In your news article on the recent Geneva meeting to discuss ethical guidelines for AIDS vaccine trials, Adrian Ivinson concluded that a "hard-won consensus" was reached. He also cited an article about the meeting that I wrote for Science, in which I reported precisely the opposite conclusion.

I well understand why Ivinson believed that a consensus had taken place—it was a confusing issue for many of the participants, some of whom may not have understood the nuances of the wordsmithing that took place. But I tape recorded the meeting and I think it was his otherwise accurate article that missed the point. Because the interpretation of what happened at the meeting could have significant ramifications, I think it's worth spelling out my evidence.

As we both reported, the contentious debate centered on current ethical guidelines that imply that people who become infected with HIV during an AIDS vaccine trial should, regardless of whether they live in a poor or rich country, receive the best proven treatment. The majority of attendees believed that the guidelines should be modified to read the "highest practically attainable standard.'' But a vocal minority would not compromise on this point, contending that all humans should be treated the same, regardless of where they live.

Near the meeting's end, Ruth Macklin did not record in the minutes, as Ivinson reported, "the consensus opinion that the guidelines should call for the 'highest practical standard'...but would stop short of demanding 'the best proven treatment.'" Macklin explicitly stated that "we did not reach agreement between those two, and therefore there was substantial disagreement." I believe confusion occurred because she did say that the group had reached consensus "on a procedural solution to the very sticky [question]."

Macklin a few minutes earlier had defined what she meant by a procedural solution. "When people disagree or are morally ambivalent, a solution is to turn it to a procedural solution, that is to say who should decide this question. We in this room are unable to decide it....But we do know that there is a procedural solution, and it's precisely the one you just named: This should be left to each country in which the trials are to be conducted. That answers the question of who should decide but it doesn't come close to answering what should be available."

At that point, Christine Grady, an ethicist who wrote The Search for an AIDS Vaccine: Ethical Issues in the Development and Testing of a Preventive HIV Vaccine, said, "How is that different?" Grady's point was that some people in the room did not think each country should be allowed to decide this question. Rather, they insisted that there be one standard for the world. From my interviews with these dissenters, I think the suggestion that they changed their thinking at the elenventh hour, as Ivinson's article implies, is inaccurate. And if their objections remained, then a substantial disagreement, not a consensus, prevailed.

See “Reply to 'Clarifying AIDS vaccine trial guidelines' “ by Adrian J. Ivinson