This paper was published in Bioethical Inquiry (2009) 6 (2): 235-7
    
    Challenging the status quo
    Dominic Wilkinson MBBS MBioeth
    Affiliations: Oxford Uehiro Centre for Practical Ethics, The University of Oxford; The Ethox Centre, Department of Public Health and Primary Health Care, The University of Oxford, Address for correspondence: Oxford Uehiro Centre for Practical Ethics, The University of Oxford, Littlegate House, St Ebbes, Oxford OX1 1PT email: dominic.wilkinson@gtc.ox.ac.uk Tel: +44 (0) 1865 286 888 Fax: +44 (0) 1865 286 886
    
    In this issue Harold Jaffe argues that the paradigm for human immunodeficiency virus (HIV) testing should change.(Jaffe 2009) Instead of offering HIV tests to patients who are suspected to be potentially infected following informed consent, testing would be routine in populations with elevated risk – unless the patient declined. Such a policy has some precedent. As Jaffe points out, opt-out testing is already the norm for prenatal testing of pregnant women in the UK, and has recently been embraced as a general approach to testing for HIV by the Centers for Disease Control and Prevention (CDC) in the United States. But a lowering of the consent requirement for HIV testing could be seen to threaten patient autonomy. After all, the reason to switch to optout testing is that more patients will end up being tested. Some of this increase may relate to more patients being offered testing. But there are also likely to be some patients who would have declined consent for testing if offered in the conventional way, who end up being tested under an opt-out system. Such patients might not understand what testing involves, or may not feel able to refuse the test. Why then should we make the change? Jaffe presents two main arguments in favour of opt-out testing.(Jaffe 2009) Identifying patients as being HIV positive enables them to receive antiretroviral drugs. It reduces their risk of HIVrelated morbidity and mortality. It would be better for patients if they found out their HIV status than if they remained ignorant. This is the paternalistic argument for opt-out HIV testing. Paternalism in medicine has a bad name. But there are different degrees of paternalism. Optout testing is at worst a form of mild paternalism since patients are still given the option of declining to be tested. Those who have strong preferences not to be tested are likely to refuse. The main difference is that individuals who are
    
    equivocal about testing, or somewhat fearful of testing are more likely to end up being tested. And this same degree of paternalism operates for almost all other diagnostic tests (with the exception perhaps of some genetic tests). The doctor identifies and orders investigations or screening tests that are believed to be of benefit. Consent is assumed. The other argument for opt-out testing is utilitarian. This strategy is likely to benefit other individuals in society. Identifying patients as being HIV positive leads to reduction in highrisk sexual behaviour, and anti-retroviral treatment reduces viral load. Both reduce transmission of the virus. The utilitarian argument for opt-out testing is particularly powerful in parts of the world where there are very high rates of HIV. The only way to stop the epidemic of HIV is to reduce the “case reproduction number” to less than one.(Granich et al. 2009) Modelling suggests that a policy in sub-Saharan Africa of universal voluntary testing and early treatment would prevent millions of deaths from HIV.(Granich, Gilks et al. 2009) The question of opt-out testing in HIV has obvious analogies with another debate in public policy – that of organ donation consent. The UK Organ Donation Taskforce has recently considered a move to opt-out consent for organ donation in the UK, (Organ Donation Taskforce 2008) and other countries including New Zealand, Australia and the United States continue to debate the issue. There are paternalistic reasons for such a policy. 65-95% of people in the UK are in favour of donating their organs after death, though only 25% sign on to organ donation registries.(Organ Donation Taskforce 2008) An opt-out system would respect the wishes of more people about the use of their organs. And there are strong utilitarian arguments in favour of such a policy.
    
    Author’s Preprint 290709; The final published version of this article can be found at http://dx.doi.org/10.1007/s11673-009-9148-3
    
    This paper was published in Bioethical Inquiry (2009) 6 (2): 235-7
    
    An opt-out system of organ donation consent would be likely to lead to a 25-30% increase in organ donation rates.(Rithalia et al. 2009) This could correspond to approximately 650 extra organs in the UK each year. Given the strong reasons in favour of opt-out systems for HIV testing and for organ donation why is there such reluctance to contemplate them? Part of the explanation may be a phenomenon known as the status quo bias, a serious and widespread cognitive bias in decisionmaking.(Samuelson et al. 1988, ; Bostrom et al. 2006) One way of countering this bias is to imagine that the status quo were reversed.(Aberegg et al. 2005) Imagine that the current consent processes for HIV testing were on an opt-out basis. Do the concerns about possible harms from opt-out testing provide sufficient reason to make a change to an opt-in consent given the benefits that would be lost? It is hard to believe that they would. Ironically, the status quo bias is also part of the reason why opt-out consent leads to higher testing or organ donation rates. Given the same preferences and reasons, patients are more likely to take up an alternative when it is presented as the default than when it is an active choice.(Samuelson and Zeckhauser 1988) This bias makes it hard for individuals to do what they have most reason to do. We can reduce the effect of the bias by the way in which choices are presented. Given that there are strong prudential and moral reasons to undertake HIV testing or to agree to donate organs after death it makes substantial sense to present these as the default position. Jaffe makes a strong case for rejecting AIDS exceptionalism, and offering HIV testing on the same basis as other diagnostic and screening tests.(Jaffe 2009) But he also identifies the potential costs of such a policy. Individuals could be subject to stigma or discrimination as a result of being diagnosed with HIV. Some patients may be diagnosed with HIV, but be unable to access anti-retroviral treatment. These are important concerns, and there are good reasons to mitigate such harms. But they should not stop us from challenging the status quo and moving to an optout approach to testing for HIV.
    
    REFERENCES Aberegg, S. K., E. F. Haponik and P. B. Terry. 2005. Omission bias and decision making in pulmonary and critical care medicine. Chest 128: 1497-505. Bostrom, N. and T. Ord. 2006. The reversal test: eliminating status quo bias in applied ethics. Ethics 116: 656-79. Granich, R. M., C. F. Gilks, C. Dye, K. M. De Cock and B. G. Williams. 2009. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet 373: 48-57. Jaffe, H. 2009. Increasing knowledge of HIV infection status through opt-out testing. Journal of Bioethical Inquiry. Organ Donation Taskforce. (2008). "The potential impact of an opt out system for organ donation in the UK: an independent report from the Organ Donation Taskforce." Retrieved 7th March, 2009, from http://www.dh.gov.uk/en/Publicationsandstati stics/Publications/PublicationsPolicyAndGuida nce/DH_090312. Rithalia, A., C. McDaid, S. Suekarran, L. Myers and A. Sowden. 2009. Impact of presumed consent for organ donation on donation rates: a systematic review. Bmj 338: a3162. Samuelson, W. and R. Zeckhauser. 1988. Status quo bias in decision making. Journal of Risk and Uncertainty 1: 7-59.
    
    Author’s Preprint 290709; The final published version of this article can be found at http://dx.doi.org/10.1007/s11673-009-9148-3

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