Vulnerable people are increasingly targeted as subjects for clinical research. Have we forgotten the lessons of past abuses?
A GREAT deal of scientific research 鈥� especially in medicine 鈥� relies on human subjects. Protecting volunteers has been a prominent social and legal issue since the 1950s, when the world recoiled from the horrors of Nazi medicine.
We have come a long way since then, but it pays to remember that the Nazis did not have a monopoly on atrocities committed in the name of science. One of the worst cases of human subject abuse was perpetrated by American scientists who, between 1932 and 1972, misled hundreds of black people with syphilis in Tuskegee, Alabama, by deliberately leaving them untreated to enable researchers to study the progression of the disease.
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Tuskegee wasn鈥檛 an isolated incident. Historian Susan Reverby of Wellesley College in Massachusetts recently uncovered another appalling ethical breach. In the 1940s, researchers from the US Public 91色情片 Service deliberately infected Guatemalan patients, prisoners and soldiers with syphilis to test whether penicillin was an effective treatment. In , she describes how in some cases infected prostitutes were paid to have sex with prisoners. This breach happened at almost the same time as Nazi doctors were on trial at Nuremberg for similar abuses.
Reverby鈥檚 revelation led the US to issue formal apologies to the victims and the Guatemalan government. It also prompted President Barack Obama to instruct his Bioethics Commission to turn its focus away from synthetic biology and take a fresh look at the protection of human subjects, so as to 鈥渁ssure that current rules鈥� protect people from harm or unethical treatment鈥�.
Obama should be applauded. But if he and the commission merely review the rules without examining the broader context in which human research occurs, they may vastly underestimate the depth of the problem. Particularly troublesome is the extent to which research on human subjects increasingly targets vulnerable people.
This is seen most clearly in clinical trials. The pharmaceutical industry spends billions of dollars each year testing experimental drugs, with a significant portion of this cost stemming from recruiting and retaining human volunteers.
Subjects for research are in high demand. A showed that the pharmaceutical industry conducted 36,839 clinical trials between 2001 and 2004 鈥� six times more than in a similar period starting in 1981. This rapid expansion is causing demand for human subjects to outpace supply. To meet the need for more bodies while keeping costs down, the industry is resorting to extreme measures, and the most vulnerable members of society are in the crosshairs.
First, poor people and undocumented immigrants are often targeted to participate in drug trials. The industry-wide practice of paying participants hundreds, and in some cases thousands, of dollars attracts poor people who are simply doing it for the money.
As a second trend, drug companies are looking to developing countries, where poverty is extreme and social services non-existent. A 2009 study in The New England Journal of Medicine () revealed that one-third of phase III clinical trials sponsored by the 20 largest American drug companies are conducted in foreign countries. Over 50 per cent of all clinical trial sites are outside the US, with India and sub-Saharan Africa becoming increasingly important. The study also found that since 2002, the US Food and Drug Administration has seen a 15 per cent annual increase in the number of clinical trial investigators it regulates outside of the US while the number of domestic investigators has fallen by 5.5 per cent overall.
While clinical trials may offer the developing world some measure of healthcare, they may also give rise to controversial research practices. For example, in Nigeria to settle charges 鈥� without admitting any wrongdoing 鈥� that it illegally tested an experimental antibiotic on children, leading to 11 deaths.
Finally, there is a movement in the US to give researchers easier access to prisoners. Current regulations, stemming from past abuses, severely restrict scientists鈥� ability to recruit prisoners for clinical research. But the Institute of Medicine 鈥� an influential government advisory body 鈥� has recommended relaxing these restrictions. While no decision has been made, the once unthinkable idea of reopening prison gates to biomedical and behavioural research is now back on the table.
These practices highlight how one of the most crucial ethical debates in science and medicine is not over speculative technologies such as synthetic biology. Rather, it concerns the more basic question of how we treat each other. With an entire research industry becoming increasingly dependent upon vulnerable populations to test experimental treatments, not enough thought has been given to issues of justice. We are not back in Tuskegee territory yet, but this approach to recruiting human subjects may give rise to outcomes that are similarly pernicious.
Obama should be commended for instructing his Bioethics Commission to look into ways to prevent further human subject abuses, but its mandate must go beyond checking the rules. Rather, the commission must examine a deeper question: is it ever ethical to ask the most vulnerable members of our society to give their bodies to science?
