through vaginal intercourse.7 For this reason, Chris Beyrer and his colleagues concluded that the high probability of transmission per act through receptive anal intercourse has a central role in explaining the disproportionate disease burden in MSM [men who have sex with men].8 For example, in the Philippines where the incidence of HIV infection is increasing, 80 percent of the new cases last year were in men who have sex with men.9 Many blame the Church for its lack of support for condom initiatives. However, a 2001 report from the U.S. Agency for International Development in the Philippines clearly stated that it is highly unlikely that the churchs position constrains condom use among high risk groups. It is dicult to conceive of a sex worker engaged in this activity who refuses to use a condom because of religious proscription.10 Even if condoms were to eliminate part of the risk of HIV transmission, their benet would soon be oset with repeated use because of what is known as cumulative risk.11 Cumulative risk is perceived intuitively in every day experiences, even if it is not calculated mathematically. Suppose there was a 1 percent risk of death when crossing a busy road. The chance of dying if you cross it one hundred

The Risk of Contracting HIV

The actual eectiveness of a condom in the reduction of HIV transmission is hard to evaluate. In 2000, a workshop was convened by four U.S. government agencies, in which it was concluded that condom use decreased the risk of HIV/AIDS transmission by approximately 85%.4 But this high a gure is only achieved under optimal conditions, not under usual or typical conditions, where risk reduction might be closer to 65 percent.5 Condoms are often used inconsistently, eliminating only part of the risk of contracting this deadly disease. This is hardly safe sex.

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VOLUME 38, NUMBER 4

BENEDICT XVI ON CONDOMS AND AIDS

GOOD THEOLOGY AND GOOD MEDICINE

Rev. James McTavish, FMVD, MD

EUTHANASIA AVOIDED
A CASE STUDY

James Brennan, MD

DEFENDING THE DIGNITY OF THE HUMAN PERSON IN HEALTH CARE AND THE LIFE SCIENCES SINCE 1972

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times does not remain 1 percent overall. Intuitively, you know that the risk of death increases the more times that you cross the busy road. In this example, the cumulative risk for crossing the street one hundred times is 63 percent. Now if we take the risk of HIV transmission from unprotected sex to be 1 percent, and the condom reduces that risk by 85 percent, then the risk of transmission is reduced to 0.15 percent for each episode. The cumulative risk is 14 percent for one hundred exposures, 31 percent for two hundred and fty exposures, and 53 percent with ve hundred exposures. Even if condoms may decrease the risk of infection in a single event, they are less eective the more one engages in risky behavior.

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as a policy of AIDS prevention. He explicitly denies both of these moves.13

Vatican spokesman Father Federico Lombardy oered the following clarication of the Popes statement:
I asked the Pope personally if there was a serious or important problem in the choice of the masculine gender rather than the feminine, and he said no, that is, the main pointand this is why I didnt refer to masculine or feminine in (my earlier) communiquis the rst step of responsibility in taking into account the risk to the life of another person with whom one has relations. ... Whether a man or a woman or a transsexual does this, were at the same point. The point is the rst step toward responsibility, to avoid posing a grave risk to another person.14

Condom Use in Specic Cases?

Benedict oered additional comments on condoms and HIV in a book-length interview with journalist Peter Seewald. Seewald asked the Pope, On the occasion of your trip to Africa in March 2009, the Vaticans policy on AIDS once again became the target of media criticism. ... Critics, including critics from the Churchs own ranks, object that it is madness to forbid a high-risk population to use condoms.12 In part of his reply the Pope said,
There may be a basis in the case of some individuals, as perhaps when a male prostitute uses a condom, where this can be a rst step in the direction of a moralization, a rst assumption of responsibility, on the way toward recovering an awareness that not everything is allowed and that one cannot do whatever one wants. But it is not really the way to deal with the evil of HIV infection. That can really lie only in a humanization of sexuality.

Pastoral Care
A widespread distribution of condoms is not going to be the simple way to combat the AIDS epidemic. The Church is correct to not pursue this policy. Regarding the use of condoms in individual cases, such as prostitution or for men who have sex with men, Benedicts recent comments shed some light on this difficult area of pastoral ministry. The Popes comments in no way condone the widespread public distribution of condoms, and his comments are fully in line with the principle of gradualism, which understands moral growth as taking place in small steps or stages.15 The use of condoms here may be a rst step toward responsibility, but it is not the only step nor the last step. In reality, the main moral issue in prostitution is not the use of condoms but why there exists so great a demand for the exploitation of women. There is a need for pastoral care for those involved in this industry. Likewise, the Church has great pastoral concern for men who have sex with men, especially in the area of disease prevention, and emphasizes that those with homosexual tendencies must be accepted with respect, compassion, and sensitivity.16 There is a great need for the development of pastoral care for those who are suering from HIV and AIDS, and we, as members of the Church, are called to be in solidarity with those living with and aected by HIV and AIDS. They are our brothers and sisters. They are our neighbors. They are the human face of Jesus in our modern time. To love them is to love God.17 Rev. James McTavish, FMVD, MD Father James McTavish, FMVD, MD, is a Catholic missionary priest with the Verbum Dei missionaries and is currently in Manila, Philippines. He is involved in formation and apostolate work, and he teaches moral theology and bioethics. He is also a member of the Philippine Catholic HIV and AIDS Network (PhilCHAN). The author wishes to thank Dr. Edward C. Green for his helpful comments on this article.
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Seewald asked next, Are you saying, then, that the Catholic Church is actually not opposed in principle to the use of condoms? The Holy Father replied, She of course does not regard it as a real or moral solution, but, in this or that case, there can be nonetheless, in the intention of reducing the risk of infection, a rst step in a movement toward a dierent way, a more human way, of living sexuality. Much has been said about these comments. Some mistakenly read it as a go signal for the use of condoms and as a practical overturning of the teaching of Humanae vitae. Others said that nothing has changed at all, insisting that the Pope was referring to homosexual sex in mentioning a male prostitute, for whom the use of condom would obviously not be contraceptive. David Jones, the director of the Anscombe Centre for Bioethics, commented on what the Pope said:
This is indeed a dramatic statement because it is the rst time that a Pope has said something positive, albeit in a very qualied sense, about the decision to use a condom to prevent infection. What should be clear is that this rst step should not be the last step: that someone in this degrading and dangerous situation needs to nd a dierent way of living altogether. ... Note what is not being said here. The Pope is not saying that the use of condoms is in itself moral or virtuous. Nor is he saying that their use can be justied on pragmatic grounds

Benedict XVI, Interview during the Flight to Africa (March 17, 2009), www.vatican.va/holy_father/benedict_xvi/speeches /2009/march/documents/hf_ben-xvi_spe_20090317_africa -interview_en.html.

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France Criticises Papal Condom Statement, htt p://www.eng lish.r.fr/, March 19, 2009, http://www.r.fr/actuen/articles/111/ article_3215.asp; and Stephen Bates, Pope Distorting Scientic Evidence about Condoms, Claims Lancet, Guardian.co.uk, March 27, 2009. 3 Edward C. Green, The Pope May Be Right, Washington Post, March 29, 2009, http://www.washingtonpost.com/wp-dyn/ content/article/2009/03/27/AR2009032702825pf.html. 4 See National Institute of Allergy and Infectious Diseases, Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention, report, July 20, 2001, http://www.niaid.nih.gov/about/organization/dmid/documents/ condomreport.pdf. 5 Saifuddin Ahmed et al., HIV Incidence and Sexually Transmitted Disease Prevalence Associated with Condom Use: A Population Study in Rakai, Uganda, AIDS 15.16 (November 9, 2001): 21712179. 6 See Marie-Claude Boily et al., Heterosexual Risk of HIV-1 Infection per Sexual Act: Systematic Review and Metaanalysis of Observational Studies, Lancet Infectious Diseases 9.2 (February 2009): 118129; and Kimberly A. Powers et al., Rethinking the Heterosexual Infectivity of HIV-1: A Systematic Review and Meta-analysis, Lancet Infectious Diseases 8.9 (September 2008): 553563. 7 Rebecca F. Baggaley, Richard G. White, and Marie-Claude Boily, HIV Transmission Risk through Anal Intercourse: Systematic Review, Meta-analysis and Implications for HIV Prevention, International Journal of Epidemiology 39.4 (August 2010): 10481063. See also Chris Beyrer et al., Global Epidemiology of HIV Infection in Men Who Have Sex With Men, Lancet 380.9839 (July 28, 2012): 371. 8 Beyrer et al., Global Epidemiology of HIV, 367. 9 Department of Health, Philippines, Philippines HIV and AIDS Registry, December 2012, http://www.doh.gov.ph/sites/default/ les/NEC_HIV_Dec-AIDSreg2012%20(1).pdf. 10 U.S. Agency for International Development, Final Evaluation of the AIDS Surveillance and Education Project (ASEP), (Manila, Philippines: USAID, 2001), 23. 11 See Edward C. Green, Rethinking AIDS Prevention: Learning from Successes in Developing Countries (Westport, CT: Praeger 2003), 110111. 12 Benedict XVI and Peter Seewald, Light of the World: The Pope, the Church, and the Signs of the Times (San Francisco: Ignatius Press, 2010), 117119. 13 David Albert Jones, Commentary from the Anscombe Bioethics Centre, regarding the Pope on AIDS and Condoms, November 21, 2010, http://www.bioethics.org.uk/images/user/ ABC%20Comment%20on%20the%20Popes%20statement%20 on%20HIV%20and%20condoms.pdf, 2. 14 John Thavis, Vatican Clarifies Popes Reference to Male Prostitution in Condoms Comment, Catholic News Service, November 3, 2010. 15 The principle of gradualism is referred to by Pope John Paul II: Man, who has been called to live Gods wise and loving design in a responsible manner, is an historical being who day by day builds himself up through his many free decisions; and so he knows, loves and accomplishes moral good by stages of growth. Familiaris consortio (November 22, 1981), n. 34. 16 Catechism of the Catholic Church, 2nd ed., trans. U.S. Conference of Catholic Bishops (Vatican City: Libreria Editrice Vaticana, 1997), n. 2358. 17 Catholic Bishops Conference of the Philippines, Who Is My Neighbor?, pastoral letter on AIDS Conclusion, July 2011, http:// cbcpforlife.com/?p=4894.

EUTHANASIA AVOIDED
In the State of Michigan, where I have practiced medicine for thirty years, euthanasia illegal. However, my clinical experience with patients who ask for physician-assisted suicide has been frequent. My last case of a patients request for assisted euthanasia has some elements that illustrate why euthanasia should remain illegal.

Desire for Euthanasia

Patient X had many of the common problems often cited as reasons to justify euthanasia: He had terminal cancer; in fact, his other physicians were correct when they told him he had less than a month left to live. He had signicant pain; it took intravenous medication to control his pain. He had diculty breathing; his cancer would ll his chest with uid, compressing his lungs. He expressed that he felt as if he was drowning with each breath he took. Drainage of this uid was painful and invasive and became necessary on a near daily basis. Thus, some might say that the patients request for enough pills to be left on his bedside to ensure that he never wake up again might seem reasonable. He had accumulation of large amounts of edema in all of his extremities. This edema not only caused pain but restricted movement and added to his negative self-image. His blood pressure was dicult to control. He required assistance with all functions of daily living. He believed that the money to care for him could be better spent on someone else. From the beginning, the patient said that he would never consent to being kept alive in the condition to which he had now degenerated. He was an outstanding advocate for a right of self-determination, including a right to euthanasia, And his attorney, who was present for many of our discussions, agreed with him. After I explained that it was illegal to assist him in euthanasia, the patient allowed the nursing sta and me to begin pain management for him. He had feared that pain control would come with mental dullness, and it had been complicated to convince him that this was not true. Trust improved when pain control improved, and it involved several days of trials of medications, some with doses too low to be fully eective. My unstated strategy during these days was simply to stall, keeping him in the hospital until he would accept the aid and comfort he deserved. He did have a legal right to ignore my medical advice and leave the hospital. For the rst ten days, he made it clear that he would use his gun as soon as he could get home. Thus, my stalling was

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Views expressed are those of individual authors and may advance positions that have not yet been doctrinally settled. Ethics & Medics makes every eort to publish articles consonant with the magisterial teachings of the Catholic Church.

expressed to him by me as a need to get him stable enough to allow him to go home. My stalling strategy allowed the use of our greatest weapon against evil: prayer. An urgent request to multiple prayer groups was answered by a slow change of his heart. As more of his medical issues were managed and his comfort improved, his request to leave for home to his hand gun began to change; they were now accompanied by a sly grin and a clear twinkle in his eye. He soon agreed to stay in the hospice center until he would die a natural death. The next day he reached out to his son, with whom he had not spoken for thirty years. They were able to reconcile, and patient X died in a day or two after this reconciliation.

protected. Killing any innocent life is always a great evil, even when the life one wants to takes is ones own. James Brennan, MD Dr. Brennan practices medicine in Sturgis, Michigan. He is also in the nal months of formation for the permanent diaconate for the Diocese of Kalamazoo.

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To the Editor: In the January issue of Ethics & Medics, Becket Gremmels makes the excellent point that illustrating the principle of double eect by applying it to palliative pain relief can cause confusion. As Gremmels explains, the lethal dose of opiate analgesics is far greater than the dose required to either relieve pain or make the patient unconscious, thus the principle of double eect need not be invoked to justify the risk of directly harming the patient with these drugs. However, opiates and sedatives may contribute to the patients death in indirect ways. For example, these medications can interfere with the coughing reex and expose the patient to the risk of fatal aspiration pneumonia. If these indirect harmful eects are infrequent, observational studies, such as the ones cited by Gremmels, may not detect a marked decrease in survival associated with the use of opiates. The United States Conference of Catholic Bishops precisely refers to the risk of indirect harm when addressing the use of palliative analgesia in directive 61 of its Ethical and Religious Directives for Catholic Health Care Services. The directive therefore cogently conveys the principle of double eect as it might apply when caring for the dying patient. Michel Accad, MD San Francisco, CA

A Dignied Death
The refusal of euthanasia to patient X allowed for many goods to be accomplished. After his death, I learned that for many years his greatest fear was rejection. By showing him respect, even though he voiced ideas that he knew were unacceptable to me, he grew to understand that I would never abandon him, and we developed a beautiful relationship. His reconciliation with his son, even though it was at the last hours before his death, was a great joy for him. It was also a source of joy for his son, and surely it will be for the rest of his sons life. The nursing sta felt good that, nally, their skills were accepted by the patient and that they had made a dierence in his life. A lifetime of pushing people away before they might reject him had nally been undermined. Our discovering this mans fears and needs, while trying to address them, gave this man peace at the time of his death. Hopefully by reading about him, more people may see through the lie that euthanasia is a right to be

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