Research Ethics in Relation to 'Resource-Poor Settings' Flashcards
Examples of the sheer scale of health inequalities
Lifetime risk of dying from complications of pregnancy and childbirth in UK: one in 8,400
In sub-Saharan Africa, the world’s poorest region, it is one in 37 (World Health Organization et al., 2019)
Circa 2010: 20 oncologists for Honduras’ 8 million people; four oncologists for Ethiopia’s 80 million (Knaul et al., 2012)
What is material deprivation?
Material deprivation refers to the inability for individuals or households to afford those consumption goods and activities that are typical in a society at a given point in time
A key social determinant of health
Food (in)security and diet quality remain key concerns worldwide
What are social determinants of health?
The economic and social conditions that influence individual and group differences in health status
Should the depth of a country’s pockets determine who gets access to vaccines for Covid-19, and when?
A key health ethics issue
Rich countries have vaccinated the bulk of their populations earlier than others
A catastrophic moral failure
Should lower-cost treatments than those associated with normal standards of care in high-income world be offered in ‘resource-poor settings’
A key health ethics issue
Cervical cancer screening: Pap cytology and HPV testing in Chicago; visual inspection with acetic acid and cryotherapy for suspicious lesions in Botswana
Stavudine-based antiretroviral therapy (less expensive, but more toxic) for HIV/AIDS in low-income countries
WHO position: A medical device that ‘is unacceptable in the donor country it is also unacceptable as a donation’ (re-used pacemakers retrieved from cadavers, sterilised and repackaged as an example), but
Accepts phenobarbital as a treatment for epilepsy in poor countries even though more toxic than more recent treatments
The case for resource sensitivity
‘This difference in care between Chicago and Botswana presents an ethical dilemma in global health: is it ethically acceptable to provide some patients cheaper treatments that are less effective or more toxic than the treatments other patients receive? We argue that it is ethical to consider local resource constraints when deciding what interventions to provide’
What are the distinctive challenges and obligations for researchers in ‘resource-poor settings’?
A key health ethics issue
Inequalities in resources (journal subscriptions, internet access, protected time for research) between researchers from high- and low-income countries
Inequalities in resources and power between researchers and research participants
More specifically, in the context of the offshoring of clinical trials to low- and middle-income countries that offer lower costs, more (and more treatment naïve) potential participants,
How voluntary is ‘informed consent’ in contexts where a clinical trial may be the only access to care, and the usual standard of care is no care at all?
In such contexts, is use of placebos or less effective treatments as controls justified when demonstrably effective therapies already exist?
Unfortunately, given the world’s level of global health assistance, nothing we do will get many people in poor countries the world’s best standard of care in a foreseeable time
Fundamental ethics question: whether we prohibit research that might ameliorate their situation even if it does not result in providing them the world’s best standard of care
Absolutists declare that research into ameliorating technologies are unethical because they are not the best. The absolutists condemn people who cannot get the best to whatever they currently have with no improvement.
Someone who believes in the principle of progress over perfection will recognise that sometimes it is necessary to conduct research on treatments that improve the situation but are not the best available in the world.
What was the declaration of Helsinki
The World Medical Association has developed the Declaration of Helsinki as a statement of ethical principles to provide guidance to physicians and other participants in medical research involving human subjects
The basic principles include respect for individuals, the right to make informed decisions, recognition of vulnerable groups, and more
Why are some settings ‘resource-poor’ and others not?
A key health ethics issue
‘The problem of scarcity is regarded as the fundamental economic problem arising from the fact that, while resources are finite, society’s demand for resources is infinite’
Whilst health economics takes scarcity as given, a critical approach to health ethics should start by asking where scarcities come from, and for whom or what resources are not scarce
A crisis unfolding? The NHS under stress in the pandemic
‘Germany has 29 ICU beds per 100,000 population, the US around 25, the UK 6.6’
The number of hospital beds in England has halved over the past 30 years
Spending on health has reduced significantly with a conservative government
Without a vaccine or a reliable test, the issues outlined here may mean that the UK will be operating a health system with the capacity of a middle-income country – but with the expectations, regulatory standards, inspection regimes and governance of a high-income one
Interrogating scarcity
In many situations, ‘scarcity is not the result of any absolute lack of a resource but rather of the decision by society that it is not prepared to forgo other goods and benefits in a number sufficient to remove the scarcity.
We must determine where – if at all – in the history of a society’s approach to the particular scarce resource a decision substantially within the control of that society was made as a result of which the resource was permitted to remain scarce. …. Scarcity cannot simply be assumed as a given’
The normalisation of ‘austerity’: Consequences of failing to interrogate scarcity
‘Austerity is the calling card of neoliberalism. Its effects follow an inverse harm law—the impact of increasing amounts of austerity varies inversely with the ability of communities to protect themselves. Austerity is an instrument of malice. …. What is promoted as fiscal discipline is a political choice. A political choice that deepens the already open and bloody wounds of the poor and precarious. …. The task of health professionals is to resist and to oppose the egregious economics of our times’ (Richard Horton, 2017)
