HIV Vaccine Trial participation in the Third World : an ethical assessment

[摘要] ENGLISH SUMMARY: This essay examines the issue of trial participation in the proposed my Vaccine Trials inSouth Arica. It is set against the backdrop of ethical issues relating to research in theThird World in general.Trial participation is examined in the context of the ethical tension that exists betweeninternational ethical research standards based on Liberal Individualism and localstandards of care and cultural norms in the Third World. Two areas of conflict areinherent here: universality versus particularity on the one hand and individualism versuscommunitarianism, on the other.The Tuskegee Syphilis Study as well as the HIV Vertical Transmission Trials are used asa point of departure to set the stage for the controversy surrounding the proposed HIV Vaccine Trials.The important concepts of informed consent, the risk-benefit ratio and fair treatment oftrial participants are framed within the Four Principle Approach of autonomy,beneficence, non-maleficence and justice. These principles form the cornerstone of theDeclaration of Helsinki. This Western ethical guideline - grounded in universality - hasbecome the mantra of all liberal democracies the world over and is chanted slavishly bythe international research community. It bears the hallmark of liberal individualism withits mandate that the concern for the interest of the individual must always prevail overthe interests of science and society. Followed to its logical conclusion, anyinfringements of the moral interests of trial participants must be viewed using a subject-orientedapproach. Such an approach sees the trial participant as being of paramountimportance and views research as highly desirable but morally optional. Clearly, this would mean the end of the road for medical research, especially in the ThirdWorld, where a truly subject oriented approach would render research tantamount toexploitation of vulnerable, educationally disadvantaged persons.In Africa, in traditional, rural communities, a moderate form of communitarianismreferred to as Ubuntu or communalism is still prevalent. In such communities, theconcept of personhood is embedded in the community or society. In these communities, abalancing approach, in which infringements on the rights of trial participants arepermissible in the name of science or society, provided the subject is not placed atsignificant risk, would be acceptable. However, liberal individualism is making inroadshere too. As such, the ethical tension between liberal individualism andcommunitarianism, which is unavoidable in research settings, is growing.This essay highlights many internal contradictions in liberal individualism - especiallywhere research ethics is concerned in Third World countries. One of the outcomes ofsuch contradiction is the attempt by the World Medical Association to amend theDeclaration of Helsinki - in the name of ethical relativism: different standards fordifferent countries or cultures.Surely, such liberal individualism cannot be seen as the endpoint of mankind'sideological evolution as Fukuyama phrases it, nor can it be the final solution to theproblems of the world and, as such, the end of history.In the context of the HIV Vaccine Trials, individual good clashes with societal good,universality with particularity and ultimately, modernism with postmodernism.In Western cultures, the individual enjoys priority; in other cultures, society is moreimportant - somewhere in between, we need to find common ground which can beincorporated into a balancing approach with minimal risk to the individual wheninfringement of rights is unavoidable.

[发布机构] Stellenbosch University