Researchers Abroad

International consensus remains elusive over what it means to provide fair benefits to developing countries involved in international biomedical research. In the May-June 2004 issue of this journal, participants in the 2001 Conference on Ethical Aspects of Research in Developing Countries nudged this divisive debate forward by arguing that making a successful intervention "reasonably available" to host populations after the completion of trials was inadequate. In the current issue, Alex London takes the debate yet another step.

London asserts that international researchers usually shield themselves from addressing larger questions of social justice in the contexts in which they work. They can do so because the international research ethics guidelines apply notions of justice only to the outcomes of research and screen out important information about their research environments. London argues that this leads to a "minimalist view" of research ethics: it accepts the status quo in the host community as the appropriate "normative baseline" against which proposed research initiatives are evaluated, it fails to situate the health needs of people in the developing world within a broader social, political, and economic context, and it limits the scope of its concern to medical research activities, abstracted from the social context. Against this view, London argues that researchers should respond to unjust socio-economic realities, in part by carrying out "duties of rectification": if researchers have relationships with organizations that have contributed to the plight of people in the host community, a special duty to aid those people is triggered.

Ironically, acting on these duties may be hampered by the very local realities London wants researchers to recognize. Ever more developing countries are engaging in transparent, fair, and democratic elections. Unfortunately, despite their political legitimacy, many elected officers are corrupt, undeserving of their position, and often not representative of the people. But because they are the "rightful" holders of office, foreign researchers have to forge formal relationships with them. London suggests that in such cases, researchers must recognize the unjust socio-political structures in the country and attempt to rectify the effects of such wrongs by, for example, providing direct assistance to oppressed populations.

In principle, this is surely right. Why should citizens in the developing world suffer doubly—first from an unfair, selfish ruling class, and then from an international research community that primarily benefits this privileged class? In practice, however, providing direct assistance to vulnerable populations ruled by corrupt governments is a tricky matter. Sovereign nations in the developing world are entitled to draw their own regulations. Foreign researchers bypassing government and providing direct aid to vulnerable populations may be seen as acting in defiance of the existing rules, undermining or interfering with the sovereign rights of the country, and this may lead to problems—not just for the researchers, but also for the populations receiving the aid. Further, if they reject government channels, it is not clear how they can distribute aid—even non-governmental organizations are subject to government regulation. Finally, if many problems in the developing world have been caused by foreign institutions, why should people there trust foreign researchers over their own flawed but democratically elected governments?

Nevertheless, practical difficulties aside, these vulnerable populations absolutely have a claim to better life conditions, and we are left to figure out the best way forward. London's suggestion is a "human development approach." Rather than ask medical researchers to reform developing countries' socioeconomic and political systems—a gargantuan task—he suggests that they try to "create and sustain social structures that secure individuals' capacity for welfare and human agency." They could satisfy this duty by focusing on interventions that would help the country meet its special health priorities.

This is better. While it is morally difficult for researchers to work in environments where injustice, poverty, and inequities are rampant, researchers are not best placed to become agents for political and economic reform. In fact, given the colonial legacies of many developing countries, their efforts would surely backfire. But London's human development approach would contribute to social and political empowerment of the community itself. An educated and empowered population has the political legitimacy and cultural validity to hold its own government accountable...