Blogs Stuart Rennie:
As every student of research ethics is now obliged to know, the 1997 clinical trials of ZDV were a watershed moment in the history of the use of placebos in international biomedical research. For those who skipped that class: US clinical trials in 1994 showed that a long-course of ZDV (zidovudine) reduced mother-to-child transmission of HIV from 25% to around 8%. Given that ZDV was too expensive for use in low-income countries with the highest HIV prevalence, clinical trials were conducted in Thailand and Uganda comparing a less-expensive, short-course of ZDV with a placebo control, i.e. a group of HIV-positive pregnant women who were given nothing to prevent the virus being transmitted to their infants. The researchers knew if they used long-course ZDV instead of placebo they could prevent some children in the trial from being infected with HIV. But they did not.
And that is when all Helsinki broke loose. But forget the well-known controversy about the standard of care appropriate for placebo controls for a minute. The ZDV trials had another, less publicized effect: it provoked calls for enhanced bioethics capacity in low-income countries. Reports such as the Nuttfield Councils The Ethics of Research Related to Health Care in Developing Countries (2002) concluded that the ethical review boards of developing countries due mostly to poor funding and inadequately trained staff may fall short of promoting high ethical standards for human subject research. Aspiring bioethicists from resource-poor countries must be trained; local ethics review must be strengthened.
The past eight years has witnessed a series of high-profile, well-resourced initiatives to do just that. Since 2000, The Fogarty International Center (a division of the NIH) has offered grants to institutions providing bioethics training programs to developing world scholars, including training in ethical review of research. The primary objective of WHOs Strategic Initiative for Developing Capacity in Ethical Review (SIDCER), launched in 2002, is to contribute to human subject protections globally by developing local capacity for ethical review of research involving human subjects and for developing policies on the ethics of health research. Just this month, the European Union unleashed NEBRA (Networking for Ethics on Biomedical Research in Africa) on the world, which aims to foster biomedical research ethics committees in Africa.
Some bioethicists may straightforwardly celebrate this development. After all, there was a gnawing suspicion that the conspicuous increase in biomedical research activity over the last decade in developing countries was motivated by the relatively easy subject recruitment, low overheads, and lax ethical controls. From this perspective, the building of local ethics review capacity can be seen as a way of bolstering protections of research participants and redirecting research priorities towards diseases afflicting resource-poor communities. And besides, if biomedical research has gone global, why shouldnt bioethics go global with it? If bioethics is a lovely thing, why not share the love? But it seems that this recent globalization of bioethics may also have its dark side.
Some aspects of the dark side are brought out forcefully in a 2004 editorial of Bioethics helpfully entitled Bioethical Colonialism? by Ruth Chadwick and Udo Schuklenk. After remarking on the extravagant funding lavished on bioethics relative to other applied ethics domains (like business ethics? oh, never mind), the authors state that the funding of bioethics training for developing world grantees come with strings attached.
The strings attached: budding research ethicists in the developing world have to undergo training in institutions of the rich north, thereby implying that there is insufficient intellectual and personnel capacity locally to train ethicists one has to be sensitive to claims by developing-world-based bioethicists that much of this training really constitutes a form of ideology transfer.
During the brainwashing training, scholars apparently receive a generous helping of fear and trembling:
[D]eveloping world-based bioethicists have raised concerns that if they were to publicly bite the hand thats feeding them (in this case funders from the north), they might soon find themselves out of the international bioethics conference circuit It would indeed be unfortunate if in a field also dedicated to issues of justice, scholars from poorer countries should find themselves executing forms of self-censorship because of concerns about how their funders might respond to the views they actually hold.
I have personally never heard such scholars speak of ideological transfer or concerns about expressing their own opinions. Which either proves the authors point, or, um, doesnt.
But Chadwick and Schuklenk are definitely onto something. The lions share of research in developing countries is bankrolled by rich pharmaceutical companies, major health institutes and prestigious universities of the North. Much of the funding for bioethical activity in low-income countries also comes from the outside. Ethical review boards in developing countries may feel pressure to rubber stamp accept research proposals already approved by their collaborating ethical review boards in the North, considering the potential professional and economic consequences of doing otherwise. Whos your Daddy?
The question, of course, is how bioethics can be promoted in the developing world without falling prey to a self-defeating neocolonialism. But that is really part of a larger issue: how can bioethics be truly globalized in a world marked by vast inequalities in wealth and power? – Stuart Rennie