Just to update you about the UK story which has been rumbling along for a while
about the HIV+ mother who is breastfeeding and does not want to have her
daughter tested.  No one in this case seems to have heard of the Coutsoudis
research (The Lancet in August) which puts a whole different perspective on
*exclusive* breastfeeding and HIV transmission.

Magda Sachs
Breastfeeding Supporter, The Breastfeeding Network, UK

Story from today's Guardian,  and comment.  The cartoon on top of the comment
shows a mother breastfeeding, with a judge in fromt of her, holding up his hand
'stop'.
Behind her is the grim reaper.


The Guardian:

      Couple warned to let baby girl have HIV test   Linus Gregoriadis  Saturday
September 25, 1999   The parents of a baby girl due to be tested for HIV were
last night warned that the child could be taken into care after they failed to
keep their appointment at Great Ormond Street hospital in London.  The couple,
who cannot be named for legal reasons, were ordered in a landmark high court
ruling this month to have their five-month-old daughter tested for the virus
against their wishes.  The couple, from north London, are believed to have left
the country before a court of appeal ruling on Monday which backed the decision
of the high court's family division.  Camden council, which applied to the
courts to have the baby tested after learning that her mother was HIV positive,
offered the couple a second chance last night, but a legal expert warned that a
court order could immediately be sought to have the baby taken into care.
Jacqui Ashley, chairwoman of the Solicitors Family Law Association's children
committee, said the council could apply to the high court for an emergency
protection order to have the child taken away from them.  She added: "The
council can now institute court proceedings to have the child taken into care on
the basis that the child has suffered or is at risk of suffering significant
harm."  Last night, however, the north London council was in a conciliatory
mood. Simon White, director of social services, said: "Attempts will now be made
to arrange a further appointment which we would urge them to keep."  He added:
"If the test is then completed then we would await the results before making
further comment. Should the test then not take place, the council will have to
seek further direction from the court."  Alison Burt, a solicitor representing
the mother, would not comment yesterday on the couple's failure to keep their
London appointment.  The baby's parents, who are opposed to conventional drugs,
fear their daughter could be stigmatised for life if she is tested positive for
HIV. They believe that alternative therapies offer the best remedy for the
virus.  The mother told a newspaper: "If you take an action that upsets parents,
it will upset the child."  On September 3 Mr Justice Wilson told the high court
that the girl's 20-25% chance of being HIV-positive made the case for blood
testing overwhelming. He ruled that the parents did not have the ultimate right
to deny her possible life-saving medical treatment.  He said: "This baby has
rights of her own. This is not about the rights of the parents, and if, as the
father has suggested, he regards the rights of a tiny baby to be subsumed within
the rights of the parents, he is wrong."  The decision alarmed civil liberty
groups who fear it could lead to other local authorities intervening in
treatments for children.  Camden council applied to the courts to have the child
tested under the 1989 Children Act after the mother had told a doctor she was
HIV positive.  The authority argued that children born with HIV usually develop
Aids. It said the baby should be treated with drugs which slow down the onset of
Aids if she was found to have the virus.  The 33-year-old mother discovered she
was HIV positive nine years ago. The father, an alternative health care
practitioner, has tested negative for the virus since he met the mother in 1997.
Since giving birth, the mother has breast fed the child which increases the risk
of HIV, according to doctors.



Test is best

We have to protect the baby from its HIV positive mother. It is our duty

John Harris
Saturday September 25, 1999

The case of an HIV positive mother refusing permission for her baby to be
tested, and the subsequent court ruling that the baby should be tested, has
re-opened old debates about parental rights and responsibilities and old wounds
resulting from prejudice against those living with HIV.
In this case the mother continues to breast-feed her baby. In Britain and in
most industrialised countries it is clearly and massively wrong for an HIV
positive mother to breast-feed children who are not HIV positive. It is also
clearly and massively wrong to deny an individual early and effective treatment.
To see why this is so we have to go back a little.
Parents do not have an absolute right, either morally or legally, to the care
and control of their children. If they have such a right at all it is because
parents are presumed to be the persons most likely to know and to care about the
best interests of their children. This entitlement to look after and make
decisions for and about children, continues only so long as parents continue to
act broadly in their children's best interests and so long as children are
incapable of making their own autonomous choices.
Most of the day-to-day decisions concerning children are both inconsequential
and harmless. For more important decisions there is often no clear way of
knowing what is in fact in the child's best interests. Once children have bonded
with parents it is almost always very much against the child's interests to
interfere in family life; this is certainly true where the question arises of
separating children from their parents. This is why we - society - try to leave
parents alone as much as possible.
The risks of transmitting HIV via breast milk are considered slight, but there
is still a small but palpable risk of transmission via this route. While
HIV/Aids remains an incurable disease, in the sense that, so far as we know, the
presence of the virus cannot be totally removed, it is no longer an untreatable
disease.
Reasonably effective treatment is costly and complicated to administer, it
depends on monitoring the amount of virus (the so-called "viral load") present
in individuals at particular times. The treatment is also too problematic to
administer to anyone who doesn't need it, hence the importance of establishing
not only whether someone is HIV positive but also the amount of viral load and
the degree of natural resistance to disease in each case and on a continuing
basis.
In breast-feeding a child whose HIV status is unknown, the mother needlessly
places the child at risk unless, as in the case of many low-income countries,
alternatives to breast milk are equally or more dangerous.
Moreover, by refusing tests which would establish not only whether the child was
HIV positive but also, if positive, the degree of danger to which that
HIV-positivity exposed the child, the mother also risks denying the child
effective treatment and protection, particularly against opportunistic
infections. Here the presumption that this parent is safeguarding the best
interests of her child is clearly defeated and the state has not only a right
but, arguably, also a duty to intervene.
One might think of an HIV positive mother breast-feeding her child as analogous
to placing it on the front seat of a car without safety restraints. However, we
enter here a complicated continuum of obligations of parents to children which
has many ramifications. To what extent are smoking and excessive consumption of
alcohol during pregnancy lifestyle choices which rebut the presumption that
parents necessarily act in the best interests of their children?
In HIV/Aids it has been demonstrated that if mothers take the drug AZT during
pregnancy and deliver by Caesarean section, they substantially reduce the risk
of transmitting HIV to their children. Should such precautionary measures be
mandatory?
These are complicated questions, the resolution of which turns in part on
resolving the question of the extent to which we may violate the autonomy and
bodily integrity of a mother in the interests of her unborn child. The law, and
most moral systems, draw a distinction between the protections to be accorded to
embryos and fetuses and those due to infants.
While these distinctions are not always coherent, they do yield a workable
practical distinction which can be drawn between intervening in the free choices
of pregnant women (or of "fathers" prior to conception) and in those of parents
towards their children. Any unclarity that remains is not about whether or not
to protect children against the palpably harmful decisions of their parents, but
rather as to how far back (if at all) to extend this principle prior to birth.
We should be reluctant to interfere in parental choices. Where we do so, we need
to be very confident that such choices are not merely unwise but are clearly and
palpably calculated to cause serious harm to children.
Breast-feeding is not an important liberty; there can be no justification for
breast-feeding where breast milk constitutes a danger to the child. Purposeless
invasive testing of children is clearly also unacceptable. But where such
testing is a prerequisite of effective and beneficial treatment for serious
disease, then, in the case of those who cannot make informed choices for
themselves, we have not only a right but a duty to protect against damaging
parental choices, however well motivated.
• John Harris is Sir David Alliance Professor of Bioethics at the University of
Manchester and currently directs a major project for the European Commission on
Communicable Diseases and Lifestyle Choices

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