Choice: HIV/AIDS and Infant Feeding

by Cathy Liles, MPH, IBCLC USA

"In order to effectively stop the spread of HIV from mother to child while at the same time protecting the health of all other infants…the choice of feeding option is the woman's by right."
1997 WHO, UNICEF and UNAIDS
(the Joint UN Programme on HIV/AIDS)

I have become increasingly concerned about the concept of choice. What does this really mean?

If a woman has not been tested, then she doesn't know anything and the choice is made for her -- she doesn't get to make the choice. If a woman is tested, and treatment is unavailable, is the use of testing moral and ethical? Then she has a choice to make, but is it a real choice?

If a women is tested and is HIV+, and further testing is unavailable -- is this ethical for the woman who has a false positive? Or for her children? She also has a choice to make, even though it is based on false information. How will her choice influence the optimization of health for her family?

If a woman is HIV+, and is offered a choice to breastfeed or formula feed and formula is not available, acceptable, feasible, affordable, sustainable or safe, does she really have a choice? Is it ethical to suggest she does? If her child dies prematurely from use of formula rather than later from AIDS, has she made an informed choice?

What constitutes informed choice?

If the experts can't even agree on the facts pro and con, how can they be reasonably communicated to an unknowing mother? If you substitute the right to choose from formula feeding to the right to choose an abortion, you will find highly vocal supporters on both sides and the ethics of the issue come into clear focus.

In an ideal world, every woman would be educated and capable of understanding a complex analysis of risks in making a decision like this -- a support of true human rights. But the world is not a perfect place and so often times women rely on the recommendations of the health experts and their health care providers. They do not act in accordance with their own judgment and discernment, adopting instead the opinions of those they respect.

As such, it is uncertain whether shifting the burden of choice to mothers who are ill-prepared to evaluate the real consequences of their actions is an ethical or moral thing to do. Asking these mothers to make a choice when there is not a community network, healthcare or resources available to support their choice, is not an ethical or moral thing to do.

As long as the focus is on prevention of mother-to-child-transmission rather than optimization of infant health that takes into consideration social, cultural, nutritional, immunological, emotional, economic and political influences - choice is an elusive concept which will be translated into a euphemism for "we recommend formula."

Copyright ©2001 AnotherLook and Cathy Liles - All Rights Reserved
Permission is granted to print and distribute this position paper in its original form.