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Are people with HIV entitled to make claims on the state for treatment if they are responsible for their own infection? The view of Cameron and Geffen is that they are. Witness to AIDS examines an article by philosopher David Benatar originally published in the Lancet which takes a different view. Benatar took issue with Cameron and Geffen for both the way they described his argument and their response to it. This led to an interesting debate between both Cameron and Geffen on the one hand, and Benatar on the other. We reprint the correspondence between them over here.

 

Benatar's original article in Lancet

Complaint from Benatar to authors

Complaint from Benatar to authors

Letter from David Benatar to Edwin Cameron

Dear Judge Cameron

It has been drawn to my attention that you discuss a short paper of mine
in your recent book, "Witness to AIDS". I have read the relevant section
and believe that you misrepresent my position to some extent. I write in
the spirit of academic debate and to correct any misunderstanding.

First, I never claimed that mothers of children with HIV are undeserving
of state-provided antiretrovial treatment. What I did say was that
"mothers of HIV-positive children who could reasonably have avoided
conception" are one category of those who are "responsible for their or
other people's HIV-positive status". My sentence employs a disjunction
and I am not claiming that mothers of HIV-positive children are
(necessarily) responsible for their own HIV-positive status. The
subsequent example I provide illustrates the first disjunct - those who
are responsible for their own HIV-positive status. It is thus unfair to
say that I never explore whether "the mothers might themselves not have
been 'innocently' infected".

Second, you entirely misread me when you imply that I am subtly
propounding the message that "we may deny life-saving treatment to the
poor" "because "HIV is transmitted through 'irresponsible' acts that are
sexual". I consistently apply the same theoretical point to all other
non-sexual forms of irresponsibility. This should be clear from the
examples I do give, even though I do not list all the examples you do. I
accept the implications of my position for all the true examples of
irresponsibility that you provide. But my argument does not imply
anything about those people with the inability to do useful work and
possibly (depending on how we fill out the details) also those who
become destitute because of their poor financial acumen. These latter
examples sound like cases where it is not irresponsibility but bad luck
in the natural lottery that accounts for their predicament.

You obviously disagree with my view that those who are responsible for
their ill-health have no moral claim, in theory, against the state for
the provision of health-care (even though you and I agree that they
should have a claim in practice). Here you do not misconstrue my
position. I should note, however, that my view in this regard is not
that outlandish. Indeed it is your view that is in greater need of
justification. Short of the practical considerations I raise, it is
rather difficult to explain why A should be required, as a matter of
justice rather than charity, to pay B's costs for B's irresponsibility.
It is not enough to say, as you do, that the modern welfare state
extends protection to people such as B. That, by itself, is a
descriptive claim, rather than a normative one. And in any event, I
agree that we do need a kind of welfare state. I deny only that it can
be justified by a requirement of justice to bail out those who act
irresponsibly.

I fear that you may have missed a central point of my paper. I
wholeheartedly support the TAC's pressure on government to provide
antiretrovirals to those who need them. I was arguing, however, that all
the blame for the AIDS problem should not be put at the door of
government, as tempting as it may be do to just that. Government has
much to answer for, but so do all those individuals who are
contributing, through their irresponsibility, to the spread of the
epidemic. Although I am sensitive to the problems of stigma, I don't
think that this should preclude our censuring those who are worthy of
censure. In some cases it will be clear who such people are. In other
cases it may not be clear and thus our criticism may have to be of a
very general kind. This criticism, as I indicated in my paper, could be
a significant tool in combating HIV. "Blaming the blameworthy provides a
further disincentive to dangerous behaviour". Although it is crucial to
demand that government respect the rights of the people, it is also
important that the people take seriously their own responsibilities.

Congratulations on the publication of your book, and best wishes for
good health.

Yours sincerely
David Benatar

Philosophy Department
University of Cape Town
Private Bag
Rondebosch
7701

Detailed response to Benatar 18 April 2005

Response by Cameron and Geffen to Benatar's letter - 18 April 2005

Monday 18 April 2005

Dear David

Thank you for writing to us in response to our criticism in Witness to AIDS of your 2002 Lancet article. We appreciate your doing so, and also the fact that you agree that the exchange our criticism generates can be posted on www.WitnesstoAIDS.com. We affirm the spirit of academic debate you endorse.

In reply, may we start by saying that we do not consider that we have misrepresented you at all. On the contrary, we think that, colloquially speaking, we let you off lightly. This is for two reasons.

The first is that in our view a signal problem with your comment is its failure to place the debate about access to antiretroviral therapy in its proper social setting. We agree that in conditions of social scarcity, it is morally justified for the state to distinguish, as one
among a number of factors, between claimants on health care resources who are responsible for their own condition and those who are not. Where resources are scarce, and conditions constrain a simple choice between helping those responsible for their own predicament and those not so responsible, then principle suggests favouring the latter. As our discussion below suggests, though, coherently defining responsibility is not a simple matter. This is particularly true of HIV transmission where a myriad of factors affect transmission through unsafe sex.

However, when resources are not scarce, there can be no principled reason for disfavouring those responsible for their own condition. We can well imagine that punitive moralism might support the opposite conclusion, but we do not think that approach principled or respectable. The principle of respect for persons suggests that where there is no scarcity of resources, all who need them should receive them – not merely for the pragmatic reasons you cite, but for reasons arising from our common personhood.

Your comment’s first principal error lies in projecting the assumption that antiretroviral therapy is an inevitably scarce resource, and hence that distinguishing between the ‘innocently’ and the ‘irresponsibly’ infected is necessary. That assumption is unwarranted. We consider it incontestable that the world can afford to provide resources to treat AIDS, on the principle of universal access, in Africa. The statistics offered in this connection are well-worn – we mention the fact that European Union subsidies to already rich farmers exceed €1bn per day. This is not to mention the cost of unjustifiable wars, or of luxury living in resource-rich countries.

In these conditions of relative opulence, we find your premise that the South African state is poor and that it is therefore morally justified in distinguishing between the ‘responsibly’ and ‘irresponsibly’ infected inappropriate and misguided. The treatment access movement has challenged iniquities in medicine pricing and access, and health care infrastructure, in a world skewed by grotesque disproportion in allocation of resources. It did not ask – as you imply – that the South African government (a middle-income developing country) should subsidise the cost of antiretroviral therapy from the existing health care budget alone, or at a cost to other health resource claimants. It demanded readjusted resource allocation, and lowered drug prices, that would cover the costs of saving poor African lives, both responsible and irresponsible.

The debate is thus hardly whether in resource-scarce conditions discernment between those responsible for their own condition and those not would be justified. It is whether in a globalised world of historically unimagined affluence, poor Africans should be allowed to
die of AIDS. In this debate – one of the great moral debates of the last and the new century – your Lancet comment took a stand. Its stand was against broadening treatment access. We find that unjustified and regrettable.

We note that your letter to us states, ‘I wholeheartedly support the TAC's pressure on government to provide antiretrovirals to those who need them’: but we doubt a reader would so conclude from your Lancet article.

Our second reason for considering that we let you off lightly is the closing jibe of your article. We chose your Lancet piece because you have argued better than anyone we know a view that is widely held: namely, that, in resource allocation contests, moral justification exists for dividing people with HIV into those who contracted it through negligence and those who did not, and that the former are somehow not entitled to treatment. Your view is somewhat more nuanced in that you admit the practical difficulties of differentiating between the two and therefore conclude in favour of treating all.

But you also state that there is ‘something ignominious about those who are responsible for their condition, and that of others,
self-righteously joining the chorus of criticism, if not leading the choir’. We consider that not only unworthy, but itself self-righteous.
We interpret it as a thinly veiled criticism of treatment activists in general and of the TAC and perhaps one of the authors in particular
(Many ‘choir-leaders’ are HIV-positive, no doubt often because of unsafe sexual acts, which we would unhesitatingly concede were in many cases irresponsible.)

We believe Lancet readers would have drawn the same conclusion. Yet if it weren't for people with HIV, who contracted it through their own doing, there would be no treatment for anyone, even those you consider morally deserving.

To proceed to more detail. We have not misunderstood that you put mothers who could reasonably have avoided transmission in the category of ‘responsible for ... other people's HIV-positive status’. Nor does our text imply such a misunderstanding. Furthermore your view does discriminate against poor people. We do not know if you believe that the sexual nature of HIV heightens the irresponsibility, because you might be entirely consistent in your view of irresponsibility: but we believe that the argument in Witness to AIDS showed that such consistency leads to odd moral positions. (We did not dissect your argument in greater depth in the book because it is aimed at a wide range of readers for many of whom a full academic response would be inappropriate and unwarranted. Instead posed a few questions to lead readers to see that consistency in your position would lead to moral positions most people would reject.)

Your position is that people responsible for their own ill-health have in principle no moral claim to state care. It is our position that in
current conditions of world affluence this is irrelevant to a claim on state care, particularly in AIDS. We will try to show here that to
maintain your position consistently leads to odd moral positions. We will not try to demonstrate that our position is correct. However, our position is also the position of the South African Constitution and every welfare state in the world including the United States (which is often mistakenly held as an example of your view because of the rhetoric of some of its leaders; but which actually has a fairly sophisticated state-funded welfare infrastructure, albeit not as elaborate as most other developed countries.) We acknowledge that there might be some pathological instance where we might concede that some irresponsible person is not entitled to state care, but we are interested here in what usually happens in society.

We particularly reject your view that ’blaming the blameworthy’ provides a disincentive to dangerous behaviour. Quite the opposite:
stigmatisation of people with HIV as irresponsible on precisely the grounds you outline is what drives the epidemic underground at huge cost in suffering and human lives . It has arguably been the biggest obstacle to dealing successfully with the epidemic and is one of the main themes of Witness to AIDS.

Response on first accusation of misrepresentation

You say we misrepresent you by suggesting that you imply that mothers of children with HIV are undeserving of state-provided antiretroviral treatment. But it is not clear from your Lancet article why you mentioned the class of HIV-positive women with HIV-positive children who could have avoided conceiving.

A reasonable reader could infer one or more of the following: (a) the woman is undeserving of making a moral claim for antiretroviral
treatment for her child, (b) the woman is undeserving of having children and (c) the woman should be blamed (in some unspecified way) for having a child in order to discourage such behaviour. If none of these were intended we can hardly be blamed for misrepresenting you; the only option left (as far as we can see) is that the inclusion of such women in your irresponsible category was for rhetorical effect.

In our position, against the background we sketch, it is irrelevant whether the woman contracted HIV through her own irresponsibility or not; she has the right to conceive and have a child and to have access to the best health-care possible for that child, pre-, intra- and post-partum, within the state's available resources. However, in the view you propose, it is important to consider the responsibility of the woman in contracting HIV: surely a woman who contracted HIV through no fault of her own (and we use fault and responsibility here as you would use it not necessarily as we conceive it) and desperately wants a child, goes through the mother-to-child transmission prevention programme and still gives birth to an HIV-positive child has not obviously acted irresponsibly, even in your conception of responsibility? Or perhaps we underestimate the consistency with which you hold your view.

By way of illustration to see how consistently far you are prepared to take your position: Tay-Sachs is a disease that effects almost
exclusively people of Jewish Ashkenazi descent. The risk of transmission if both parents carry the genes that code for the Hex-A  protein is 25%. There is no cure for Tay-Sachs, no mechanism for reducing the transmission rate and death usually occurs within the  first three years of life. One of us knows a family that gave birth to a child with Tay-Sachs. The child died. They then proceeded to try  again, quite consciously, to have another child. The risk of transmission remained 25% (probability of transmission is independent of the status of the first child), almost the same as the risk of mother-to-child HIV transmission in the absence of an antiretroviral intervention.

Would you characterise these parents as irresponsible, or perhapsundeserving of moral claims on the state should treatment for  Tay-Sachs become available? If not, then surely you cannot characterise the mothers of HIV-positive children, who ‘innocently’  contracted the disease and wilfully conceived a child as irresponsible.


If you have not done so, we respectfully suggest you read the section ofthe book on Nontsikelelo Zwedala. She has just had another  child, perhaps because she, like many other people, loves the joy of raising children. We find it hard to fathom that she could be  judged as irresponsible if her child contracts HIV, the risk of which is much less than 25% because she is taking triple-drug therapy.

Response on second accusation of misrepresentation

You say we misread you when we imply that you promote the message that'we may deny life-saving treatment to the poor' 'because  HIV is transmitted through "irresponsible" acts that are sexual'. It is true that you use other non-sexual examples of irresponsible acts, but the proposition that other non-sexual irresponsible acts forfeit moral claims does not negate the implication that the sexual nature of HIV transmission has a particular opprobrium of irresponsibility. We believe you associated yourself with such an implication (unless you are willing to take your position to a consistent extreme).

The examples you give are traditionally thought of as irresponsible acts (and indeed they are - who could deny that smoking,  overeating, alcoholism etc are irresponsible, but we do not believe this to be linked to whether people who do this receive state- funded care, nor does the Constitution).

But let's look at examples of self-incurred injury that are not so loaded: What about serious runners? With very high probability they risk injuries that will require expensive medical treatment at some point in their lives? What about people who work too hard and  consequently suffer from depression and other stress-related diseases, or people who drive home from work in a state of fatigue and  consequently have a serious accident? Do none of these people have a moral claim to treatment?


One of us, Nathan, ate large chunks of cheese and did not increase his water intake following a kidney stone incident, in contradiction of doctor's orders. Subsequently he got another kidney stone (which might or might not have been related to his unchanged  irresponsible behaviour). If he was not lucky enough to be able to afford private care, would he have no moral claim on state care for the second incident even though he behaved irresponsibly? Seems ridiculous doesn't it? Surely eating too much cheese and not  drinking enough water is morally different and less irresponsible than having unprotected sex? But if so, why?

Which adult human being has not brought some misfortune on her- or himself at some point in life? Should we never be rescued by the  state for our self-inflicted misfortunes? How far are you prepared to take the moral austerity that arises from your position? Unless you take it all the way, it becomes inconsistent or you need to differentiate, somehow, between unsafe sex and other everyday irresponsible things that ‘normal’ people everywhere do.

Discriminating between the rich and the poor

Your view inevitably differentiates between the poor and the well-off, because only the former must encounter the resource-poor conditions in which the opprobrium of their conduct is visited with denial of care. The well-off have no need to make moral claims on the state because they can afford private care. The poor have no choice. If they don't make claims on the state for their health they remain sick or die. Your argument is thus irrelevant to well-off people (the state subsidy of medical insurance plans aside) and is applicable only to the poor.

A consequence of your argument is that well-off people can act irresponsibly and sort their own health out, but if their financial
position changes through their own incompetence and they become dependent on the state they suddenly have no right, if your view is consistently held, to make moral claims. You cannot escape this example by saying that financial positions change through the lottery of life.


Yes, some people suffer financially due to chance. But some other people make terribly poor financial decisions, perhaps through recklessness or lack of financial intelligence, and consequently lose their financial security and become dependent on state health-care.

We can take your argument that irresponsibility negates moral claims against the state to its consistent but very illiberal conclusion: if a well-off person contracts a disease through no fault of her own but becomes poor through her own financial incompetence (as opposed to chance) then she has no moral claim to state health-care because she has acted irresponsibly in order to get to the point where she needs state care.

You also leave out an example that would pose a moral dilemma for many people holding your view. Even criminals who get injured in the course of doing their illegal deeds have a Constitutional claim to state care, so why not the rest of us for harming ourselves or others doing non-criminal deeds? Are you prepared to say criminals have no moral claim to state care for injuries or diseases inflicted through illegal acts? To maintain consistency in your position, you have to answer yes, but such a view is extremely illiberal.

Furthermore, it is easy to determine if a criminal is injured through his own criminal negligence (in contrast to determining the responsibility of a person who contracted HIV), so we could in practice deny criminals, at least some of them, medical care. If you do believe that criminals are entitled to medical care, would you argue that alcoholics, over-eaters, irresponsible HIV contractors and transmitters, runners, and the normal foible-burdened mass of humanity are entitled to a lesser moral claim?

What the above examples demonstrate is that taking your argument to its consistent conclusion leads to unacceptable moral positions, which many who think that ‘guilty’ HIV contractors and transmitters should not be entitled to state-sponsored treatment would not endorse.

With thanks and our best regards

Edwin Cameron and Nathan Geffen

Latest letter from Benatar to authors

Latest letter from Benatar to authors

20 April 2005

Dear Edwin and Nathan

Thank you for your reply, disturbing though it is. What is most
troubling about it is that it further entrenches your (partial)
misunderstanding of my position. It is regrettable that you still cannot
see how you have misrepresented my argument. I encourage those following
this correspondence to read my paper for themselves (“HIV and the
Hemi-Nanny State”, The Lancet Infectious Diseases, Vol 2(7), July 2002,
p. 394). Unless they too misunderstand, they will see that my paper was
not an argument against state provision of antiretrovirals. My paper
does not, as you suggest it does, take a “stand … against broadening
treatment access”. I argued that, all things considered, the state
should provide antiretrovirals both to those who are and to those who
are not responsible for being HIV positive. At the heart of my short
paper was an argument for personal responsibility and against pinning
all the blame for the AIDS epidemic on government. I was suggesting,
implicitly, that AIDS activists be more nuanced in their moral views
about the AIDS epidemic.

You think that readers would not conclude from my article that I
(wholeheartedly) support the TAC’s pressure on government to provide
antiretrovirals to those who need them. I’m surprised at this, given
that I said in reference to HIV treatment that “the state has reason to
provide social services to all who need it” and that “a state that does
not meet these obligations is worthy of criticism …”. Moreover, even if
readers could not conclude from my paper that I support the TAC’s
pressure on government, they could not conclude from that that I am
opposed to the TAC’s efforts. I do not say more about my support for the
TAC’s campaign, because that is not the point of that particular paper.
I leave to others the endless repetition of popular views. That practice
has its value, but I prefer to express important views that are not
usually expressed, which has a different kind of value.


Scarce resources:

Towards the beginning of your reply you claim that it is an assumption
of my argument that resources to provide antiretrovirals are scarce –
because in the absence of scarcity there would be no reason to
differentiate between those who are and those who are not responsible
for contracting HIV. Your point here turns partly on an ambiguity in the
term “scarce resources” – namely between “finite resources” and
“insufficient resources”. You are quite right that if resources were
literally infinite, there would be no in-principle reason to withhold
resources even from those who were responsible for their ill-health. But
resources are not infinite. Following this recognition, “scarce
resources”, if this term is not to refer to all resources, refers to
“insufficient resources” – there not being enough to treat everybody.
Now the important point is that my argument, contrary to what you
suggest, does not presuppose a scarcity of resources in this second
sense. Even if there are sufficient resources, these still have to come
from somebody and thus opportunity costs are incurred. The (recurring)
question is whether we can really offer an in-principle argument (rather
than my pragmatic argument) for why some people should pay those costs
in order to treat others who have failed to take responsibility for
themselves. I’ll say more about how to answer this question later.


Getting personal:

In the second main point of your reply I gain some further insight into
why you have reacted so vehemently to my piece and possibly into why you
have misunderstood me. You have taken my piece far too personally. You
write that I offered a “thinly veiled criticism of treatment activists
in general and of the TAC and perhaps one of the authors in particular”.
In response, I note the following. First, my criticism of those
treatment activists, and especially those who are responsible for being
HIV positive, who want to pin all the blame for the HIV epidemic on
government is not veiled at all, not even thinly. I stand by that.
Government, culpable though it is, does not bear all the responsibility
and thus it is not appropriate to allocate all the blame to government.
But no part of my criticism was directed personally at either of you.
Although I knew the HIV status of one of you, because of your public
statement, I most certainly had neither of you in mind when I wrote my
piece. Central to my argument is that one often cannot know who is and
who is not responsible for the HIV infection of themselves or others. I
certainly never presumed to know this about you or anybody else in
particular.


Blame and stigma:

You reject my claim that “blaming the blameworthy” provides a
disincentive to dangerous behaviour. You insist that “[q]uite the
opposite: stigmatisation of people with HIV as irresponsible … is what
drives the epidemic underground”. This is partly an empirical question,
but it is also partly a conceptual one. Blaming the blameworthy and
stigmatising people with HIV are not identical. A nuanced view can
preclude stigmatising HIV-positive people while blaming that subset of
HIV-positive people who are culpably spreading the epidemic. However, it
is precisely because we often cannot know who is and who is not
responsible that one should not ordinarily sit in judgement of
particular HIV-positive people. There will be some cases where we have
no such epistemic impediment. For instance, a convicted rapist, who has
been found by a court of law to have wittingly or recklessly infected
his victim, is deserving of personal blame. Nor is there any intrinsic
problem with stigmatizing that person. Something like stigmatization, on
the expressive view of punishment, is exactly what criminal punishment
is about. It is irresponsible and inappropriate for us to tip-toe
delicately around those, for example, whom we have excellent reason for
thinking have intentionally or recklessly trodden on the vital interests
of others.


Mothers of HIV-positive children:

I turn now to your more detailed responses. You deny that you
misrepresented my position when you stated that I include “among the
‘undeserving’ … mothers of children with HIV …” In defence of your
claim, you say that it is not clear from my article why I, to use your
words, “mentioned the class of HIV positive women with HIV-positive
children who could have avoided conceiving”. I think it should be
abundantly clear to you. Here is the relevant passage from my paper:
“… many HIV-positive people are responsible for their or other people’s
HIV-positive status. In this category are mothers of HIV-positive
children who could reasonably have avoided conception. Similarly
responsible are those who ignored warnings about the dangers (to
themselves and others) of unprotected sex, especially with multiple
partners, and those who force themselves on virgins in the erroneous and
culpable belief that this will cure them of HIV”.
Understanding a simple logical operator – the disjunction – avoids
misunderstanding of this passage. A disjunction is true if one of the
disjuncts is true. The relevant disjunction here is: “… many
HIV-positive people are responsible for their or other people’s
HIV-positive status”. I then provide examples. They are examples of one
or other of the disjuncts (although I do not exclude the possibility of
a weak disjunction which, unlike a strong disjunction, can be true even
if both disjuncts are true). “[M]others of HIV-positive children who
could reasonably have avoided conception” is an illustration of the
second disjunct – namely, those who are responsible for other people’s
HIV-positive status. I concede that I did not spell that out, but I was
writing, under the severe space limitations of an opinion column, for an
educated adult audience. Given how obvious it is that “mothers of
HIV-positive children” are not necessarily responsible for their own
HIV-positive status, I would have had to have had an extremely dim view
of my readers to assume that they were incapable of comprehending an
exemplification of a disjunction.

You wonder why I even mention HIV-positive women who could have avoided
but did not avoid conception. The answer should have been clear to you.
Those women who know they are HIV-positive, who know the significant
risks of transmitting HIV to the children they bear and who could have
avoided conception are culpably responsible for producing an
HIV-positive child. Such conduct is blameworthy and should be blamed,
just as we should blame (culpable) child-abusers. I do not believe, as
you seem to believe, that parents have a right to conceive children who
stand a high chance of suffering a serious disability or disease (at
least if the right in question is a moral rather than a legal one). This
applies not only to HIV-positive woman, but equally to other conditions
such as the carriers of conditions such as Tay-Sachs. Thus your
provision of the Tay-Sachs case is not a counterexample to my position.
I apply the same judgement to it as I do to HIV. (For more on the
philosophical issues, see my paper “The Wrong of Wrongful Life”,
American Philosophical Quarterly, Vol. 37, No. 2, April 2000, pp. 175-183.)

In neither the HIV case nor the Tay-Sachs case would I suggest that the
state should withhold treatment from the child, even in principle. I
don’t know why you keep insisting that I think it should. These are both
cases of people who are not responsible for their condition. But I do
think that in both cases we may blame the parents for taking such great
risks of producing suffering children. Although prospective parents have
an understandable interest in having and rearing children, this interest
does not have absolute weight and can be outweighed by the interests of
their prospective children. Nobody has a right to have a child
irrespective of how much that child may suffer. You seem to think that a
moral right to have children is stronger than it really could be. (These
issues are treated in much greater detail in a forthcoming book of mine.)


Personal responsibility:

Much of your reply criticizes the logical implications of my claim that
ideally X should not have to pay for those of Y’s healthcare costs that
result from Y’s irresponsibility. One problem with your argument is that
you harness intuitions from non-ideal or practical cases to assault my
claim about ideal or theoretical cases. Although effective rhetorically,
this strategy is notoriously defective as a rational strategy. This is
because people have difficulty disengaging their judgements about ideal
cases from their intuitions about non-ideal cases. Put another way, it
is no use your raising intuitions about messy practical cases in order
to undermine a theoretical point, especially given that I share your
intuitions about the former.

You cite a number of cases – including serious runners who bear a great
risk of injuring themselves, hard workers who risk stress-related
disorders, those who drive fatigued and thus risk a serious accident,
those who ignore doctors’ instructions and become ill. In practice, I
share your view that all these people have a (non-absolute) claim on the
state for healthcare if they are unable to pay for it themselves. The
question is whether that claim is founded on their entitlement to care
for conditions for which they are responsible. I deny that it is. In
response it will not suffice to say, as you do, that a country’s
constitution says otherwise, because a constitution is made for the
non-ideal world. It similarly will not do to cite a principle of respect
for persons, because that principle cuts both ways. Why should X be
required to respect Y’s freedom to harm himself and then be required to
pay Y’s subsequent healthcare bills? That may respect Y, but it
disrespects X. There are very good reasons in the actual world to
require X (via the State) to pay for Y’s expenses. However, there are no
good reasons in an ideal world – a world in which, for example, we know
exactly who is responsible for causing exactly how much of their
healthcare costs.

There are further complexities that you ignore, however. To say that
ideally (although not in practice) the state has no duty to pay for
people’s costs resulting from their own irresponsibility, is not to
claim that all cases of irresponsibility stand or fall together.
Irresponsibility is a matter of degree. One can think, without
inconsistency, that ill-health that is the actual but unlikely outcome
of some action is deserving of more state attention than ill-health that
is the actual and highly likely outcome of some action. There are other
important variables too. What all this shows is that, contrary to your
assumption, one does not have to make the same judgement about all cases
of irresponsibility. However, what distinguishes the cases is not
whether they are sexual or not, as you suggest I’m claiming, but rather
other factors, such as the degree of irresponsibility. If the
transmission of HIV from mother to child, for example, were an extremely
rare phenomenon, we would need to judge witting maternal transmitters
less harshly than we should judge them given the actual transmission
rates. In short, I think you will find that I am entirely consistent in
my judgements, although my consistency is sensitive to a number of
relevant considerations that you ignore. They are thus not nearly as
hard to swallow as you suggest. Indeed, I think that they are much
easier to accept than are your views.


Rich and Poor:

Finally you charge me with differentiating unfairly between rich and
poor. “The well- off”, you say, “have no need to make moral claims on
the state because they can afford private care. The poor have no
choice.” Here again you ignore the important distinction between ideal
and non-ideal cases. That most poor people are poor through no fault of
their own is a further argument for having a hemi-nanny state in
practice. None of this undermines my in-principle remarks about whether
one person ideally has a claim on others to pay the costs of his own
irresponsibility.

You raise the case of criminals. I do not think that criminals have an
in-principle claim on the state to pay for injuries incurred in the
commission of a crime (assuming appropriate limits of the criminal law).
But again there are good reasons in practice for the state to pay for
treatment of such injuries, where the criminal cannot cover these costs
himself. Prisoners are a slightly different case from criminals who are
not prisoners. Since prisoners’ liberty is heavily restricted, the state
acts not as a hemi-nanny but as a full nanny for the prisoner during the
period of incarceration.

Conclusion:

I made a number of claims in my original paper, which I render explicit
here:

1.The state has a duty to provide antiretrovirals to all those
HIV-positive people who are unable to purchase these themselves.
2.This duty is not founded on any in-principle moral entitlement of
those who are responsible for having contracted HIV.
3.Government does not bear all responsibility for the AIDS epidemic, and
some of the responsibility lies with those who contract HIV or transmit
it to others when they could reasonably have avoided this.
4.There is something ignominious or unseemly about those who are
responsible for having contracted HIV wanting to pin all the blame for
AIDS on the government.

In saying that my article takes a “stand …against broadening treatment
access” you misrepresent me as denying rather than affirming the first
claim. That aside, we both agree on the first claim, as it seems we do
on the third one. I have now responded to each of your arguments against
the second claim. I conclude now by offering a clarification about my
final claim. In saying that there is something ignominious about those
who are responsible for having contracted or spread HIV
“self-righteously joining the chorus of criticism [of the government],
if not leading the choir”, I do not suggest that they may not engage in
such criticism, all things considered. It would be appropriate, however,
if that criticism were tempered with an acknowledgement of individuals’
personal responsibility for the spread of HIV. That acknowledgement
would not diminish government’s actual obligations. It would show more
nuance. Activists might shun such nuance, but if they do so they invite
the criticism I have offered.

With best wishes,

Yours sincerely
David Benatar Letter from David Benatar to Edwin Cameron

Dear Judge Cameron

It has been drawn to my attention that you discuss a short paper of mine
in your recent book, "Witness to AIDS". I have read the relevant section
and believe that you misrepresent my position to some extent. I write in
the spirit of academic debate and to correct any misunderstanding.

First, I never claimed that mothers of children with HIV are undeserving
of state-provided antiretrovial treatment. What I did say was that
"mothers of HIV-positive children who could reasonably have avoided
conception" are one category of those who are "responsible for their or
other people's HIV-positive status". My sentence employs a disjunction
and I am not claiming that mothers of HIV-positive children are
(necessarily) responsible for their own HIV-positive status. The
subsequent example I provide illustrates the first disjunct - those who
are responsible for their own HIV-positive status. It is thus unfair to
say that I never explore whether "the mothers might themselves not have
been 'innocently' infected".

Second, you entirely misread me when you imply that I am subtly
propounding the message that "we may deny life-saving treatment to the
poor" "because "HIV is transmitted through 'irresponsible' acts that are
sexual". I consistently apply the same theoretical point to all other
non-sexual forms of irresponsibility. This should be clear from the
examples I do give, even though I do not list all the examples you do. I
accept the implications of my position for all the true examples of
irresponsibility that you provide. But my argument does not imply
anything about those people with the inability to do useful work and
possibly (depending on how we fill out the details) also those who
become destitute because of their poor financial acumen. These latter
examples sound like cases where it is not irresponsibility but bad luck
in the natural lottery that accounts for their predicament.

You obviously disagree with my view that those who are responsible for
their ill-health have no moral claim, in theory, against the state for
the provision of health-care (even though you and I agree that they
should have a claim in practice). Here you do not misconstrue my
position. I should note, however, that my view in this regard is not
that outlandish. Indeed it is your view that is in greater need of
justification. Short of the practical considerations I raise, it is
rather difficult to explain why A should be required, as a matter of
justice rather than charity, to pay B's costs for B's irresponsibility.
It is not enough to say, as you do, that the modern welfare state
extends protection to people such as B. That, by itself, is a
descriptive claim, rather than a normative one. And in any event, I
agree that we do need a kind of welfare state. I deny only that it can
be justified by a requirement of justice to bail out those who act
irresponsibly.

I fear that you may have missed a central point of my paper. I
wholeheartedly support the TAC's pressure on government to provide
antiretrovirals to those who need them. I was arguing, however, that all
the blame for the AIDS problem should not be put at the door of
government, as tempting as it may be do to just that. Government has
much to answer for, but so do all those individuals who are
contributing, through their irresponsibility, to the spread of the
epidemic. Although I am sensitive to the problems of stigma, I don't
think that this should preclude our censuring those who are worthy of
censure. In some cases it will be clear who such people are. In other
cases it may not be clear and thus our criticism may have to be of a
very general kind. This criticism, as I indicated in my paper, could be
a significant tool in combating HIV. "Blaming the blameworthy provides a
further disincentive to dangerous behaviour". Although it is crucial to
demand that government respect the rights of the people, it is also
important that the people take seriously their own responsibilities.

Congratulations on the publication of your book, and best wishes for
good health.

Yours sincerely
David Benatar

Philosophy Department
University of Cape Town
Private Bag
Rondebosch
7701

Read the relevant section from Witness to AIDS.

Reference from 3rd para on page 196 to end of 4th para on page 197.

A further truth is that the skepticism espoused sometimes seems to be compounded by the unexpressed reluctance some of its proponents feel in endorsing treatment options for those who have AIDS. The unspoken assumption is that their plight is their own fault, and that therefore they do not ‘deserve’ treatment.

In one of the United Kingdom’s leading medical journals, a Cape Town philosopher, David Benatar, considered the contention that treatment is a basic and uniform human right. He argues that there is no moral obligation for government to treat those who contract HIV through ‘negligence, indifference, arrogance or weakness’. Only because there are many people who contract HIV through no fault of their own, and because it is difficult or impossible for the public health system to differentiate between the ‘responsible’ and the ‘irresponsible’, should treatment be made universally available.

Among the ‘innocent’ Benatar includes children who receive the virus from their mothers, haemophiliacs, rape survivors, those who contracted the virus before the ways in which it is transmitted were known, as well as those who contract the disease even though they have taken reasonable precautions.

Included among the ‘undeserving’ are mothers of children with HIV, those who do not take precautions with multiple sex partners and ‘those who force themselves on virgins in the erroneous and culpable belief that this will cure them of HIV.’ Whether the mothers might themselves not have been ‘innocently’ infected is not explored. The writer agrees that there are good reasons for the state to provide social services for those who require them ‘through no fault of their own’. By contrast, ‘there is something ignominious about those who are responsible for their condition, and that of others, self-righteously joining the chorus of criticism [about government’s failure to treat] if not leading the choir’.

The author’s conception of ‘innocence’ and ‘irresponsibility’ betrays many problems. Even if we concede that the way in which many people acquire HIV and indeed be ‘irresponsible’, it is hard to see why this should justify denying them treatment that can save them from a terrible death. Does their ‘irresponsibility’ justly condemn them to the lingering suffering of death from AIDS?

Social services are a staple of the modern state. The admitted implication of the argument is that cigarette smokers, over-eaters, and self-injuring negligent drivers should be disbarred from healthcare. But we must take its implications further. What about those who become destitute because of their poor financial acumen or inability to do useful work? Should they, too, be denied social services? What about sportsmen, or even casual runners, who choose to exercise and so develop injuries? And what about those who become sick because they do not exercise? Or those who over-exercise?

The modern welfare state extends protection to these people, even in the face of their own imprudence. The question is whether the fact that HIV is transmitted through ‘irresponsible’ acts that are sexual makes it easier for us to deny life-saving treatment to the poor. I think this is the case that is subtly being propounded. I think that sexual shame and rebuke still infests many of the arguments about ‘irresponsibility’ and ‘sustainability’. This is external stigma re-surfacing again.

The real question is: how much humanity are we willing to muster in how we respond to stigma?

The argument is complicated by the fact that in the eyes of some the poor are ever undeserving. The argument about ‘cost’ is often an expedient that seeks to justify withholding available resources from poor people who are cast as ‘undeserving’ or ‘irresponsible’, or the authors of their own misfortune.

Edwin Cameron: Witness to AIDS - 2013

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