component of the program, it did not affect the mandatory prenatal counseling component for state-regulated facilities. Since the vast majority of HIV-positive women receive prenatal care in these facilities, many pregnant women still are required to receive counseling about perinatal transmission.

Reaction to the New York Legislation

Reaction to the New York legislation was offered by several designated respondents as well as by workshop participants. Most disagreed with the New York legislation and were skeptical about the effectiveness of mandatory newborn testing in reducing perinatal transmission.

Dr. Amitai Etzioni, a professor at George Washington University, was the only respondent to offer qualified support for mandatory newborn testing (Etzioni, 1998). He framed the question of mandatory versus voluntary newborn testing as one that weights the potential harm to the mother, in terms of her privacy and autonomy, against the interests of the child. He preferred voluntary testing, performed in the prenatal setting and with consent, to mandatory newborn testing. But he did not feel that voluntary testing alone would completely eliminate the problem of perinatal transmission because a small proportion of women would not agree to be tested. He emphasized that privacy is not an absolute legal right and there are circumstances in which legislation is justified to violate privacy concerns. He viewed mandatory newborn testing as appropriate because the interests of the newborn should take priority; however, at the same time, he argued for policies to improve counseling when test results are released, to increase voluntary prenatal testing, to increase penalties against unauthorized disclosure of test results, and to increase penalties for discrimination against those who test positive. He likened New York's conversion from the anonymous to the mandatory program to a clinical trial that is halted because early signs of success make it unethical to continue the study in a blinded fashion.

Dr. Alan Fleischman, with the New York Academy of Medicine, articulated his fervent opposition to the New York legislation. He disagreed with the premise that mandatory testing prevents HIV transmission for two fundamental reasons: (1) test results are not available in sufficient time for the mother to avoid HIV transmission through breast-feeding, and (2) mandatory testing discourages women from obtaining prenatal care from a health care system they see as punitive.

Dr. Fleischman argued instead that mandatory testing may increase the likelihood of HIV transmission. He suggested that the specter of mandatory testing of newborns discourages obstetricians from counseling women in pregnancy, when prevention would be far more effective, because of the assurance that the newborn eventually will be tested. Likewise, pediatricians may also be discouraged from advising women against breast-feeding when the newborn's HIV status is unknown.

Dr. Fleischman also presented results from his national surveys of neonatologists' attitudes towards HIV-infected babies. The surveys revealed neonatologists,



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