The debate over maternal-fetal HIV transmission prevention trials in Africa, Asia, and the Caribbean: racist exploitation or exploitation of racism?

Global Health Perspectives on Race in Research: Neocolonial Extraction and Local Marginalization

Best practices in global health training prioritize leadership and engagement from investigators from low- and middle-income countries (LMICs), along with conscientious community consultation and research that benefits local participants and autochthonous communities. However, well into the 20th century, international research and clinical care remain rife with paternalism, extractive practices, and racist ideation, with race presumed to explain vulnerability or protection from various diseases, despite scientific evidence for far more precise mechanisms for infectious disease. We highlight experiences in global research on health and illness among indigenous populations in LMICs, seeking to clarify what is both scientifically essential and ethically desirable in research with human subjects; we apply a critical view towards race and racism as historically distorting elements that must be acknowledged and overcome.

No person left behind: Mapping the health policy landscape for genomics research in the Caribbean

The Caribbean has long been an under-represented geographical region in the field of genomics research. Such under-representation may result in Caribbean people being underserved by precision medicine and other public health benefits of genomics. A collaboration among regional and international researchers aims to address this issue through the H3ECaribbean project (Human Heredity, Environment, and Health in the Caribbean), which builds on the lessons and success of H3Africa. The Caribbean project aims to target issues of social justice by encouraging the inclusion of diverse Caribbean communities in genomics research. This paper explores a framework for the ethical and socially acceptable conduct of genomics research in the Caribbean, taking account of the cultural peculiarities of the region. This is done in part by exploring research ethics issues identified in indigenous communities in North America, Small Island Developing States, and similar endeavours from the African continent. The framework provides guidance for interacting with local community leaders, as well as detailing steps for obtaining informed consent of all participants. Specifically, the authors outline the methods to ensure effective interaction and enforce full transparency with study participants to combat historical neglect when working with under-represented communities in the Caribbean.

Ethical challenges in mass drug administration for reducing childhood mortality: a qualitative study

Background

Mass drug administration (MDA) of medications to entire at-risk communities or populations has shown promise in the control and elimination of global infectious diseases. MDA of the broad-spectrum antibiotic azithromycin has demonstrated the potential to reduce childhood mortality in children at risk of premature death in some global settings. However, MDA of antibiotics raises complex ethical challenges, including weighing near-term benefits against longer-term risks—particularly the development of antimicrobial resistance that could diminish antibiotic effectiveness for current or future generations. The aim of this study was to understand how key actors involved in MDA perceive the ethical challenges of MDA.

Methods

We conducted 35 semi-structured interviews from December 2020–February 2022 with investigators, funders, bioethicists, research ethics committee members, industry representatives, and others from both high-income countries (HICs) and low- and middle-income countries (LMICs). Interview participants were identified via one of seven MDA studies purposively chosen to represent diversity in terms of use of the antibiotic azithromycin; use of a primary mortality endpoint; and whether the study occurred in a high child mortality country. Data were analyzed using constructivist grounded theory methodology.

Results

The most frequently discussed ethical challenges related to meaningful community engagement, how to weigh risks and benefits, and the need to target MDA We developed a concept map of how participants considered ethical issues in MDA for child mortality; it emphasizes MDA’s place alongside other public health interventions, empowerment, and equity. Concerns over an ethical double standard in weighing risks and benefits emerged as a unifying theme, albeit one that participants interpreted in radically different ways. Some thought MDA for reducing child mortality was ethically obligatory; others suggested it was impermissible.

Conclusions

Ethical challenges raised by MDA of antibiotics for childhood mortality—which span socio-cultural issues, the environment, and effects on future generations—require consideration beyond traditional clinical trial review. The appropriate role of MDA also requires attention to concerns over ethical double standards and power dynamics in global health that affect how we view antibiotic use in HICs versus LMICs. Our findings suggest the need to develop additional, comprehensive guidance on managing ethical challenges in MDA.

Graphical Abstract

Avoiding Gender Exploitation and Ethics Dumping in Research with Women

There is a long history of women being underrepresented in biomedical and health research. Specific women’s health needs have been, and in some cases still are, comparatively neglected areas of study. Concerns about the health and social impacts of such bias and exclusion have resulted in inclusion policies from governments, research funders, and the scientific establishment since the 1990s. Contemporary understandings of foregrounding sex and gender issues within biomedical research range from women’s rights to inclusion, to links between human rights, women’s health and sustainable development, and the increasing scientific and funding expectation for studies to consider the sex (biological) and gender (cultural) implications of research design, results and impact. However, there are also exploitation issues to consider when foregrounding the inclusion of women as research participants, especially for research ethics committees and institutional review boards. A hidden risk is that exploitative research designs and practices may be missed, particularly by reviewers who may not have a nuanced understanding of gender-based harm. Utilizing contemporary case studies of ethics dumping, this paper highlights some of the concerns, and makes recommendations for IRBs/research ethics reviewers to help ensure that essential research is undertaken to the highest ethical standards.

Big pharma and the problem of disease inflation

Over the course of the past decade, critics have increasingly called attention to the corrosive influence of the pharmaceutical industry on both biomedical research and the practice of medicine. Critics describe the industry's use of ghostwriting and other unethical techniques to expand their markets as evidence that medical science is all-too-frequently subordinated to the goals of corporate profit. While we do not dispute this perspective, we argue that it is imperative to also recognize that the goals of medical science and industry profit are now tightly wed to one another. As a result, medical science now operates to expand disease definitions, lower diagnostic thresholds, and otherwise advance the goals of corporate profit through the redefinition and expansion of what it means to be ill. We suggest that this process has led to a variety of ethical problems that are not fully captured by current critiques of ghostwriting and other troubling practices by the pharmaceutical industry. In our conclusion, we call for physicians, ethicists, and other concerned observers to embrace a more fundamental critique of the relationship between biomedical science and corporate profit.

The Ethics of Globalizing Bioethics

In the last decade, there have been efforts to globalize the field of bioethics, particularly in developing countries, where biomedical and other research is increasingly taking place. We describe and evaluate some key ethical criticisms directed towards these initiatives, and argue that while they may be marked by ethical, practical, and political tensions and pitfalls, they can nevertheless play an important role in stimulating critical bioethics culture in countries vulnerable to exploitation by foreign agencies and/or their own authorities.

Adverse events and placebo effects: African scientists, HIV, and ethics in the 'global health sciences'

This paper builds on the growing literature in 'postcolonial technoscience' by examining how science and ethics travel in transnational HIV research. I use examples of two controversial US-funded studies of mother-to-child transmission in Africa as case studies through which to explore quandaries of difference and inequality in global health research. My aim is not to adjudicate the debates over these studies, but rather to raise some questions about transnational research, science, and ethics that often get lost in public controversies over the moral status of such trials. Using interviews conducted with American and Ugandan HIV researchers as well as relevant material published in the popular and medical press, I argue that debates over research practice and the conditions under which practices are deemed ethically legitimate or questionable reflect the challenges faced by African researchers seeking to participate in global health science. In doing so, I show how questions of scientific legitimacy and authority are played out in debates over who decides what constitutes 'the normal' in human biological research and who can legitimately 'speak for Africa' regarding the ethics of research design and practice. I conclude that researchers from'resource-poor settings' must often walk a tightrope between claims of difference from the global North and assertions of sameness, in which a claim too forceful in either direction can undermine the ethical--and thus scientific--legitimacy of their research.

A magic bullet for the “African” mother? Neo-Imperial reproductive futurism and the pharmaceutical “solution” to the HIV/AIDS Crisis

On the basis of a close reading of popular and medical texts which address a debate over the ethics of clinical drug trials funded by the United States and designed mainly for sub-Saharan Africa, I argue that international public health discourse about infant HIV infection in that region reflects and legitimates a neo-imperialist, anti-reproductive justice ideology. Participants share a fetal-centered logic that US-funded biomedicine must shoulder the burden of rescuing sub-Saharan Africa from itself by using the bodies of HIV-positive pregnant women to transmit biomedicine's magic bullet—antiretroviral drugs—to the next generation. The survival of the fetus, disguised as the well-being of the HIV-positive woman and accomplished by the magic of biomedical research, becomes the survival of a region otherwise doomed by its present state of economic, political, and medical incapacity. This version of what queer theorist Lee Edelman (2004, No Future: Queer Theory and the Death Drive) calls “reproductive futurism” redounds to the benefit of the more explicitly women-hating and nationalist ideologies of still-powerful right-wing movements against reproductive and sexual rights.

Manufacturing mistrust: issues in the controversy regarding foster children in the pediatric HIV/AIDS clinical trials

The use of foster children as subjects in the pediatric HIV/AIDS clinical trials has been the subject of media controversy, raising a range of ethical and social dimensions. Several unsettled issues and debates in research ethics underlie the controversy and the lack of consensus among professional researchers on these issues was neither adequately appreciated nor presented in media reports. These issues include (1) the tension between protecting subjects from research risk while allowing them access to the possible benefits of research; (2) the blurring of the potentially conflicting roles of investigator and physician and the boundaries between research and therapy; (3) the adequacy of Institutional Review Board oversight; and (4) trust and the relationships among physicians, investigators and industry. The media controversy about the pediatric HIV/AIDS clinical trials can be seen as a means of "manufacturing mistrust" in health care, research and social services that have not always met the needs and expectations of the public. In an era of emerging infections, it is critical to the public's health that people understand the role of rigorous and ethical research in the development of safe and effective care. Investigators, journalists and the public need to become knowledgeable about major ethical issues in the conduct of research in order to engage in dialogue about balancing research risks and benefits and to be able to distinguish fact from distortion in an era of multiple and rapid transmission of information.

Informed recruitment in partner studies of HIV transmission: an ethical issue in couples research

BACKGROUND

Much attention has been devoted to ethical issues related to randomized controlled trials for HIV treatment and prevention. However, there has been less discussion of ethical issues surrounding families involved in observational studies of HIV transmission. This paper describes the process of ethical deliberation about how best to obtain informed consent from sex partners of injection drug users (IDUs) tested for HIV, within a recent HIV study in Eastern Europe. The study aimed to assess the amount of HIV serodiscordance among IDUs and their sexual partners, identify barriers to harm reduction, and explore ways to optimize intervention programs. Including IDUs, either HIV-positive or at high risk for HIV, and their sexual partners would help to gain a more complete understanding of barriers to and opportunities for intervention.

DISCUSSION

This paper focuses on the ethical dilemma regarding informed recruitment: whether researchers should disclose to sexual partners of IDUs that they were recruited because their partner injects drugs (i.e., their heightened risk for HIV). Disclosing risks to partners upholds the ethical value of respect for persons through informed consent. However, disclosure compromises the IDU's confidentiality, and potentially, the scientific validity of the research. Following a brief literature review, we summarize the researchers' systematic evaluation of this issue from ethical, scientific, and logistical perspectives. While the cultural context may be somewhat unique to Eastern Europe and Central Asia, the issues raised and solutions proposed here inform epidemiological research designs and their underlying ethical tensions.

SUMMARY

We present ethical arguments in favor of disclosure, discuss how cultural context shapes the ethical issues, and recommend refinement of guidance for couples research of communicable diseases to assist investigators encountering these ethical issues in the future.

Benefits to research subjects in international trials: do they reduce exploitation or increase undue inducement?

There is an alleged tension between undue inducement and exploitation in research trials. This paper considers claims that increasing the benefits to research subjects enrolled in international, externally-sponsored clinical trials should be avoided on the grounds that it may result in the undue inducement of research subjects. It proceeds from the premise that there are good grounds for thinking that, at least some, international research sponsors exploit trial participants because they do not provide the research population with a fair share of the benefits of research. This provides a prima facie argument for increasing the benefits for research participants. Concern over undue inducement is a legitimate moral concern; however, if this concern is to prevent research populations from receiving their fair share of benefits from research there must be sufficient evidence that these benefits will unduly influence patients' decision-making regarding trial participation. This article contributes to the debate about exploitation versus undue inducement by introducing an analysis of the available empirical research into research participants' motivations and the influence of payments on research subjects' behaviour and risk assessment. Admittedly, the available research in this field is limited, but the research that has been conducted suggests that financial rewards do not distort research subjects' behaviour or blind them to the risks involved with research. Therefore, I conclude that research sponsors should prioritize the prevention of exploitation in international research by providing greater benefits to research participants.

Can context justify an ethical double standard for clinical research in developing countries?

Background

The design of clinical research deserves special caution so as to safeguard the rights of participating individuals. While the international community has agreed on ethical standards for the design of research, these frameworks still remain open to interpretation, revision and debate. Recently a breach in the consensus of how to apply these ethical standards to research in developing countries has occurred, notably beginning with the 1994 placebo-controlled trials to reduce maternal to child transmission of HIV-1 in Africa, Asia and the Caribbean. The design of these trials sparked intense debate with the inclusion of a placebo-control group despite the existence of a 'gold standard' and trial supporters grounded their justifications of the trial design on the context of scarcity in resource-poor settings.

Discussion

These 'contextual' apologetics are arguably an ethical loophole inherent in current bioethical methodology. However, this convenient appropriation of 'contextual' analysis simply fails to acknowledge the underpinnings of feminist ethical analysis upon which it must stand. A more rigorous analysis of the political, social, and economic structures pertaining to the global context of developing countries reveals that the bioethical principles of beneficence and justice fail to be met in this trial design.

Conclusion

Within this broader, and theoretically necessary, understanding of context, it becomes impossible to justify an ethical double standard for research in developing countries.

Ethical review of health research: a perspective from developing country researchers

BACKGROUND

Increasing collaboration between industrialised and developing countries in human research studies has led to concerns regarding the potential exploitation of resource deprived countries. This study, commissioned by the former National Bioethics Advisory Commission of the United States, surveyed developing country researchers about their concerns and opinions regarding ethical review processes and the performance of developing country and US international review boards (IRBs).

METHODS

Contact lists from four international organisations were used to identify and survey 670 health researchers in developing countries. A questionnaire with 169 questions explored issues of IRB review, informed consent, and recommendations.

RESULTS

The majority of the developing country researchers were middle aged males who were physicians and were employed by educational institutions, carrying out research on part time basis. Forty four percent of the respondents reported that their studies were not reviewed by a developing country IRB or Ministry of Health and one third of these studies were funded by the US. During the review process issues such as the need for local language consent forms and letters for approval, and confidentiality protection of participants were raised by US IRBs in significantly higher proportions than by host country IRBs.

CONCLUSION

This survey indicates the need for the ethical review of collaborative research in both US and host countries. It also reflects a desire for focused capacity development in supporting ethical review of research.

International criminal prosecution of physicians: a critique of Professors Annas and Grodin's proposed International Medical Tribunal

Society benefits from physicians who seek truth and healing for the good of humanity. Despite ethical admonishments to “do no harm,” however, physicians have caused some of the most appalling human rights abuses of the twentieth century. Physicians, alone or in concert with the state, have willfully abused their medical knowledge and debauched their profession in furtherance of human rights violations. Compounding their crimes, physicians often have been complicit in following oppressive regimes in abusive practices against their citizens. Ironically, it is their knowledge of this healing art that allows physicians to take part in this injurious conduct; and it is this knowledge that states seek to harness in buttressing violative policies. In fact, for nations bent on violating human rights, it is “much easier for governments to adopt inherently evil and destructive policies if they are aided by the patina of legitimacy that physician participation provides.”

Enrolling the uninsured in clinical trials: an ethical perspective

Research participation by individuals who lack health insurance raises significant but seldom-discussed ethical issues for clinical investigators. Of particular concern are the possibility that their lack of options for getting care at the time of enrollment makes the uninsured susceptible to undue inducement to join trials and the possibility that their inability to access research products after trials leads to their exploitation. In tension with these concerns, however, is the right of the uninsured to fair consideration for research participation. We discuss these competing issues and make recommendations for how investigators can both protect uninsured research participants and provide the uninsured with fair access to research in their recruitment and enrollment strategies.

Informed consent and the history of inclusion of women in clinical research

The purposes of this paper are to (a) discuss the troubled history of informed consent for research on women and its ramifications for women's participation in clinical trials; (b) interrogate current informed consent practices as to their accountability and justice in the treatment of women; and (c) recommend to nurse researchers and clinical nurses ways of improving the practice of informed consent in research with women.

Options for prevention of HIV transmission from mother to child, with a focus on developing countries

Use of antiretroviral drugs among HIV-infected pregnant women in many developed countries has significantly reduced rates of mother-to-child HIV transmission, demonstrating that this route of transmission is amenable to intervention. Prevention of transmission in developing countries has proved to be more difficult, although recent advances in short-course antiretroviral drug interventions have made it an immediate possibility, rather than a distant hope as it was seen to be in the recent past. Non-antiretroviral drug interventions, including washing of the birth canal with antiseptic solution and micronutrient supplementation, have not been found to be effective at interrupting mother-to-child HIV transmission, but may have other benefits for maternal and child health. An important issue for developing countries is prevention of postnatal HIV transmission through breast feeding. In most developing countries, formula feeding is not a reasonable option, given the higher rates of mortality from diarrheal and respiratory disease associated with avoidance of all breast feeding. A promising new line of research has recently been broached with the findings from a study in South Africa, which demonstrated that exclusive breast feeding is associated with a significant reduction in postnatal transmission of HIV.

Researcher and researched--community perspectives: toward bridging the gap

In the process of initiating a new community-based research project, the authors wanted to understand the experiences of community members and researchers in community-based research projects and to develop guidelines to improve future projects. They conducted qualitative, key informant interviews with 41 people involved at all levels of community-based research projects in Seattle. Respondents were identified using a snowball sampling technique. More problems than successes were discussed by informants, including dissatisfaction with the focus of research, which some said is marked by a lack of cultural appropriateness and relevance. Power imbalances, lack of trust, and communication difficulties impeded collaboration. According to respondents, many problems could be avoided if the community were involved from the beginning in setting research priorities and developing and implementing interventions. Meaningful collaboration between communities and researchers is characterized by early involvement of communities, power sharing, mutual respect, community benefit, and cultural sensitivity.

Ethics of medical research in developing countries: the role of international codes of conduct

Many statisticians work with informal codes of ethics, and are probably unaware of the existence or content of rules which have been drawn up to govern statistical practice. Medical statisticians will be aware of codes of conduct for medical research, and most codes of professional ethics have some dependence on evidence. Statisticians, therefore, have a valuable contribution to make to debates on ethics which concern scientific soundness, data and perceptions of risk. A lively debate on the revision of the widely respected Declaration of Helsinki, to reflect issues arising from research in developing countries, particularly HIV research, centres on questions of study design, data analysis and assessment of risk. Collectively owned multiprofessional work requires each of the various professions to take responsibility for the conduct of the research, and the impact that it might have. Statisticians share important responsibilities in maintaining ethical medical research in all countries.

Ethical issues in tuberculosis vaccine trials

Bacille Calmette-Guérin (BCG) vaccines are widely used, even though estimates of efficacy have ranged from zero to 80%. BCG is a relatively safe vaccine, but it can cause disseminated infection, especially in immunocompromised hosts. Thus, the development of a more reliably efficacious and safer vaccine is important to the control of tuberculosis. The testing of any new vaccine in human populations presents a number of ethical challenges that must be addressed. These include (1) the appropriateness of conducting such trials in developing countries; (2) the use of a BCG-vaccinated population as the control group; (3) the provision of tuberculin skin-test screening and preventive therapy to study participants; (4) the involvement of various "communities" in the trial(s); (5) the structure and process of ethical review; (6) establishing an effective method of obtaining informed consent; and (7) the roles and responsibilities of researchers and others in ensuring that trial results are available to the study population after the trial ends.

The Declaration of Helsinki and research in vulnerable populations

Mooted changes to the Declaration on the agenda of the World Medical Association have sparked a vigorous debate on international research issues. The medical, research and ethics communities in Australia need to participate more broadly in this debate.

Research bioethics in the Ugandan context. II: Procedural and substantive reform

In July 1997, the voting representatives at the National Consensus Conference (NCC) on Bioethics in Health Research voted unanimously to adopt the proposed Guidelines for the Conduct of Health Research Involving Human Subjects in Uganda (Guidelines). This vote represented the culmination of a three-year journey towards the development of a coherent and cohesive framework for the ethical review of health research involving human subjects in Uganda.

Attendees at the NCC included both voting representatives and non-voting participants. Voting representatives had been designated by the institutional entity with which they were affiliated to represent that entity at the NCC and to voice the concerns and opinions of the entity and its constituents.

Meta-Review of Sampling Dilemmas in Health Education Research: Design Issues and Ethical Precepts

Discussed is the previously unexamined relationship in health education literature between sampling techniques used in health behavior research and the ethical dilemmas investigators in the field must regularly negotiate. The intent is to describe the inherent weaknesses in both areas and to offer possible options for improvement The concepts of two-level randomization, validity of inferring results to a source population, snowball, and central location intercept sampling strategies are explored. The ethics of selecting specific sampling approaches as well as research designs to conduct research on “hidden populations” or disenfranchized cohorts such as runaways or intravenous drug users, is also examined. Recommendations are offered to enhance these two interrelated domains of inquiry and thus strengthen the image of the field both academically and publicly.