Economic globalization has profound implications for health. The scale of injustice at a global level, reflected in inexorably widening disparities in wealth and health, also has critical implications for health related research – in particular when the opportunities for exploiting research subjects are carefully considered. The challenge of developing universal guidelines for international clinical research is addressed against the background of a polarizing, yet interdependent, world in which all are ultimately threatened by lack of social justice. It is proposed that (...) in such a world there is a need for new ways of thinking about research and its relevance to health at a global level. Responsibility to use knowledge and power wisely requires more radical changes to guidelines for research ethics than are currently under consideration. (shrink)

Clinical research has become a burgeoning activity in recent years, largely stimulated by the pharmaceutical industry's interest in new drugs with high marketing profiles. Several other forces fuel this thrust: the increasing dependence of academic medical institutions on research funding from industry; the need for large, efficient multicenter trials to obtain reliable and statistically significant results in the shortest possible time for drug registration purposes; and access to research subjects in countries. The intense interest in HIV/AIDS research and recent controversies (...) about revisions to the Helsinki Declaration, which have been seen by some to be motivated by the desire to facilitate exploitative research in countries, have stimulated renewed interest in the ethics of clinical research. (shrink)

The blinkered debate on organ donation neglects the widening gap between the developed and developing worldsThe current debate about organ donation and the associated advocacy for selling kidneys, while laudable for its concern about increasing the ability to save the lives of some people with chronic renal failure, is characterised by four features that locate the reasoning process within a narrow and inadequate framework. Firstly, the focus on saving lives is myopic, with the lives of the most privileged in the (...) world receiving most attention. Secondly, the debate is firmly set within a value system in which market values dominate. Thirdly, health is considered from a highly individualistic perspective with little understanding of the importance of social solidarity in health. Finally, a constricted moral vocabulary is used to discuss the ethics of organ sales.MYOPIC CONCERN FOR SAVING LIVESMany articles making pleas for more organs begin by describing the number of people waiting for donated organs, the number of donors who could give organs but are not doing so, and how many lives could be saved if more organs could be made available. Great concern is expressed about a few thousand …. (shrink)

I am very pleased to see the response by J S Taylor to my critique of the “organs debate”. He makes some notable and important points, but also some errors to which attention should be drawn.Taylor erroneously attributes to me concern that the organ debate excessively focuses on saving the lives of a few people. My concern was about the narrow framework within which the debate is embedded and that it focuses on the lives of a few privileged people—those who (...) can pay—while largely neglecting the lives of those who cannot. The fact that some attention has been paid to such issues in some journals does not negate the importance of my claim. Moreover, it is not that the question of millions of premature deaths has …. (shrink)

Since the early 20th century, bioethics in South Africa has moved through several stages, responding to the same forces and developments as elsewhere, for example in the United Kingdom and United States. In addition, some unique developments in South Africa, for example the death of Steve Biko, the HIV/AIDS pandemic, and a peaceful transition to democracy with increased focus on human rights have given bioethics in South Africa its own dimension. Bioethics in South Africa reflects the general concerns of the (...) field elsewhere, but it also stands at the intersection of the concerns of both developed and developing worlds. Thus, issues such as resource allocation, HIV/AIDS, and medical research take on an urgency and character that reflect South Africa's particular historical, geographical, and social conditions. (shrink)

Following promulgation of the Nuremberg code in 1947, the ethics of research on human subjects has been a challenging and often contentious topic of debate. Escalation in the use of research participants in low-income countries over recent decades , has intensified the debate on the ethics of international research and led to increasing attention both to exploitation of vulnerable subjects and to considerations of how the 10:90 gap in health and medical research could be narrowed. In 2000, prompted by the (...) discussions over several years that led to the US NIH launching a capacity building programme on research ethics for members of research ethics committees in developing countries, we advanced a ‘new look’ for the ethics of international research.1 Since then progress has been made on several fronts.First, our ideas—considered somewhat radical and impractical at the time—have been provocatively addressed by scholars who have either contested them or advanced similar conceptions of what obligations international researchers have to research participants and communities in low income countries before, during and after clinical trials. Second, those researchers who have been sympathetic to our ideas have either endeavoured to put these into practice or have investigated the feasibility of doing so. Third, the intractability of the 10/90 gap and the escalation of interest in global health have sensitised many to the need to amplify the uptake of these ideas in practice.Here, we briefly review the conceptual and practical developments in international research ethics. While much conceptual progress has been made (and the concepts are now appearing …. (shrink)

Interest in the ethics of research on human subjects, stimulated by atrocious human experimentation during WWII and the resultant Nuremberg Code, has been sustained by examples of unethical research in many countries and by proliferation of codes and guidelines. Such interest has intensified in recent years in association with expanding international collaborative research endeavors. The ongoing controversy in international research ethics takes place at two levels. At the practical level it is about the competing concerns of those predominantly interested in (...) doing research to advance knowledge and those who, while supporting the need for research, are more acutely aware of the potential to exploit vulnerable participants, especially in developing countries. At the level of theory the controversy pits ethical universalism against moral relativism.In her recent review of agreements and controversies in international research ethics, Ruth Macklin has concluded that, despite seeming agreement on several issues, many different viewpoints persist. In her view it is unlikely that these will be resolved easily. (shrink)

Interest in the ethics of research on human subjects, stimulated by atrocious human experimentation during WWII and the resultant Nuremberg Code, has been sustained by examples of unethical research in many countries and by proliferation of codes and guidelines. Such interest has intensified in recent years in association with expanding international collaborative research endeavors. The ongoing controversy in international research ethics takes place at two levels. At the practical level it is about the competing concerns of those predominantly interested in (...) doing research to advance knowledge and those who, while supporting the need for research, are more acutely aware of the potential to exploit vulnerable participants, especially in developing countries. At the level of theory the controversy pits ethical universalism against moral relativism.In her recent review of agreements and controversies in international research ethics, Ruth Macklin has concluded that, despite seeming agreement on several issues, many different viewpoints persist. In her view it is unlikely that these will be resolved easily. (shrink)

Widening disparities in health within and between nations reflect a trajectory of ‘progress’ that has ‘run its course’ and needs to be significantly modified if progress is to be sustainable. Values and a value system that have enabled progress are now being distorted to the point where they undermine the future of global health by generating multiple crises that perpetuate injustice. Reliance on philanthropy for rectification, while necessary in the short and medium terms, is insufficient to address the challenge of (...) economic and other systems spinning out of control. Innovative approaches are required and it is suggested that these could best emerge from in-depth multidisciplinary research supported by endeavours to promote a ‘global mind-set.’. (shrink)

Medical practitioners have traditionally seen themselves as part of an international community with shared and unifying scientific and ethical goals in the treatment of disease, the promotion of health, and the protection of life. This shared mission is underpinned by explicit acceptance of traditional concepts of medical morality, and by an implied link between individual human rights and the ethics of medical practice long enshrined in a range of World Medical Association (WMA) and other medical codes. These have been powerful (...) instruments exhorting individual practitioners to promote health and to defend universal principles in order to protect their patients and the physician-patient relationship even in the face of authoritarian state coercion and imposed national ideologies and policies. There has been widespread support for this approach and this should be intensified. (shrink)

Intense scientific work on HIV/AIDS has led to the development of effective combination drug therapies and there is hope that effective vaccines will soon be produced. However, the majority of people with HIV/AIDS in the world are not benefiting from such advances because of extreme poverty. This article focuses on the pandemic as a reflection of a complex trajectory of social and economic forces that create widening global disparities in wealth and health and concomitant ecological niches for the emergence of (...) new infectious diseases. While the biomedical approach to HIV/AIDS is necessary, has prolonged the lives of many individuals and could offer much at the level of population health, it cannot, in isolation, improve the health of populations. To achieve the latter will require understanding and addressing the deeper social causes of pandemics. Broadening the discourse on ethics to include public health ethics and the ethics of international relations could contribute to reducing the impact of the pandemic and to preventing the emergence of new infectious diseases in the future. (shrink)

ABSTRACT A major focus within the modern bioethics debate has been on reshaping power relationships within the doctor–patient relationship. Empowerment of the vulnerable has been achieved through an emphasis on human rights and respect for individual dignity. However, power imbalances remain pervasive within healthcare. To a considerable extent this relates to insufficient attention to social injustice. Such power imbalances together with the development of new forms of power, for example through new genetic biotechnology, raise the spectre of increasing social injustice. (...) Attention will be drawn to the need to extend the bioethics debate to include ethical considerations regarding public health. Changes in political philosophy will also be required to reshape international power relations and improve population health. (shrink)

In meeting the challenges of fashioning a new health care system, South Africa stands poised to contribute to a better future for its own citizens and the subcontinent.

In meeting the challenges of fashioning a new health care system, South Africa stands poised to contribute to a better future for its own citizens and the subcontinent.

Given the fragility of individual and population wellbeing in an interdependent world threatened by many overlapping crises, the suggestion is made that new legal mechanisms have the robust potential to reduce human vulnerability locally and globally.

The most common response to the challenge of protecting health through law is to focus on protecting the rights of vulnerable individuals and to enhance their access to health care. Each one of us is vulnerable or potentially vulnerable because of the fragile, existential nature of the human condition. Catastrophic and unexpected events could instantaneously transform us from a state of total independence and potential vulnerability to one of extreme vulnerability and complete dependence. Some legal provisions have the potential to (...) provide a modicum of protection when we find ourselves in those situations. There are also legal provisions that contribute to beneficial social circumstances; for example, legislation enabling universal access to medical care, and operationalizing respect for the individual’s right to health care, as advocated for by other authors in this issue. (shrink)

This series of responses was commissioned to accompany the article by Singer et al, which can be found at http://www.biomedcentral.com/1472-6939/2/1. If you would like to comment on the article by Singer et al or any of the responses, please email us on [email protected].

The military might of the modern era poses devastating threats to humankind. Wars result from struggles for material or ideological power. In this context the probability of flouting agreements made during peaceful times is great. The rights of victims and the rights of medical personnel are vulnerable to State and military momentum in the quest for sovereignty. Scholars, scientists and physicians enjoy little enough influence during times of peace and we should be sanguine about their influence during war. But we (...) also must avoid becoming co-opted by partisan political forces. The universal ideals for which we strive, need to be cherished and kept central in our field of vision if we are to rise above man's basest instincts and if we are to preserve professional integrity, individuality and humanitarian concern for the sanctity of life — even the lives of our foes who are engaged in battle against us. Such compassion also recognizes the coercion implicit in recruiting persons into wars they detest and which pits them against their own image. Man's inhumanity to man, most evident during war, must not be allowed to pervade the sanctuary of medical care. Health professionals must constantly be encouraged to serve humankind with empathy and compassion and great social effort needs to be expended to facilitate this role globally and under all conditions. (shrink)

A major strength of this capacity building programme is that it encourages cross-cultural considerations in the application of research ethics principles to research in developing countries.

Background Tuberculosis is a major cause of morbidity and mortality globally. Recent scholarly attention to public health ethics provides an opportunity to analyze several ethical issues raised by the global tuberculosis pandemic. Discussion Recently articulated frameworks for public health ethics emphasize the importance of effectiveness in the justification of public health action. This paper critically reviews the relationship between these frameworks and the published evidence of effectiveness of tuberculosis interventions, with a specific focus on the controversies engendered by the endorsement (...) of programs of service delivery that emphasize direct observation of therapy. The role of global economic inequities in perpetuating the tuberculosis pandemic is also discussed. Summary Tuberculosis is a complex but well understood disease that raises important ethical challenges for emerging frameworks in public health ethics. The exact role of effectiveness as a criterion for judging the ethics of interventions needs greater discussion and analysis. Emerging frameworks are silent about the economic conditions contributing to the global burden of illness associated with tuberculosis and this requires remediation. (shrink)

Conventional and well-established guidelines for the ethical conduct of clinical research are necessary but not sufficient for addressing research dilemmas related to public health research. There is a particular need for a public health ethics framework when, in the face of an epidemic, research is urgently needed to promote the common good. While there is limited experience in the use of a public health ethics framework, the value and potential of such an approach is increasingly being appreciated. Here we use (...) two examples of adolescent women as potential candidates for participation in microbicide trials to illustrate how ethical decisions for public health research can be enhanced by drawing on both traditional research ethics guidance, and the emerging framework for public health ethics. (shrink)

In this paper, we propose a new model for development, one that transcends the North–South dichotomy and goes beyond a narrow conception of development as an economic process. This model requires a paradigm shift toward a new metaphor that develops sustainability, rather than sustains development. We conclude by defending a ‘report card on development’ as a means for evaluating how countries perform within this new paradigm.

D Benatar argues that in the author’s recent article Moral theories in teaching applied ethics, the author overlooked important roles that could be played by moral theories in such teaching. In this reply, the cases that Benatar suggests are considered and for each an alternative approach is suggested that will avoid the costs discussed in the original paper and will also be a more effective response to that particular issue.

David Benatar argues that coming into existence is always a harm, and that – for all of us unfortunate enough to have come into existence – it would be better had we never come to be. We contend that if one accepts Benatar’s arguments for the asymmetry between the presence and absence of pleasure and pain, and the poor quality of life, one must also accept that suicide is preferable to continued existence, and that his view therefore implies (...) both anti-natalism and pro-mortalism . This conclusion has been argued for before by Elizabeth Harman – she takes it that because Benatar claims that our lives are ‘awful’, it follows that ‘we would be better off to kill ourselves’ (Harman 2009: 784). Though we agree with Harman’s conclusion, we think that her argument is too quick, and that Benatar’s arguments for non-pro-mortalism deserve more serious consideration than she gives them. We make our case using a tripartite structure. We start by examining the prima facie case for the claim that pro-mortalism follows from Benatar’s position, presenting his response to the contrary, and furthering the dialectic by showing that Benatar’s position is not just that coming into existence is a harm, but that existence itself is a harm. We then look to Benatar’s treatment of the Epicurean line, which is important for him as it undermines his anti-death argument for non-pro-mortalism. We demonstrate that he fails to address the concern that the Epicurean line raises, and that he cannot therefore use the harm of death as an argument for non-pro-mortalism. Finally, we turn to Benatar’s pro-life argument for non-pro-mortalism, built upon his notion of interests, and argue that while the interest in continued existence may indeed have moral relevance, it is almost always irrational. Given that neither Benatar’s anti-death nor pro-life arguments for non-pro-mortalism work, we conclude that pro-mortalism follows from his anti-natalism, As such, if it is better never to have been, then it is better no longer to be. -/- . (shrink)

In a recent commentary, S R Benatar criticised the debates over organ donation and kidney selling for being located within a “narrow and inadequate framework”. Benatar levels four charges against those who engage in the current organs debate: that they myopically focus on saving lives; that they accept the dominance of market orientated approaches to health care; that they reify individualism, and that they engage in limited moral arguments. Given the importance of the organs debate it is imperative (...) that the misunderstandings of it on which Benatar’s criticisms are based are dispelled. Accordingly, I will consider and reject each of his objections in turn. (shrink)