Radical international research ethics?

I am part of a public health research team in Kinshasa, Democratic Republic of Congo currently conducting a study of the use of free bednets supplied to HIV positive women. Recently I was called in, as ethics consultant, to help with the following issue. Despite receiving bednets and an educational session explaining their use, and despite receiving malaria prophylaxis, some of the women ended up with clinical malaria anyway. Is the research team responsible for their treatment and hospitalization costs?

The question was complicated by a variety of local factors: that some of the women given free bednets at the clinic exchanged them for food on the way home; that the local hospital was often unwilling to see the sick women without guarantee of payment, while almost none of the women had money to pay up front; that the local doctors misdiagnosed some of the women, who were treated, hospitalized but actually turned out not to have malaria after all. The ethical issue of researcher responsibility for ancillary care in failed states is one messy problem. No matter what you decide, there is a sense of unfairness.

In a provocative recent publication, the South African bioethicist Solomon Benatar argues that we should view these small, messy research ethics problems as signs of systematic dysfunction in a complex and unstable world. Pregnant women in Kinshasa are not poor, HIV positive, vulnerable to further disease and excluded from a (sub-standard) health care system ‘by accident.’ The larger forces responsible for their plight include: unfair global trade relations; the international arms trade; extractive and environmentally destructive foreign investments; debt repayments; despotic local leaders supported by powerful foreign nations; the lack of attention to economic and social rights; the tendency to direct development aid on emergencies and perceived security needs of privileged societies.

According to Benatar, this system of forces is powerful but not built to last: it not only undermines global health, but helps fuel ongoing wars, genocides, refugee crises, famines, terrorism and other forms of instability and social disruption. And in an increasingly interconnected world, wealthier nations cannot reasonably expect to continue reap the benefits of the system without feeling its ill consequences. Even if the poor do not rise up against the rich, multi-drug resistant tuberculosis and bird flu might.

When ethical problems are traced back to vast ‘upstream forces’, there is a danger of moral paralysis: what can we possibly do? Benatar argues that we, in the more privileged societies, first need to substantially change the way we see the relationship between ourselves and distant others. The citizens of wealthy nations are ‘implicated in the generation and maintenance of forces that perpetuate social injustice and poverty’ and therefore have a responsibility toward those most affected by those forces. Assuming this responsibility requires us to expand our moral imaginations and see ourselves as connected to all other human beings, and empathize with the deprived and vulnerable in a way that transcends national, religious and cultural differences.

Perhaps out of discretion, Benatar omits the next logical step: expansion of moral imagination in practice would come with a real cost. It would entail the sacrifice of power and wealth on the part of wealthier nations and its citizens. And while many of us in international biomedical research would consider ourselves liberals, and be sympathetic towards Benatar’s arguments, his vision is essentially for radicals. How far are researchers – and bioethicists – from developed nations honestly willing to go, considering that we too are beneficiaries of the system we deplore? In international research ethics, the global is all too personal.