摘要：Objectives . Using opinion data from experts, we examined the context of the argument for mandatory testing of psychiatric patients. Methods . Vignettes were distributed to experts on HIV and mental illness. Respondents were asked to provide appropriateness ratings for different hypothetical clinical decisions regarding HIV management. Results . Respondents were reluctant to impose testing without informed consent in most circumstances. The presence of risk factors or danger to another increased appropriateness ratings modestly. Conclusions . Despite experts’ tendency to emphasize individual rights, public reluctance to mandate testing is unlikely to extend to people with serious mental illness. No argument for mandatory testing can be persuasive if improved voluntary testing can achieve adequate detection rates. Voluntary testing protocols should be studied to determine which successfully identify infected individuals. Interest in the now well-documented spread of HIV among those with serious mental illness was largely confined to mental health professionals until 2 events in the late 1990s called attention to this issue in broader, policy-related discussions. The first was the 1997 passage by the New Jersey legislature of a bill that required all patients admitted to state psychiatric hospitals to be tested for HIV, even if they did not consent. 1– 3 Had a last-minute veto by a moderate Republican governor not forced legislators to include a requirement that patients give informed consent, 4 HIV testing would have been mandatory for all new admissions throughout the state psychiatric hospital system, setting a precedent for other states. The second event was the highly publicized arrest, in the fall of 1997, of Nushawn Williams, an HIV-positive man who was believed to have infected scores of women in Chautauqua County, New York, and New York City. Shortly after Williams was arrested on a drug charge, reports indicated that he had previously been diagnosed with schizophrenia. A New York Post columnist, concerned that a claim of mental disability might be used to evade legal accountability, complained, in an inflammatory lead, that “It’s crazy to put this vulture in a cuckoo’s nest.” 5 These 2 events highlight how public attention to the spread of HIV in a population not typically considered in this context can challenge previously established public attitudes and public policy. The working policy consensus developed in the 1980s carried an implicit image of AIDS patients, their motivations, and their likely responses to specific policies. Mandatory HIV testing was initially rejected as unworkable, politically insupportable, and ethically problematic. As changes in this implicit image begin to reflect new epidemiologic and therapeutic realities, the implications of older policies are not always clear. It remains to be seen whether HIV testing may be mandated for some people with serious mental illness. We examine the debate on this issue. Definitions of serious mental illness vary, 6, 7 but they typically incorporate information on diagnosis, disability, and illness duration. The category usually includes many with schizophrenia and bipolar disorder, as well as other conditions, such as recurrent major depression and personality disorders, when these produce high levels of impairment. 8 While many of those falling into this category have received inpatient psychiatric care at some point, all but the most severely ill spend most of their time in the community, where they rely on outpatient settings for services. Since the New Jersey legislation targeted inpatient admissions—and, as a practical matter, because blood is routinely drawn on admission, and mandatory testing seems more likely to be adopted in inpatient rather than outpatient settings—we primarily focus on hospitalized patients, mentioning outpatient care only when it seems relevant. Public rhetoric over mandatory testing has had an alarmist cast, but the ethical issues raised by the spread of HIV among the seriously mentally ill are by no means simple. They have been debated within the profession for over a decade. 9– 19 Without an effective treatment to offer in the first years of the epidemic, some experts felt that the benefits of early detection and treatment were insufficient to justify the intrusiveness of testing and the distress it caused. 15 Counseling and confidentiality protections in the mental health system were thought to be so inadequate that knowledge of one’s HIV status was arguably more burdensome than beneficial. 20 Nevertheless, advocates for mandatory testing argued that knowledge of a patient’s HIV status was crucial for differential diagnosis of some psychiatric complaints, 10 and that patients with severe mental illness were often unaware of their HIV risk and serostatus and thus were unlikely to seek voluntary testing. 21 It was also proposed that an exception to the AIDS confidentiality rule be made for psychiatric patients deemed dangerous. 11 Recent changes in the logic and prevailing discourse of prevention provide an important context for our examination of this issue. One early and influential prevention paradigm focused efforts on modifying the behavior of the entire population. Any less universal focus (on, for example, “risk groups”) was viewed as undesirable because it was liable to undermine the message that each individual was responsible for his or her own protection. In the words of a popular expression of the period, “AIDS doesn’t discriminate.” Targeted prevention, it was held, might also foster an “us–them” attitude by the public, weakening an already fragile social solidarity. 22 The case for targeted prevention is no longer viewed with such suspicion. In 1996, between 37% and 64% of US adults with HIV were not receiving appropriate care, either because they were unaware of infection or because they had not accessed services. 23 Yet a review of applications for Centers for Disease Control and Prevention (CDC) prevention funds found that most did not name people with HIV as a priority population for prevention. 24 In this context, efforts to decrease risk behavior by people with HIV/AIDS have acquired increased legitimacy. 25– 28 This new approach emphasizes the need to increase the number of people who know their serostatus among those already infected, who can then be brought into care and recruited as partners in prevention. This new framework has been put into action with the CDC’s SAFE (Serostatus Approach to Fighting the Epidemic) initiative 24 and its “Know Now” media campaign to encourage testing. 28 Today, early detection of HIV infection is widely encouraged. 29 New testing procedures may reduce the stress and inconvenience of HIV testing, since it is now possible to use urine or saliva rather than blood, and provide initial information on test results almost immediately (although it is still necessary to run a Western blot test to confirm a positive test, which takes time). 30 The promise of life-extending treatments can now be weighed against the adversities of testing. Given the evidence that, among those with serious mental illness, behaviors that increase the risk of HIV transmission are comparatively common, 31, 32 documented rates of HIV infection are elevated, and HIV testing practices are inadequate, some action is warranted to increase rates of HIV testing. In this study, we discuss ethical and policy issues raised by the use of mandatory testing to increase testing rates, examining testing policies in the context of the historical and contemporary social context in which they have arisen.
