Review of Jennifer Hawkins Exploitation and Developing Countries
Jennifer Hawkins in her paper on exploitation and research ethics recognizes two principles of research which are being violated in many developing countries. She refers to the first principle as the principle of standard care, and the second principle the principle of clinical equipoise. Although these two principles seem to be logically inextricable, Hawkins notices that the two principles are not logically connected and that this can be seen when the two background assumptions usually associated with them are missing as can often be the case in developing countries.
The first principle requires research subjects to receive whatever the current standard of care is for the illness. If there is no treatment currently available then the use of placebos is allowed. The second principle the principle of clinical equipoise states that only under the condition that there is genuine disagreement within the medical community about which treatment is more beneficial for the subject are Randomized Control Trials (RCT) allowed to be used. Adhering to these rules provides researchers with the expectation that no one will be made worse off than prior to the research.
These two principles in the context of the developed world seem to be logically inseparable with the presence of two common background assumptions. The first assumption is that in the developed world there would never be any need to seek out new treatments which would be less effective than existing treatments. The second assumption is that in developed countries the treatments which are available are always the best existing treatments available and so there is no incentive to participate in research which may lead to someone getting inferior or dangerous untested treatment. When the assumptions which are present in the more developed countries are no longer applicable, such as the case in the less developed countries Hawkins thinks it is easier to see that satisfaction of one principle is neither necessary nor sufficient for satisfaction of the other.
The case in which standard of care is understood in terms of the standard which is locally available is an example under which one of the two principles can be satisfied without the other. To illustrate this, the example of a small imaginary tribe in Africa is useful. It is easy to envision such a tribe in a remote African area in which due to the remote location of the tribe the existing treatments are a fraction of the available options to those in more developed countries. Furthermore, because of economic restraints a vaccine with a slightly less effective than a full strength one may be of value because of the possibility of it being provided at a cheaper rate. Under these conditions both background assumptions are no longer present, and it can be seen how the first principle may be fulfilled without the second, supposing that the local remedies are wholly inadequate at fighting the disease when compared to western methods. In this scenario it would mean that the principle of standard care would be provided, the research subjects would be at least receiving the basic care normally provided and yet there would not be clinical equipoise. It would seem reasonable that within the medical community the majority would prefer the weaker version of the western vaccine than the local remedy. This shows that the two principles are logically independent of one another because the first principle would be fulfilled but not the second.
Andrew Milroy 