testing for syphilis and hepatitis B provided a model. For newborns, the wide-scale and broadly accepted tradition of screening for congenital conditions, such as phenylketonuria (PKU), served as the standard.1 The promise—although based on only minimal clinical evidence—that early intervention might protect the fetus or at least enhance the life prospects of babies at risk for HIV infection was used to argue against ethical concerns about the coercive identification of infected women, most of whom were black or Hispanic, and the related dangers of exclusion from housing, social services, and health care itself that might be imposed on women and infants so identified. In the spring of 1991, evidence of the effectiveness of initiation of prophylaxis against Pneumocystis carinii pneumonia in HIV-positive infants who had yet to develop symptoms but had CD4 cell counts of fewer than 1,500 further fueled the arguments by pediatricians for newborn testing (Centers for Disease Control, 1991). However, none of the arguments overcame the opposition to mandatory testing by many health and other experts. In the words of a special committee of the Institute of Medicine (Hardy, 1991:1-2):
History has revealed that mandatory screening programs are frequently inflexible, often because they are legislated, and that program modification over time proves difficult. … Voluntary HIV screening (with specific informed consent) permits greater flexibility than mandatory screening in accommodating change. The committee opposes any mandatory newborn or prenatal screening program (other than anonymous screening for surveillance purposes).
In 1991 the controversy over the risk posed to patients by HIV-infected health care workers who undertake invasive procedures reopened the question of testing medical personnel (Barnes et al., 1991). Some people argued that testing was not an issue because the risk of HIV transmission is extremely small. However, others believed that infected clinicians had a duty to inform their patients about their own HIV status or to seek advice from colleagues about withdrawing from the practice of invasive procedures; for them, testing was an issue that had to be confronted. Although some believed that mandatory screening of health care workers was not called for, most who believed that infected clinicians had a moral and professional duty either to inform their patients regarding their serologic status or to desist from invasive procedures held that the "duty to inform or withdraw" imposed a correlative responsibility on institutions to identify. Hovering over the entire debate has been the recognition that any policy of screening for health care workers would inevitably produce pressure for the mandatory testing of patients as well. (For further discussion of this subject, see "Confronting Occupational Risks" and "HIV-Infected Practitioners and Risks to Patients" in Chapter 3).