Catholic Medical Quarterly Volume 62(2) May 2012, 31-42
The centrality of the person in the prevention and treatment of HIV disease: Exploring new frontiers
Pontifical Council for Healthcare Workers, Vatican 27-28 May, 2011
Dr. Edmund P. Adamus. Director of Pastoral Affairs, Archdiocese of Westminster, England.
The remit of the Department of Pastoral Affairs is to support and resource marriage and family life, care of the vulnerable and marginalized and the dignity of the person in medical and bio-ethics. Since May 2010 we have been exploring the possibility of establishing a diocesan Caritas agency to enhance and expand our resources. In the field of HIV/AIDS a religious of the Daughters of Charity was employed part-time for outreach work until 2008. This was followed by a period of review. One of the main conclusions was to establish a team of priests willing to be available for anyone affected by HIV/AIDS seeking spiritual/pastoral support, or the sacraments from someone other than their local priest. Ten priests were approached including two hospital chaplains, an ethnic chaplain from Africa and a qualified psychotherapist; the latter to assist with enquirers needing specialist counselling. In due course the team gathered for sessions of in-service education from a Catholic professional public health official with expertise in theology and psychology as well as a day of recollection.
Due to the disproportionate and negative media attention on the issues of HIV/AIDS prevention and the Catholic Church in 2009 and 2010, we decided to delay launching the service, partly to avoid the risk of unhelpful media attention in the build up to the Papal visit but also to await for more guidance for the whole Church from the Holy See. It was suggested at the press conference for the book “Light of the World,” that ‘many things must be rethought and expressed in new terms'  but what are those terms?
A key component of all our work has been the promotion of authentic human sexuality in the light of Blessed John Paul II’s catechesis, a theology of the body. In our support of marriage preparation and enrichment with a keen focus on natural fertility awareness, couples have shared their dismay, indeed a sense of deep indignity at the implication that it is impossible, unhealthy or a suppression of masculinity and femininity to abstain from sexual intercourse. They tell us that the commonplace notion of compulsion in respect of sexual intercourse irrespective of one’s physical health is deeply insulting, for true love cannot be encompassed within the concept of compulsion.
So what of the approach in supporting those with HIV? Theology of the body, in that it concerns the human body, informs those with physical and psychological ailments and their carers. One of the problems with being a patient is a threat to losing one’s subjectivity. A tension exists between remaining a “subject of one’s illness” and becoming an “object of treatment.”  Healthcare encompasses spiritual well being, and is a mutual complementarity of personhood between healer and patient, based upon the reality that we are created in the image and likeness of a relational, triune God. This sense of personhood is characterised by relationships of love, acceptance, and above all of complete self-donation.
The Team is acutely aware of being sensitive to the disposition of the person with HIV who wants pastoral support, for as the recipient of this care, he or she is actually being a GIFT for the pastor, whereby their vulnerability is an occasion for service. Such reciprocity may shed light on how the social stigma associated with HIV can be transfigured in to a concrete sharing in the suffering of the Saviour. The spiritual guide is a gift of self to the one with HIV by viewing with them the pain of stigma through the prism of Christ’s shame and humiliation. Hopefully this process might erode the need for anonymity paving the way for the one with HIV to be cherished by the worshipping community. This anthropological reality is confirmation of the communion of persons. Furthermore if the sickness of HIV afflicts the life of the primary agents of evangelization, i.e. spouses; then it is the serodiscordant couple to whom we must be especially attentive. This is Ecclesia de Trinitate, that is to say, reflecting the face of Christ in her own and ‘giving her life concretely in the martyrdom of charity.’ 
Salvifici Doloris, no. 29, talks about suffering being present “in order to unleash love in the human person.” The priest, who encounters the emotional, psychological and spiritual suffering of those with HIV, is called to show the biblical compassion of the Good Samaritan. (In Hebrew, rahamin)  This love is likened to that of maternal care of the womb. When we ponder on the physiological role of the mother towards her unborn child to nourish but also prevent toxins from harming the child; then the parable brings in to very sharp focus the fiduciary duty of the pastor to garnish his care with pastoral teaching of unequivocal integrity in the realm of sexual ethics. As Pope Paul VI eloquently put it in Humanae Vitae n29:
It is an outstanding manifestation of charity towards souls to omit nothing from the saving doctrine of Christ.”
This concerns our consistency in exercising the spiritual works of mercy as well as the corporal ones. For the marriage afflicted with HIV, it means assisting spouses, with prudential patience, to illumine the conscience to embrace sexual abstinence as a unique expression of the wisdom of Colossians chapter1:24 “I fill up in my flesh what is lacking to [not in] the sufferings of Christ for the sake of His Body, which is the Church.” 
It is spiritual direction inviting one to say: ‘I have been crucified with Christ. It is no longer I who live, but Christ who lives in me’ Gal. 2:19. And in the context of the serodiscordant couple such martyrdom of love is infused with a sacrificial power to ‘release formidable energies.’ (Familiaris Consortio n43) [7 ]
All spouses have a unique mission to reverence the imago Dei inscribed into their marital witness. Perhaps, above all others God calls the serodiscordant couple to remind the entire Church of the need for complete self-donation. 
Paragraph 15 of the encyclical Humanae Vitae states;
the Church does not consider ” illicit the use of those therapeutic means necessary to cure bodily diseases, even if a foreseeable impediment to procreation should result [.] provided such impediment is not directly intended,”
It is suggested that the serodiscordant couple who use a condom may intend first and foremost to prevent or minimize the risk of infection not to contracept. However the encyclical speaks of means that will affect a “cure.” A condom can hardly be described as having curative powers nor can it have parity with the medicinal effects of anti-retroviral drugs. A more truthful pastoral response is to support the serodiscordant couple in sexual continence for the real preservation of their entire health. Gaudium et Spes n51 insists that marital intercourse must “preserve the full sense of mutual self-giving and human procreation” and that subjective intentions cannot make right what is objectively wrong in this area.  According to Bishop Anthony Fisher;
“..this is not to impugn the faith of the spouses or deny their desire to be united, fruitful and graced. But by rendering sexual acts non-marital, the use of condoms renders them ineffective for signifying those things. Just as a person who puts a consecrated host in a pyx does not receive Holy Communion – even if he does this reverently – so a couple who use a condom exclude the giving and receiving required for fides, proles and sacramentum.”  (i.e. unity, family and God)
The integrity of the union is not diminished by a life without sexual intercourse. So long as the union was consummated at some earlier point even if in an extreme case it was only once: it still constitutes the domestic church. [11, 12]
However as Matthew Hanley eloquently puts it; ‘the seemingly “common sense” presupposition that condoms will decrease infection rates does not easily give way to the common sense observation that promoting devices capable of reducing risk encourages people to take more risks.’ It is an opinion shared by Bishop Anthony Fisher who also states;
“Providing information on how to make a behaviour safer, naturally communicates implicit approval or tolerance of the behaviour itself, especially in a culture which tolerates such behavior.” 
In the formation process for the clergy team we have reflected upon the wisdom of several moral theologians [15, 16] including Fr. Tadeusz Pacholczyk a leading ethicist in the US who states:
“A husband who has AIDS would never want to subject the wife he loves to a potentially death-dealing act, which is what sexual intercourse could become for them, even while using a condom (which has a failure rate). Would it be a loving act to subject her to the risk of a possibly fatal encounter, even for something as beautiful as conjugal intimacy in marriage? .. Learning to love each other in different and non-genital ways is, an integral component of every successful and enduring marriage, and an HIV infection merely brings greater urgency and immediacy to the task.” 
Our project will try to convey to sceptics that the Church actually holds the human person in higher regard, and that what it proposes is humane, possible in God’s grace and fulfilling. It is a response to the ardent plea of Pope Paul VI to “create an atmosphere favourable to the growth of chastity so that true liberty may prevail over license and the norms of the moral law may be fully safeguarded.” (HV, 22)
I would like to conclude by recalling that the holy dignity of offering our suffering to God especially through joy-filled chastity is much more than any technical and clinical decision.  To seek pastoral solutions within the moral law to support authentic human sexuality especially in marriage is more vital now than it ever was. Many might be critical of the Church on this, accusing it of unnecessarily picking its way through such pedestrian problems, nevertheless such efforts deserve our reverence and love. The Lord Jesus comes to us in his Church, and each pedestrian action of Christ as he walked this earth was not as significant perhaps as his sermon on the mount, his countless miracles or his sacrifice on Calvary. And yet when he picked his way through the crowded, twisting streets of Jerusalem on any ordinary day, he rendered it extraordinary and his footsteps left the ground holy where he walked. So too, I pray his healing love is reflected in these humble yet significant aspirations, deliberations and actions to uphold the absolute dignity of persons infected as well as affected by HIV/AIDS. 
To assist the priests in their discernment about joining the team we posed some likely questions and answers for them:
- How long would I be involved in this initiative? However long or short you wish
- Would I be expected to see people indefinitely? No. Anyone needing long-term support would be directed to those agencies/groups which would benefit them
- What would be the extent of my ‘case-load’? Entirely at your discretion and subject to demand which would be managed by liaison with the dept and other team members
- Who can I turn to for advice? The dept will be happy to supply you with relevant literature/guidance on the subject, as well as contact details for professionals.
- Would I need to report on anything? No, but the Pastoral Dept welcomes any comments or informal feedback on the initiative at your discretion.
- Is it possible to support people via email if they prefer? Yes. The crucial issue is that they FEEL welcomed and genuinely supported by the Church.
- How will the availability of the priest be made known? Via the usual diocesan communications so that people can approach any one of the team with anonymity. Some referrals may come via the dept, though it is not envisaged that there will be many.
- Should individuals be encouraged to seek support from their local clergy and parish community? Certainly, if they feel it is possible and part of an overall process but they must not feel under pressure to do so.
- Will the team members be expected to liaise with external agencies working in the field of HIV/Aids? Any collaboration with external agencies or neighbouring dioceses will be coordinated by the Pastoral dept as and when the need arises so as not to add to the workload of the clergy involved.
- One is reminded of the comments by Cardinal Christian Wiyghan Tumi,
Archbishop of Douala, Cameroon, at the International Eucharistic
Congress in Quebec City on June 2nd 2008;
“The Eucharistic person is a dangerous person, burning with the fire of the spirit and whose only purpose is to extend that fire and to become fire for others. This person is a person of daring, a person of confrontation, a person of radicalism, gospel radicalism, and of the absolute. The person of the Eucharist is a person who never compromises - who only opts for God, opts for humans. Such a person is not welcomed by those who do not want to hear his message, but nevertheless has a Christian obligation of charity to live and speak the truth. The person of the Eucharist who loves, disturbs everybody, shakes everybody and might even give them a bad conscience or the feeling of a bad conscience. Our vocation as witnesses to the gospel is to give others a bad conscience so that the other person knows how to distinguish bad from good, evil from good and when a person does evil their conscience accuses them.” Cardinal Tumi received a standing ovation.
- This does not mean that Christ’s passion was insufficient – the Greek word hysterema ‘what is lacking’ stands in opposition to ‘what is superadundant’ periseuma –Just as God’s being superabounds in letting us be finite alongside the Infinite, and God’s omnipotence does not obliterate but rather creates our freedom, so also the plenitude of Christ’s redemptive sufferings do not suppress the need for our sufferings but give them a new value.
- Rick and Barbara Wise, a non-Catholic serdiscordant couple founded www.wise-choices.org, a ministry dedicated to encouraging young people to save sex until marriage. Barbara has HIV and they have refrained from intercourse for over 17 years. They kept silent for 9 years but now WiseChoices has spoken to over 80,000 people in 22 US states and 3 foreign countries. Their video has been translated into Spanish, Russian and Hungarian.
- A study of 520,000 couples (where over 730,000 spouses were hospitalized at least once over a nine year period of observation) concluded that the hospitalization of a spouse is associated with an increased risk of ill-health and even death of the care-giving spouse. Is this not a manifestation that THEY ARE INDEED NO LONGER TWO BUT ONE FLESH IN THE SPIRIT? Is this not the primordial COMMUNIO PERSONARUM? Cf. Nicholas A. Christakis and Paul D. Allison. Mortality after hospitalization of a spouse. New England Journal of Medicine 2006; 354:719-30.
- This is why Wojtyla/John Paul used 'bracketing' as a means to suspend
judgement and look at, and only at, a specific thing – “the act - in
relation to” – as a way of looking at phenomena and experience without
deforming the interpretation because all the relations have been
declared and acknowledged. i.e. The ecclesial/trinitarian nature of the
marital act open to life. And in Veritatis Splendor, n103 & n105;
“It would be a very serious error to conclude that the Church's teaching is essentially only an `ideal' which must then be adapted, proportioned, graduated to the so-called concrete possibilities of man, according to a balancing of the goods in question. [.] such a policy corrupts the morality of society as a whole, since it encourages doubt about the objectivity of the moral law in general and a rejection of the absoluteness of moral prohibitions regarding specific acts, and it ends up confusing all judgements about values.”
- In territories where Catholics have no access to the sacraments does that make them less Catholic because they have no clergy to minister to them? We wouldn't send them unconsecrated altar breads to eat so that they can mimic the experience of Holy Communion, so why would we encourage serodiscordant couples to condomise their sexual lovemaking under the pretense of sacramental matrimonial grace. Just like the altar bread cannot be the Real Presence of Christ without the words of institution, neither can condomised intercourse effect grace or signify nuptial blessing without the important distinguishing mark - which sets the conjugal act apart from all other forms of physical expression of tenderness- of the deposition of semen which renders it the expression of full self giving. * The persecuted Church deprived of sacraments is still the Church. The serodiscordant faithfully married couple who abstain is still the domestic church. If there is such a thing as baptism by desire, can it not be deemed possible for spouses to attain a kind of one flesh union in the spirit by desire? After all, if as Christ says it is possible for a man to look upon a woman lustfully and commit adultery with her in his heart (including a husband towards his wife according to theology of the body) then it must be equally possible by virtue of the interior gaze for spouses to look upon one another in such purity of heart and love [without sexual intercourse] that they achieve the same levels of intimacy possible in and as a consequence of the sexual act. *Decretum Circa Impotentiam quae Matrimonium Dirimit. CDF May 13th 1977
- Cf “..since the bond which comes into being by the will of the spouses constitutes the juridical reality of the biblical "one flesh" (Gn 2: 24; Mk 10:8; Eph 5:31; cf. Can. 1061 §1), and its continuing validity does not depend on the subsequent conduct of the couple during their married life.” Address to the Tribunal of the Roman Rota, 2009.
- Dec. 9, 2010 (Zenit.org) M.Hanley: "Affirming Love,Avoiding AIDS: What Africa Can Teach the West."
- Anthony Fisher, 'HIV and Condoms Within Marriage', Communio: International Catholic Review, Summer, 2009, p.7
- "..one can ask oneself if it is truly an act of love for an HIV + [person] to have relations with a healthy person. Like a sufferer from tuberculosis, from pulmonary plague or cholera, an HIV+ [person] knows that he can infect his partner. So if one really loves someone, one is going to avoid [...] running the risk of death. And it is well known that condoms are not [totally] reliable… In morality the principle of the lesser evil is very simple. It consists of saying that when one is confronted by two inevitable evils, one must choose the lesser of these two evils...To have relations with an HIV [infected person] and trying to protect oneself with condoms is not something inevitable. There is always the freedom to have or not have this type of relations." Interview by Arianne Rollier Rome June 2006 (emphasis mine)
- An opinion shared by the eminent non-Catholic scientist, Dr. James McEvoy, of Yale University Chemistry Department, who concludes that “the Catholic Church's recommendations in Africa, however irritating they might be for many Europeans, are [.] medically correct.” Letters; The Spectator magazine p.28.14th May 2007
- ‘A mutual giving is worlds apart from a mutual taking. What people do not know when they go to the altar is that the best wedding party is a bevy of virtues: humility, detachment, self-control, the habit of giving; not to speak of a bevy of arts and habits, including the habit of laughter. Chastity cannot exist alone. She must have her entourage. From such pleasant company she can retire to her bridal couch and understand the words of the Sarum rite: “with my body I thee worship”. If a person is worth dying for, she is worth everything short of it.’ Extract from an Advent meditation of the Bishop of Aberdeen, Scotland. 8th December 1956 taken from The Tablet archive.
- “The assent of the intellect, [..] does not remain without fruit, because it purifies the will and predisposes the reason to a more attentive consideration of the question and permits, in the final analysis, the culling of the motives of perplexity that seemed invincible but in reality were dictated by prejudices.” =y ‘On Continuity.’ Francesco Arzillo.
- “Impotence and Sterility – A Recent Decision of the Holy See. Implications for Medical Practice.” Thomas J O’Donnell SJ. L’Osservatore Romano (English Edition) 5 January 1978, p.9.