Considering Therapeutic Misconception...The Conflated Patient/Subject

A good friend of mine posted this link on my Facebook wall the other day. For several years, this embarrassing illustration of the consequences of bioethical inadequacy has haunted the pharmaceutical giant. Much of the focus of the Pfizer debacle has centered on the unethical conduct of the clinical trial in Kano. I contend that focus should lie not primarily with the procedural and infrastructural problems that allowed such ethical misconduct in the first place. We should equally focus on the deep seated issues of scarcity of resources and lack of access to medical care that make clinical trials the only alternative for so many in developed world to obtain drugs for treatment- therapeutic or otherwise.

Charles Lidz and Paul Appelbaum defined and extensively researched what they call the Therapeutic Misconception. They contend that it "occurs when a research subject fails to appreciate the distinction between the imperatives of clinical research and of ordinary treatment, and therefore inaccurately attirubutes therapeutic intent to research procedures." The developing world is faced with a quandary whereby access to clinical trials and other research may be the only means for obtaining treatment, even though the treatment may not prove beneficial to the patient/subject. Patients and subjects become conflated, while the objectives of the investigator and clinician remain separately defined. For many, participation in clinical trials without a full appreciation of the risks, benefits and alternatives results in inadequate consent for participation. For others, the guarantee of study drugs, therapeutic or not, is incentive enough. How should one balance ethical obligations with the need for advancement of science and technology, and sound data? The line separating coercion and incentive has all but blurred with the increase in outsourced clinical trials. How do we  reconcile this? I argue that bioethics and public health must form an integrated discourse by which we address practical public health issues incorporating bioethical theories and ideas. Logical? Practical? What are your thoughts?

Weaving bioethics, economics and foreign aid...

A couple of years ago, I came across a brilliant book by reknowned economist Dr. Dambisa Moyo, titled Dead Aid. In it, she offers some very compelling and oftimes controversial analyses on the problem of international NGOs and other agencies providing foreign aid to developing countries, particularly in Africa. The premise for her book is, summarily, that foreign aid has been a crippling and regressive force in Africa, and that elimination of aid will help spur individual countries to explore innovation, sustainable economic and agricultural programs and other means of reducing rates of poverty. She contends that aid removes the incentive for leaders to be held truly accountable for the status of their (our) societies, and that it breeds rampant corruption.

What with the increase in microloans for communities in the developing world, I foresee that the paradigm shift has already gone from provision of aid to a more constructive, sustainable system on the small scale in the developing world. Dr. Moyo's central argument has strong economic, public health and ethical implications for the future of Africa. Let's consider the issue of foreign aid from a bioethical perspective. From the deontological perspective, one can simplistically argue that the provision of aid is a necessary act of goodwill to those that "have not". But does the "rightness" of the distribution of foreign aid to the developing world mitigate what Dr. Moyo describes as a "disease" and "trap" for poor African nations? Consequentially speaking, one could argue that providing sustainable means of economic development in the form of microloans and other programs would be more beneficial and thus more ethically sound than the simple provision of foreign aid, which could inadvertently breed corruption. 

Ultimately, economic growth and decreased poverty are inextricably linked to greater health outcomes. A nation's health is directly proportional to it's human capital and productivity. A closer analysis of the link between economic growth, poverty and health outcomes fosters an shift from theoretizing to practical application of bioethical principles from a multicultural perspective, and an influence on national and international policies the world over.