Sunday, July 31, 2005

The ethics of foreskin

One of the highlights of last week’s International AIDS Society conference in Brazil was the presentation of new data suggesting that circumcision significantly reduces a man’s chance of becoming infected by HIV through hetrosexual intercourse. A study sponsored by the French National Agency for AIDS research (ANRS) and conducted with over three thousand HIV-negative young (18-24 yrs.) South African men found that circumcision reduced female-to-male HIV transmission by approximately 65%. The ANRS 1265 study is the first randomized controlled trial demonstrating a strong protective effect of male circumcision on HIV transmission. Data from two similarly designed studies in Uganda and Kenya will be available in 2007. (And no, none of these trials are double-blinded.)

The suspicion that circumcision could reduce the risk of men acquiring HIV through heterosexual intercourse has been around since 1986. Since then, around thirty studies have indicated a positive association between circumcision and lowered HIV transmission, but these studies (and their policy implications) have long been controversial. Skeptics have questioned their scientific validity, while others have deep reservations about the ethics of circumcision as a public health intervention, even if the causal relationship between circumcision and transmission is confirmed.

According to skeptics, previous studies have proven incapable of demonstrating that lower transmission rates among circumcised men are due to the removal of foreskin itself rather than confounding variables. For example, much has been made of the lowered HIV acquisition rates among circumcised Muslim males, but this could be due to differences in sexual ethics and other cultural factors, such as prohibitions against alcohol. Especially in Africa, the rite of circumcision is closely tied to ethnicity, making it difficult to disentangle the effects of circumcision from behaviors rooted in local tradition. If a website passionately devoted to the virtues of males remaining ‘intact’ is anything to go by, the new ANRS study may leave skeptics cold. It is worth pointing out that during medical history circumcision has also been said to prevent insanity, paralysis, bedwetting, excessive masturbation, impotence, tuberculosis, prostate cancer, syphilis, cervical and penile cancer. Foreskins have long been unpopular in medical circles.

But there are ethical worries about implementation even if the conclusions of the study seem solid. The ‘good news’ may cause a sharp demand for circumcisions in sub-Saharan Africa, but at present they are most likely to be performed by traditional healers in less-than-hygienic circumstances. Circumcision may also increase unsafe sex practices in so far as men and women come to regard it as a ‘natural condom’: a tragic outcome, since a policy of circumcision does nothing to reduce the risks of male-to-female transmission of HIV. And if circumcision is encouraged but the long-term protectiveness of circumcision turns out to be much less than supposed, the damage to public confidence in the medical establishment and the impact on the fight against HIV/AIDS could be enormous.

Wednesday, July 27, 2005

Children, witches and bioethics

In June this year, three Angolans in London were convicted of abusing an eight-year old orphan Angolan girl by (among other cruelties) beating her with a belt, cutting her with knives, and rubbing chili peppers in her eyes. But it was not just the gruesome details that caught the British public’s attention. It was the motives of the torture: the girl was regarded by her tormentors as a witch. What might seem an obvious case of child abuse was, in the eyes of the perpetrators, a matter of ‘do-it-yourself exorcism’.

The case has drawn attention to the fact that in central African countries plagued by war poverty and state collapse, a significant number of children are regarded as witches. While general beliefs in witchcraft and spiritual possession is not at all uncommon in countries like Angola or the Democratic Republic of Congo, the idea of the child-witch is relatively new and deeply disturbing. Children as young as three years old can be accused of bringing misfortune on households – everything from unemployment to the death of family members – and cast out into the street to fend for themselves. According to Save the Children, 60% of the 30,000 street children in Kinshasa, capital of the Democratic Republic of Congo, are accused of being possessed by evil spirits, capable of casting spells, flying at night, transforming into non-human animals or consuming human flesh. Children infected by AIDS are particularly susceptible to accusations of witchcraft.

The child-witch phenomenon in Central Africa has spawned a veritable industry of self-appointed ‘healers’. Family members who want to rid their child of demonic possession often turn -- with what little money they have -- to traditional African practitioners or evangelical ministers. In either case, the child may be forced to undergo painful exorcisms, in abominable conditions, sometimes lasting days. Some don’t survive the ordeal.

What has all this got to do with bioethics? Plenty. Bioethics is not just about the ways North Americans and Europeans come to terms with the ethical implications of their expensive technologies. Those who practice bioethics in central Africa have little choice but to reflect critically on how traditional healing practices and influential local forms of religion impact on health and human rights. The influence of beliefs in witchcraft and satanic possession in these regions is unlikely to diminish soon, but local bioethicists could do a great service by redirecting these energies away from the most vulnerable members of society.

Tuesday, July 26, 2005

Unduly induce us, please

The Austrian philosopher Ludwig Wittgenstein famously claimed that many traditional philosophical problems are ultimately rooted in conceptual confusions. Once these confusions are carefully exposed and analyzed, he believed, the problems are not just answered: they forfeit their original status as genuine problems, and simply vanish into thin air.

In this week’s Lancet, Ezekiel Emanuel et. al. make a noble attempt to make the problem of undue inducements disappear. Undue inducement is commonly regarded a standard research ethics problem and is viewed as particularly acute in international biomedical research. On the one hand, researchers are instructed not to provide excessively attractive incentives to prospective research participants, because this ‘offer you can hardly refuse’ could undermine the voluntary element of consent. On the other hand, much of international research takes place in impoverished countries where simply having blood pressure taken for free by a medical practitioner could be wildly seductive. Many an international researcher has agonized over how to recruit participants in low-income countries without violating their autonomy in the process.

According to Emanuel et. al., worries over undue inducements in international research are misplaced. Properly understood, undue inducements involve (1) the offer of a highly attractive good where (2) the offer undermines the persons judgment and (3) has them agreeing to take serious risks that threaten his/her fundamental interests. But in fact (3) is doing all the ethical work here. Inducements in research are only unethical according to Emanuel et. al. if they entice the participant to enter a study with a highly unfavorable risk-benefit ratio. Inducement itself, in other words, is not the problem: inducement into unduly risky research is the problem. As long as a research study fulfills basic ethical requirements – including the minimization of risk – then the problem of ‘undue inducement’ vanishes.

The argument seems to have an interesting implication. There appears to be nothing in principle stopping researchers from pulling out all the stops in terms of benefits, for as long as the research study is in ethically good shape, even awesome inducement is not undue inducement. In moderate and low-risk studies, why not just offer research subjects whopping big sums of cash to join?
Given the current state of health research budgets, and the general reluctance to substantially reduce global inequalities, the lavishing of benefits on developing world research participants is unlikely to happen. But it is nice to hear that there is nothing ethically against it.