Obviously, foreign experts should not be given the task of defining a particular country’s health strategy; likewise, however, countries should not disdain using the best up-to-date scientific knowledge that is available. If we accept this premise, it becomes immediately evident that the method adopted for preparing the PNDS involves totally implicit tradeoffs, and has been based on assumptions that are not borne out by modern thinking on public health issues.
More specifically, Côte d'Ivoire’s approach to the UNAIDS Initiative is completely consistent with the health strategy it has adopted over the last three decades, consisting of developing a health system copied from a foreign model, without considering whether the services provided are accessible or effective. As regards the particular problem that concerns us here, the strategy clearly favors providing treatment over combating the epidemic itself; however, a prerequisite for adopting this latter course of action would be the implementation of profound reforms in the health system, and that is exactly what it is felt must be avoided!
Nevertheless, in a situation like this one must not be too quick to use ethical considerations as a justification for rejecting the view that preventive measures targeted toward high-risk behavior are more cost-effective than treating patients by means of antiretroviral drugs. "... [certain] people believe that it is the doctor’s duty to do everything possible for the patient in front of him or her, no matter what the costs. But in a resource-constrained system ‘cost’ means ‘sacrifice’ (in this case the value of benefits foregone by the person who did not get treated). Thus ‘no matter what the costs’ means ‘no matter what the sacrifices borne by others.’ This does not sound to me like a very ethical position to be in." ([14].) "Moreover, if medical ethics include an injunction to deal justly with patients, then there has to be some weighing of the benefits to one person against the sacrifices of another. So I think that this supposed ethical conflict between the economists’ argument that costs (i.e. sacrifices) must be taken into account in every treatment decision, and the precepts of medical ethics, is non-existent, because medical ethics does not require everything possible to be done for one patient no matter what the consequences for any of the others." ([14].)
So, does a concern with justice form part of the Hippocratic legacy? If the dictates of professional ethics governed exclusively the relationship between the doctor and each individual patient, they would not be concerned with justice, and the word would not appear in the Hippocratic oath; nevertheless, the oath does contain two absolutely clear references to the idea of avoiding injustice ([15]). The doctor swears to prevent the "regimen prescribed" (i.e. his therapeutic skills) from being used to commit any injustice to patients. The problem of justice arises only when a group of patients, or a population, is the object of consideration, not just an individual patient.
Obviously, a discussion of the cost-effectiveness of interventions can take us still further. It has been shown that the annual cost of treating an AIDS patient, which varies with GNP, is very slightly higher than the annual cost of educating 10 primary school students ([2] pages 38-39). As a result, when resources are limited, providing care means denying education, and vice versa.
Such choices are extremely difficult, and in order to make them every society must be aware what values it intends to protect, and its citizens must share in those choices. The technocratic decisions that affect us simply reflect the delicate balance among the various competing interests, whether these are concerned with commercial benefits or control of the system itself, and such decisions make reference to ethics only when it suits them; i.e. only when such considerations have nothing to say about justice or the dignity of the patient. For decisions to respect the dignity of the individual, the patient has to have risen in status "from being a mere object of treatment to becoming a subject, and a partner of the doctor, with access to knowledge." (Vidal et al. [12] page 121.) Furthermore, the citizen has to have risen in status from being a mere pawn in a pretense of political life to becoming an informed participant and decision-maker.
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