Researchers trying to resolve the questions surrounding the AIDS epidemic may feel like Hercules trying to slay the Hydra: for every head that is cut off, two new ones grow in its place. Doctors have never treated their patients in a social vacuum, but the expectations and anxieties engendered by AIDS are bringing fundamental changes in clinical p-actice. Drugs are being raced from the laboratory bench to the bedside, health care providers are being forced to recognize new types of family constellations, and the general public is being shocked into awareness of the importance of prudent infection control policies. Clinical practitioners have had to deal with the ethical consequences of routine and arcane decisions as never before, knowing that yesterday's experiment or hospital rounds can become tomorrow's lead feature in the news media.

It is often said that all human life, irrespective of its quality or kind, is equally valuable and that our life-and-death decisions for seriously ill or handicapped infants must not be based on the quality or kind of life in question. As the Protestant theologian Paul Ramsey has put it:

The view that all human life—irrespective of its quality or kind—has equal worth may well be the simplest answer to the difficult issues raised about the treatment of infants born seriously ill or with major handicaps; but there are two questions that need to be asked about this simple answer.

The acquired immunodeficiency syndrome (AIDS) and the entire spectrum of disease associated with infection by the human immunodeficiency virus (HIV) are the subject of intense international interest and concern. From the viewpoint of the World Health Organization (WHO), HIV is not simply one of a series of newly recognized diseases emerging during the past decade but is a problem with several biological and epidemiological features that justify a unique sense of urgency among public health officials, political leaders, and the general public.

This article describes the evolution of a global perspective and response to HIV, reviews the current international epidemiological situation, explores the principal elements, both conceptual and operational, of WHO's global strategy for HIV control, and discusses the major approaches to HIV prevention in the current global context.

I agree with Dr. Kuhse and Prof. Singer on many points. It is of course ethically defensible to decide sometimes that a seriously handicapped newborn baby may be better off dead, that medicine can do no more to help, and that to stop or not initiate medical treatment may be the best we can do. It is equally true and ethically defensible that these decisions are sometimes based at least in part on predictions about the baby's present and future quality of life. It would be foolish to pretend that quality-of-life considerations should be or can be excluded from these decisions. I argue that the interests and wishes of the family must be given serious consideration, if not that they should be decisive at the expense of the newborn's best interests.

I do, however, seriously object to the claim that some infants with severe disabilities should be killed. I will not repeat the familiar philosophical and other arguments as to why there is arguably, given certain conditions, a significant moral difference between not treating and killing. Instead, my refutation of infanticide will take a more indirect route.

The question in my title—a deliberate inversion of Kuhse and Singer's now-famous question, “Should the baby live?”—is one that is being asked more and more frequently. As Gerald Gruman has observed:

The medical care needs of aged persons, and how we, as individuals and societies, will fulfill these needs in an era of a perceived scarcity of medical resources, are a frequent topic of discussion today. The “scarcity” of medical resources is frequently a given in discussions of allocation priorities.

The death of William Schroeder in Louisville, Kentucky, on August 6, 1986, brought to a close a remarkable chapter in public human experimentation. Artificial heart implants represent the most public experiments in the history of the world. The manner in which they are conducted is a matter of utmost public and professional concern, since it graphically portrays the seriousness with which we take our laws and ethical rules regarding the protection of the rights and welfare of human subjects. Unfortunately, the brief history of artificial heart implants is neither a happy nor a proud one. Begun with high hopes and therapeutic intentions with the Barney Clark implant, the permanent procedures rapidly became little more than publicity stunts used to advertise Humana, Inc., a for-profit hospital chain. Indeed, on the night Mr. Schroeder died, Humana Hospital Audubon sent its public relations director to justify the experiment to a national television audience on Nightline, apparently because no physician at the hospital was willing or able to publicly defend the experiment.

Jeremy Bentham, the founding father of utilitarianism, would have been delighted by technology assessment. Contemporary health policy planners are, unwittingly, aping the great man's felicific calculus, as they attempt to discern the efficacy and safety of magnetic resonance imaging or cardiac bypass surgery or extracorporeal shockwave lithotripsy. They try to design methods to calculate the effects of these technologies on mortality and morbidity and to compare the costs of one to the costs of alternatives. In recent years, the methods of technology assessment have been refined, but they remain, in essence, a copy of Bentham's proposal to plan and effect a rational course of action and to create a rational world.

The great philosopher and social reformer is, of course, still with us in a dessicated form. He bequeathed his body to the fellows of University College, London, and to this day his mummified figure is encased in a glass box, sitting in his favorite chair, dressed in his own clothes, his waxen face peering out with a bemused smile.

Most medical practice in the United Kingdom is carried out within the National Health Service (NHS), which offers a comprehensive service essentially free of charge to all citizens. Courts of law cannot take the availability of free care into account in determining the level of damages to be awarded to the patient—in other words, in assessing the cost of putting right the damage sustained by the patient, it is assumed that the restorative treatment will be obtained privately. Nevertheless, the fact that the patient did not have to pay directly for the treatment in the first place is in itself a disincentive to bringing actions in negligence against a doctor or health authority. As Professor Miller has put it, “Since disposable income is not diminished by paying for medical services patients are less likely to express their unhappiness about unsatisfactory results in a manner that seeks monetary results.”