Avoiding the missionary position

An intriguing book has just been published by Oxford University Press, edited by Catherine Myser, and entitled Bioethics around the Globe. The book examines, from loosely anthropological or sociological perspectives, variations in how bioethics is conceived and practiced in different parts of the world, as well as attempts to spread 'Western-style' bioethics globally. In regard to the latter, Raymond de Vries and Leslie Rott have written a provocative essay in which bioethics training programs (in the United States, continental Europe and the UK) are compared with old-style missionary work in developing countries. Either bioethics experts are flown into developing countries to spread the 'good word' of bioethics, or the natives are flown to Western centers of bioethics excellence, where they gather and return home with the 'right' bioethics notions and approaches.

If there was only one true way of doing bioethics, that those in the more affluent countries of the north just happened to latch onto, this would be less problematic. But as the rest of the book makes plain, bioethics wherever it is practiced tends to be heavily flavored by local morality, social conditions, and cultural norms. This means that attempts (however well-intentioned) to transfer Western bioethics into non-Western settings is going to be a bit weird at best, and harmful at worst. De Vries and Rott speak of various ills: blindness of Western bioethicists to the shortcomings of their own culture and to the cultural assumptions embedded in conceptions of informed consent and autonomy; the lack of cultural fit between what budding non-Western bioethicists get taught and what is relevant in their own culture. And what might be seen as relevant may arguably be relevant for the wrong sort of reasons. Learning how to set up an IRB might be interesting for those in the developing world hoping to attract funding and resources from research agencies, but that seems to miss the ethical point about protection of human participants in research. In these post-colonial exchanges, much is lost in translation.

How can the missionary trap be avoided? It is no simple thing. The dominant bioethics culture in the world is Anglophone, European-American, and secular with Christian overtones. Developing countries who want to expand their understanding and skills in this area are confronted with that particular world in the 'classic' texts, the most prestigious programs, and high-impact journals. Those interested in bioethics in the developing world need to be encouraged to (critically) tap into the 'Western' style of bioethics while also (critically) engaging with their own local moral traditions for guidance and inspiration. Only in this way will alternative bioethics traditions emerge. Those -- like the author of this blog -- involved in bioethics capacity-building projects in developing countries may still have a delicate role to play as facilitator or catalyst. In any case, the bioethics missionary has to be phased out, and replaced by those willing to listen as much as lecture.

Globalization of health research: old story, new twists

When a story comes out called Big Pharma's Global Guinea Pigs, you can be sure of a number of things. There will be talk about the Tuskagee syphilis study, and if the author has been getting out lately, reference to the recent revelations about abusive US-led research in Guatamala during the 1940's. There will be mention of pharmaceutical companies outsourcing their research to cut costs, avoid red tape (read: institutional review boards) and gain access to research participants who are 'drug naive' (read: do not have regular access to adequate health care). The fact that FDA makes overseas site inspections as frequently as solar eclipses is brought in, giving the impression that when trials take place abroad, no one is really at the regulatory wheel. There is a good deal of truth to all of this, and perhaps it needs to be said repeatedly, given the challenges that the 24-hour news cycle poses to human retention. But it does get pretty tedious, so at this point I tend to scan these sorts of texts in search of a new twist.

The new twist in this particular news item is this:

In the United States, the Justice Department has mounted an investigation under the Foreign Corrupt Practices Act to see if drugmakers are offering overseas bribes, and clinical trials are firmly in the spotlight. That's because doctors in many countries are government employees and therefore any payments to them deemed above fair market value might be viewed as bribes. Britain, too, is introducing a strict new Bribery Act in July that also covers such overseas payments.

This is new, because most news items about global health research are focused on the possibility of research participants being exploited. Here, it is about alleged harm caused to medical institutions and patients by paying health care workers too much. Because just paying persons too much is not in itself a bribe: it is a bribe when the person starts bending rules for money, like a policeman on the take. And the rules being bent might come down to harm to research participants in the end, such as when overseas physicians in the pocket of Big Pharma 'massage' inclusion criteria for studies in order to satisfy the need for large sample sizes. As the global health research market grows, gets more diverse and complex, and the usual suspects get increasingly aware of the usual criticisms, the emergent ethical problems appear as new wrinkles in the old story.