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Abstract

The concept of exploitation refers to a very actual, though highly complex, phenomenon in human affairs, generally, and in international biomedical research in particular. There is no consensus as to whether the phenomenon has only a “thick” (i.e., negative) moral connotation, although such a pejorative meaning is mostly associated with it. Exploitation refers to actions that often seem to involve inﬂicting harm on people, treating people with disrespect or injustice, and interacting with vulnerable people with whom one stands in an unequal relation of power. As such, it usually involves the degradation of human beings who stand in unequal and vulnerable relations to people or institutions that are more privileged. Exploitation can and does often occur in the actual practice of international biomedical research. It thus represents one of the most actual moral risks to be faced and dealt with in efforts to humanize the world via effective medical care. The threat of exploitation invites individuals to develop an enlarged sense of responsibility for their fellow human beings in the developing world. It must be argued that enlarging this sense of responsibility not only requires a heightened sense of altruism. It indeed also implies a more enlightened sense of self-interest.

Introduction

“Exploitation” is an important concept in the moral vocabulary of current-day global bioethics. The reason for this is the fact that, in much of the literature, exploitation ﬁgures prominently as a core issue in the understanding of some of the most important predicaments of this (relatively new) ﬁeld of bioethics (Benatar 2000; Benatar et al. 2003; Macklin 2004; Resnik 2003; Sample 2003). Exploitation is mostly regarded as morally blameworthy and as something that needs to be avoided, particularly in the context of biomedical research. The National Bioethics Advisory Commission in the USA, for example, declares the following in their report:

“Exploitation in any form can be construed as a human rights violation by virtue of its failure to recognize the inherent dignity of every human being, a precept embodied in the Universal Declaration of Human Rights. It follows that all parties have a fundamental obligation to avoid exploitation when conducting research, especially in poorer, less advantaged countries. In any case, exploitation is a serious moral wrong, and a fundamental obligation exists to refrain from behaviour that constitutes or promotes it.” (“Ethical Issues in International Research – Setting the Stage,” 2001)

The term “to exploit,” as has been shown by Wertheimer, originally has both a morally neutral and a morally non-neutral or morally critical meaning (Wertheimer 1996, p. 10). In the neutral sense, one might say that “Peter exploited his knowledge of music in order to impress his new girlfriend,” in which case one simply means that he applied his music knowledge to his own beneﬁt in his effort to impress the girl. Mostly, however, the term “to exploit” is used in a morally negative sense, i.e., in a sense in which the action of exploitation is regarded as morally wrong or dubious. As will later be shown, some authors (e.g., Wertheimer 1996; Resnik 2003) do argue that there are instances of exploitation that are not necessarily morally wrong. Others (e.g., Sample 2003) argue that the only morally relevant meaning of the notion of exploitation is its so-called “thick” meaning, i.e., a meaning which necessarily carries a morally critical connotation. The possible and desirable meanings of the term will be more fully analyzed in a later section of this research paper .

Exploitation is a phenomenon that can occur at the level of individual, institutional, and (inter-) national activity. Individuals can exploit (an-) other individual(s); institutions (i.e., instances of collective human action, such as corporations or universities) can exploit individuals and other institutions; and whole countries (both in the sense of governments or the citizenry of a country) can exploit people, institutions, or other countries.

The concept has gained in prominence, particularly in the aftermath of large-scale research programs that have been launched in the so-called “developing world” since the second half of the twentieth century. The agents of these programs are by and large medical researchers of the developed world in general and large pharmaceutical conglomerates who indulge in widespread research in particular. At the international level, exploitation can occur in many areas. In the area of geopolitics, it is, for example, often argued that Palestinians in the current state of Israel are exploited by the government of the USA in the sense that the latter country refuses to cease its military aid to Israel, not primarily for the sake of safeguarding Israel against Arab aggression but also to reassure the pivotal Jewish lobby in a key state (for presidential elections) such as New York. In this research paper , however, the focus will be on issues of exploitation that are relevant in the bioethical context, i.e., issues of possible exploitation in research and health care-related matters that evoke deep moral concern in a bioethical context.

The outline of this contribution is as follows: After this introduction, a few remarks will be made about the background to, and the historical development of, the moral issues evoked by the activity of exploitation in the biomedical context. Thereafter, an accurate as possible deﬁnition of the notion of exploitation will be investigated, bearing in mind the complexities of some of the literature in which this has already been attempted. This will be followed by a discussion of the ethical problems evoked by clear-cut instances of exploitation in the global biomedical context. The article will be completed by a conclusion, a set of Bibliography :, and some suggestions for further reading.

A Brief History Of Exploitation In The Biomedical Context

The world has changed profoundly since the birth of modern bioethics in the aftermath of the Second World War. These changes pertain to widening international economic disparities, the emergence of new infectious diseases, new consumption patterns, new wars, advances in science in technology, and many other factors. One of the important implications of these changes is that bioethics is increasingly challenged to not only interest itself in the “micro-level of inter-personal relationships” but also to concern itself with the “the meso-level of institutions and nations and [with] the macro level of international relations” (Benatar et al. 2003, p. 108). If this happens, a “new mindset” could be promoted that is currently required to improve health and well-being all over the world. What must be acknowledged is the increasing complexity and interdependence of the world in which we currently live. This growing complexity indicates how narrowly health, human rights, and economic opportunities are related. It is a serious question whether the models in terms of which human ﬂourishing has mainly been understood up till the present, particularly in the West, have adequately espoused the value of the dignity of all people and the need to promote that dignity through optimal development, particularly in less-privileged environments and societies (Ibid.).

What is increasingly becoming clear in the current-day world are the stupefying economic and health-care inequalities between developed and developing countries. The following facts and statistics are relevant in this regard and starkly illustrate these inequalities. First to note are the indefensible general income disparities between people in the developed and developing worlds. “At the beginning of the twentieth century, the income of the richest 20 % of the world’s population was nine times that of the poorest 30 %. By 1960, it was 30 times as large.; and since then the gap has widened ever more rapidly to the point where at the end of the [20th] century the richest ﬁfth had an income 80 times that of the poorest ﬁfth.. .Today, 2 billion people live on less than US$2 per day, and more than a quarter of the world’s population lives under conditions of ‘absolute poverty” (Benatar et al. 2003, p. 112). Sub-Saharan Africa generates no more than 1 % of the total wealth produced in the world. It has been reported in Time magazine (3 May 2004, p. 14) that there has been a 15 % drop in GDP per capita in sub-Saharan Africa between 1981 and 2001. There has also been a 91 % increase in the number of people living on less than $1 a day in the same region over the same period.

Income disparities between richer and poorer countries are, therefore, in spite of inﬂated political rhetoric at international level in favor of their reduction, increasing all the time. The buying power of all the countries south of the Sahara (South Africa excluded), in total, just about matches that of a country such as Norway. African countries also carry extremely heavy debt burdens – often, as in the case of South Africa, incurred by an illegitimate previous regime. The insistence on debt repayments in Africa has been described as the modern equivalent of slavery.

Apart from the general disparities of wealth and income, the extraordinary – in fact stunning – inequalities between developed and developing worlds in terms of health-care needs and provision must be noted. Life expectancy is, for example, generally regarded as a relatively trustworthy indicator of health status in a society. To illustrate the discrepancy between ﬁrst and third-world regions, in countries such as Italy, Switzerland, and Sweden, life expectancy is well over 80 years, whereas in countries such as Chad, Guinea-Bissau, and South Africa, it is dropping beneath 40. Another signiﬁcant indicator of discrepancies in the health systems of developed and developing worlds is the availability of medical doctors. A developed country such as Spain has 370 doctors per 100,000 members of the population. The USA has 245. Compare that to the ﬁgures of 10 (Guinea), 2 (Sierra Leone), and just more than 1 (Liberia) per 100,000 in the indicated developing countries – speciﬁcally mentioned in the light of their plight in terms of the Ebola epidemic which, at the time of writing (October 2014), is raging in those countries.

Spending on health care is probably the most pronounced indicator of inequalities in this regard. The USA spends above 50 % of the total health-care expenditure in the world. This US expenditure is in fact spent on only 5 % of the world’s population. In this current year (2014), the USA spends more than twice as much per capita on health care ($8,745) than the average developed country does ($3,484). Compare this annual per capita spending on health in the USA with a country such as Mozambique, whose total per capita spending on health is $49 (health care spending around the world, country by country (2012))!

All of these facts and developments indicate that the plight of the developing world, in spite of occasional increases in economic growth rates, is not signiﬁcantly improving and have increasingly supported the conviction that bioethics has to be reconceived on a global scale. Benatar et al. argue that the ﬁrst requirement is the development of a “global state of mind” (2003, pp. 129–133). The greatest moral challenge brought forth by globalization is the need to think of humanity in more communitarian terms. There is indeed a great need for a new moral language of public health which is informed by the realities of reciprocity and interdependence.

Conceptual Clarification

What exactly the term “exploitation,” particularly in the context of global bioethics, means is a quite complicated matter. Before focusing on a deﬁnition that works best for the global context referred to in the previous section, it might help to reﬂect on some general conceptions of exploitation that one ﬁnds in the philosophical literature.

One of the standard texts in the debate about the meaning of exploitation in the literature is Alan Wertheimer’s book with the simple title Exploitation (1996). For Wertheimer, “A exploits B when A takes unfair advantage of B” (Wertheimer 1996, p. 10). He elaborates: “A engages in harmful exploitation when A gains by an action or transaction that is harmful to B where we deﬁne harm in relation to some appropriate baseline. A engages in mutually advantageous exploitation when in relation to the same baseline, A gains unfairly or excessively by an action or transaction that is beneﬁcial to B” (Wertheimer 1996, p. 207). This deﬁnition seems to claim two things: (1) Exploitation occurs when the interaction or “transaction” between two parties is unfair, in the sense that it unduly beneﬁts one of the parties. (2) Exploitation can be both harmful and “mutually advantageous,” although, even in the case where both parties gain, one gains unfairly or excessively compared to the other. “Mutually advantageous” exploitation could be illustrated by an example by Ruth Sample. A married woman dearly wants to have children. Her husband also wants children but is not prepared to, in any way, be involved in their daily care or share the housework. He is willing to provide for them ﬁnancially but will otherwise only selectively care for them, e.g., in emergencies when she is not available. The wife decides that she would rather have children under these circumstances than not at all. The husband is satisﬁed that his conditions are met, and they so agree to form a family under these conditions (Sample 2003, p. 9).

In this example, a “transaction” is accomplished that is mutually advantageous (both husband and wife attain what they want), but the transaction seems unfair, since the wife clearly will carry a heavier burden than the husband in order to make the arrangement work. Compare this to the following examples by David Resnik: “Suppose a man is selling water at the edge of the desert at exorbitant prices. Or suppose that he is selling what he insists is rare French wine, when it is really cheap American wine in a French bottle” (Resnik 2003, p. 235). These examples evoke undoubted moral indignation. As Resnik points out, this indignation is caused by three elements that clearly characterize the examples: harm, disrespect, and injustice. “If you take advantage of a person and harm that person, show lack of respect for that person, or treat that person unjustly, then you have exploited that person” (Ibid.).

Another inﬂuential notion of the term “exploitation” is that of Robert Goodin (cf. Goodin 1985, 1987, 1988). He argues that vulnerability is the source of people’s moral obligations to one another. The fact that other people are dependent on us and our ability to help them obligates us as moral agents to do so. He therefore deﬁnes exploitation of persons as “wrongful behaviour [that violates] the moral norm of protecting the vulnerable” (Goodin 1988, p. 147).

Goodin’s notion of exploitation is well illustrated by some of the best-known cases of exploitation in the history of bioethics. One is the Tuskegee syphilis trials where, in the early 1930s, black men from very poor backgrounds who contracted syphilis were put on a trial, without their consent, to ascertain the “natural progression of untreated syphilis” at a time when a cure was not yet available. (The trial was their only access to decent medical care, and they were lured to stay in the trial with beneﬁts such as occasional hot meals.) When, in the early 1940s, it became well known that penicillin is an effective treatment for syphilis, these black men were not offered or made aware of that possibility, and the “control arm” that observed the “natural development of the disease” (mostly developing into serious brain damage, terrible suffering, and death) was continued into the 1960s, when it became public knowledge and caused an enormous public outcry. The men were ostensibly vulnerable, and what happened to them was a clear case of severe exploitation in Goodin’s sense. The same is also true for the victims of the Willowbrook hepatitis study in New York where a new vaccine for hepatitis was tested on mentally disabled children who could not give consent and whose parents faced the predicament of having to take their children out of school if they did not give consent. These children, as well as their parents, were clearly extremely vulnerable in the sense of being dependent on others to provide adequate care for children who could not look after themselves.

A shortcoming of Goodin’s notion is that the conditions of vulnerability are not satisfactorily explained. Sometimes he creates the impression that he invokes a utilitarian criterion for identifying vulnerability, with the implication that exploitation would only occur if the consequences for the exploited are unambiguously bad. At other times, he identiﬁes exploitation with taking advantage of others and asserts that such advantage taking is bad in itself, irrespective of any consequences. (For a comprehensive critical discussion of his views, see Sample 2003, pp. 27–54.)

Allen Buchanan has deﬁned exploitation as “.. .the harmful, merely instrumental utilization of [another person] or his capacities, for one’s own advantage or for the sake of one’s own ends” (Buchanan 1985, p. 87). This deﬁnition afﬁrms that the inﬂiction of harm is a necessary condition for identifying an action as exploitative. That does not seem self-evident. Sample offers an example to illustrate: “A Catholic missionary offers to help a hungry, sick man. However, she requires that, as a condition of receiving assistance, the needy man must attend mass each day. The needy man is Hindu” (Sample 2003, p. 8). In this case, the needy man is exploited by the missionary in the sense that he is instrumentally utilized to further the end of the missionary (i.e., the Christianizing of the community in which she works), but it would require much imagination to view the missionary’s actions as harmful.

In the conceptual analysis up till now, it is clear that exploitative actions often seem to involve inﬂicting harm on people, treating people with disrespect or injustice, and interacting with vulnerable people with whom one stands in an unequal relation of power. That raises the question of whether these elements are all necessary and sufﬁcient conditions for a coherent and consistently applicable notion of exploitation. It has already been shown that the inﬂiction of harm does not seem to be an either necessary or sufﬁcient condition. The same goes for disrespect or injustice. If a ﬁrst-world industry opens a factory in a very poor area of some developing country, mainly for the sake of acquiring cheap labor (since trade unions are also forbidden in that country), and pays the laborers only subsistence wages, knowing full well that the jobs on offer are the only possibilities for work in that area, they are exploiting vulnerable people on the basis of an unequal relation of power, and they might even be acting unjustly. Are they, also, showing disrespect for the workers? On the face of it they are, after all, offering them a chance of survival that would have gone begging if they did not invest in that country in this way. The workers, given the fact that this factory is their only chance for work, will probably grab the opportunity; both parties thus seemingly draw advantage from the situation.

David Resnik (drawing on the work of Alan Wertheimer), in his comprehensive analysis of the notion of exploitation, comes to the conclusion that not only are there instances of exploitation generally, and of exploitation in research speciﬁcally, that are not wrong but that there are also degrees of exploitation. His argument is “to show that calling a human activity exploitative does not prove that the activity is wrong” (Resnik 2003, p. 241), to which he adds in his conclusion: “Although highly exploitative research is immoral, minimally exploitative research may be morally justiﬁed because other moral considerations may outweigh the wrongfulness of exploitation” (Resnik 2003, p. 251). In concluding this conceptual analysis, one more effort will be made to, in view of conceptual difﬁculties, come to a clearer understanding of exploitation generally – a conception that, in spite of Resnik’s and Wertheimer’s doubts about the possibility of sustaining a morally pejorative understanding of the term, nevertheless attempts to reconstruct the “thick” (i.e., overwhelmingly critical and negative) meaning that prima facie is implied by the term. To it will be added a conception that is also directly related to the international biomedical research context referred to earlier.

The notion indicated is that of Ruth Sample in her book with the outspoken title Exploitation: What It Is and Why It’s Wrong (Sample 2003). She calls the notion that she develops, mainly in response to that of Wertheimer and Goodin (whose views she analyzes in two comprehensive chapters), exploitation as degradation. She claims that it “comports with some basic Kantian ideas of respect for persons” but that it is not “speciﬁcally Kantian.” Her notion of exploitation is “better described as pluralistic yet objectivist about value and is consistent with the view that human beings have objective and intrinsic value” (Sample 2003, p. 56). The following quotation is a succinct and neat summary of the notion of “exploitation as degradation”:

“The basic idea is that exploitation involves interacting with another being for the sake of advantage in a way that degrades or fails to respect the inherent value in that being. It is this lack of respect that explains the badness of exploitation. The consequences of such disrespect are connected to, but not constitutive of, the exploitation.. .What motivates this understanding is the following intuition. Other human beings possess a value that makes a claim on us. In exploitation, we fail to honor this value in our effort to improve our own situation. With respect to humans, we do this in a number of ways. First, we can fail to respect a person by neglecting what is necessary for that person’s well-being and ﬂourishing. Second, we can fail to respect a person by taking advantage of an injustice done to him. Third, we can fail to respect a person by commodifying, or treating as a fungible object of market exchange, an aspect of that person’s being that ought not to be commodiﬁed. My claim here is that a lack of respect for the value in human beings is what uniﬁes these disparate forms of exploitation judgment, and that it is what motivates the charge of exploitation when that charge is made.” (Sample 2003, pp. 57–58)

This circumscription of degradation as the core component of exploitation makes it clearer why, in the example of the factory workers above, exploitation does take place without it being clear that the workers are harmed. In material terms, they are beneﬁted, because they now gain wages that they would not have had without the jobs in the factory. Sample’s point, however, is that, even though they are (at least materially) not harmed, they are seriously exploited, since the entire rationale behind the action of the industrialists amounts to, essentially, a degradation of the workers. They are paid wages, but wages that would never have been acceptable in their home country or in a context where trade unions – often regarded as a human right – are legal. They are exploited in the sense that they actually are looked upon by the industrialists as less than full-ﬂedged human beings; they are hardly more than mechanisms for optimal proﬁts. They have no prospects for improvement. In terms that Karl Marx might well have used, their exploitation and continued subsistence living are a condition for the continued presence of the industrialists in their community. Exploitation not only comes to the fore when people are harmed or are acting unjustly or taking advantage of others; people are indeed exploited when they interact with others, in order to promote their interests, in a way that degrades the humanity of the others they are interacting with. It is very difﬁcult – if not impossible – to identify forms of exploitation that meet this description and that could nevertheless not be regarded as morally wrong.

Even though the notion of exploitation that has just been suggested might seem attractive, the fact remains that it looks upon exploitation as fundamentally an interaction between individuals, and it also does not fully resonate with the context of global bioethics and the issue surrounding exploitation that a global bioethics confronts one with. In concluding this section, a deﬁnition of exploitation will be suggested that has a more direct bearing on the exploitation issues in international biomedical research.

This suggested deﬁnition is that of Ruth Macklin, formulated in her seminal book Double Standards in Medical Research in Developing Countries (Macklin 2004). For Macklin, “Exploitation occurs where wealthy or powerful individuals or agencies take advantage of the poverty, powerlessness, or dependency of others by using the latter to serve their own ends (those of the wealthy or powerful) without adequate compensating beneﬁts for the less powerful or disadvantaged individuals or groups” (Macklin 2004, pp. 101–102).

This deﬁnition has the following commendable components:

It sees the subjects of exploitation not only as individuals but also possibly as groups or institutions – even countries.
It acknowledges that exploiters are always more powerful and/or considerably wealthier than those being exploited; there is, in the exploitation that occurs in international biomedical research, always unequal power and wealth relations.
Exploitation entails beneﬁting oneself at the cost of others; others are used for the beneﬁt of the exploiter or for furthering the ends of the exploiter. In the Kantian sense, exploited people are not looked upon or treated as ends but only as means to ends. They are thus also degraded in the sense that Sample draws our attention to.
Even in situations where it could be suggested that the exploited people are not harmed because they receive some beneﬁt from the interaction with exploiters – beneﬁts that would not accrue to them if no such (albeit exploitative) interaction was forthcoming – the beneﬁts/compensations of the exploited persons are inadequate or considerably less than fair or just.

Exploitation In A Global Biomedical Context

In the section preceding the conceptual analysis, the developments which indicate and exacerbate the growing inequalities between (people living in) developed and developing countries were noted. This is a situation that is clearly conducive to large-scale exploitation on a global level. In the peoples and institutions of developed and developing countries, it is apparent that there are not only massive inequalities in terms of wealth and opportunity but also signiﬁcant inequalities of power. As can be expected, acts of exploitation that are morally indefensible can occur and have occurred in this context. At the same time, it is also noticeable that there is not a universal moral consensus on the exploitative nature of all the events that have been listed as instances of exploitation.

A number of morally problematic instances of exploitation in the context of global biomedical research have indeed occurred. Space does not allow a comprehensive discussion in this regard. In the rest of this research paper , four examples will be discussed:

Inadequate Benefit-Sharing

The ﬁrst of these are instances where the beneﬁts of research, done by a large pharmaceutical corporation in a developing country, were not adequately shared with or made available to the people of the developing country where the research for the new drug was in fact done.

An example of such a possibility occurred in Thailand in the early 1990s. At this time, a trial for a new vaccine for hepatitis A was conducted with children from the ages of 1 to 16 in Northern Thailand. The result was that the vaccine was found to be safe for a period of at least 1 year. Given its clear potential for improving public health, the trial was approved by the Thai Minister of Public Health. However, the vaccine was never made widely available in the Thai health-care system. “This is because it was determined not to be cost-effective to mount a routine vaccination program for children in Thailand – a calculation that could easily have been made in advance of the trial. In fact, the main reason for doing the trial was to ensure the availability of the vaccine in industrialized countries for people who travel to developing countries. The manufacturer, Smith Kline Beecham licensed the hepatitis A vaccine, and this has been its primary use” (Macklin 2004, p. 106). It is clear that in this case the Thai people – members of a developing nation – were exploited for the beneﬁt of people in the developed world, since the beneﬁts of the outcomes of the research done within the Thai society were not made available to that society.

The Relevance Of Cutting-Edge Research For Developing Countries

There is no comparison between the available resources and actual spending on health care between the richer and poorer parts of the world, as was noted earlier on. The inequality in terms of health-care provision is succinctly illustrated by a comparison of health-care research spending, as well as the priorities that are revealed in the patterns of research spending. Ninety percent of global expenditure on medical research is on diseases causing 10 % of the global burden of disease. Of the 1,223 new drugs for medical treatment developed between 1975 and 1997, only 13 % were for the treatment of tropical diseases so prevalent in a continent such as Africa (Benatar et al. 2003, p. 110). In this regard in particular, there is a serious suspicion of exploitation. An enormous amount of drug trials is done on the continents containing developing countries, e.g., Africa, Asia, and South America; in 1990 it was calculated to be at least 600 in Africa alone. Many of these trials, however (as is evident from the ﬁgures just quoted), yield drugs that are directed at diseases and conditions that, on the one hand, are irrelevant in the context of the developing world. At the same time, the diseases that are rampant in developing countries (particularly malaria and tuberculosis) are not the focus of the drug research of the pharmaceutical consortia since the ﬁnancial yield of such research cannot compete with the yield of drugs attuned to the ailments of people in developed societies.

Gardels writes in this regard: “Two-thirds of the world’s population are superﬂuous from the perspective of the market. By and large we [people in developed countries] do not need what they have; they [people in developing countries] can’t buy what we sell” (Gardels 1993, pp. 2–3). Benatar in this regard also writes about the problem of so-called “me-too” drugs that usurp an undue amount of investment by pharmaceutical companies in view of their proﬁtability – drugs with only marginal potential for beneﬁts. It can be expected that if the possibility arises to develop drugs that could, for example, effectively and safely prevent obesity or hair loss or face wrinkles, the pharmaceutical companies would concentrate all possible attention on these, not because they contribute to health (they hardly do) but because they would be in such a demand from afﬂuent ﬁrst-world citizens who will pay exorbitant prices for them. “There is also a drive to develop ‘lifestyle drugs’ for improving the quality of life and alleviating the symptoms of old age. The desire to make vast sums of money from medicinal drugs can be viewed as a modern version of the gold rush. Why make drugs for sick people who cannot afford them [and who mainly live in developing countries] when one can make drugs for people with resources who seek marginal improvements or those who are well and will pay for the possibility of a healthier old age? Proliferation of clinical research, much of it promotional and of dubious scientiﬁc value, follows” (Benatar 2000, p. 563).

What is interesting in these examples is that the phenomenon of exploitation does not so much occur in what is actually done directly to less privileged people in the developing world but in what is effectively accomplished through omission which, in this case, takes the form of actions actually committed for the sake of quite limited beneﬁts to the privileged few.

Commodification And Profit-Seeking In Clinical Research

Closely related to the previous point is the simple fact that clinical research is increasingly driven by market forces, particularly the drive to attain maximum proﬁts for the shareholders of the large, often multinational, pharmaceutical conglomerates that do most of the research. It must remain a serious ethical question whether the logic of markets and proﬁt-making in business is reconcilable with the logic of medical practice which seeks, primarily, the health, well-being, and relief from suffering of patients. Health care and particularly the drugs for medical ailments are increasingly seen as commodities by means of which enormous proﬁts can be attained. It is a known fact that the pharmaceutical conglomerates are the most proﬁtable legitimate businesses in the world, with proﬁt ranges often approaching or transcending 30 %. In this kind of world, it can easily happen that inhabitants of the developing world, who most often have no other access to decent health care (cf. the statistics quoted earlier), will jump at the opportunity to act as the guinea pigs of new drugs that are tested, not primarily for their own potential welfare but for that of people with much money or reliable medical insurance across the ocean. This is exploitation in its crudest form. To put the problem in perspective, Benatar provides the following ﬁgures: “In the United States, more than $11 billion is spent each year by pharmaceutical companies in promoting and marketing drugs (between $8,000 and $13,000 on each physician) – a process that has been shown to affect prescribing and professional behaviour. Furthermore, 89 % of annual global expenditure on health is on the 16 % of the world’s population that bears 7 % of the global burden of disease” (Benatar 2000, p. 564).

Double Standards In International Clinical Research

The issue in this regard pertains to the question as to when research is done in the developing world for ailments prevalent there, the same standards of safety and scientiﬁc rigor obtained. The best-known example in this regard are the controversial trials in which considerable shortened regimens of zidovudine (AZT) to prevent mother-to-child transmission of the HI virus were tested in African countries against placebo – an event which caused the then editor of the New England Journal of Medicine, Marcia Angell (1997), to protest against the ethics of these trials on the basis of the fact that different standards were allegedly applied than would obtain if the research was done in the original countries of the members of AIDS Clinical Trial Group who did the study. The objections from Angell and her supporters were mainly twofold. Firstly, the minimum known standard of care that was at that time known to be effective for HIV-positive patients was the AZT 076 protocol. Now a study took place in which participants were not given that minimum acknowledged standard of care but where the shortened AZT regiment (later also an even shorter nevirapine regimen) was tested against placebo. The Helsinki Declaration of the WHO forbids placebo-controlled double-blind trials in cases where an acknowledged minimum standard of care is not made available to all participants in the trial. Clearly, according to Angell, a different standard for the safety of the participants was here applied. Secondly, she claimed that such a study could and would never be done in the home countries of the researchers. Because these studies were done in Africa, the local population was exploited to participate in a dangerous enterprise.

This is a complex case. The researchers retaliated that it was quite unrealistic to regard the 076 AZT regimens as the “acknowledged mini-mum standard of care,” since that standard in these countries was indeed nothing, hence the need to test the regimen against placebo. To insist on the 076 AZT regimens as standard for all participants would in addition sabotage the entire trial because of the prohibitive costs implied. The researchers also indicated that all participants gave informed consent and were willing to participate, given the dire need for an effective and affordable drug to prevent mother-to-child transmission of HIV. Available space does not allow a comprehensive analysis and adequate judgment of the controversy. This case does, however, illustrate the danger (if possibly not the actual reality) of exploitation in international biomedical research: powerful researchers who test a protocol among vulnerable participants in a context where participation in the trial is these participants’ only recourse to proper health care and where their situation is desperate. It would, however, in this case, be unfair to accuse the researchers of degrading the participants; the research was done with the sincere intention of alleviating the plight of thousands of HIV-positive women and their unborn children.

Conclusion

The concept of exploitation refers to a very actual, though highly complex, phenomenon in human affairs, generally, and in international biomedical research in particular. There is no consensus as to whether the phenomenon only has a “thick” (i.e., negative) moral connotation, although such a pejorative meaning is mostly associated with it. Exploitation refers to actions that often seem to involve inﬂicting harm on people, treating people with disrespect or injustice, and interacting with vulnerable people with whom one stands in an unequal relation of power. As such, it usually involves the degradation of human beings who stand in unequal and vulnerable relations to people or institutions that are more privileged. Exploitation can and often does occur in the actual practice of international biomedical research. It thus represents one of the most poignant and actual moral risks to be faced and dealt with in efforts to humanize the world through the proliferation of available and effective medical care.

The threat of exploitation makes it imperative to develop an enlarged sense of responsibility for fellow human beings in the developing world who are dependent on the expertise and prowess of the world’s more privileged populations. It must be argued that enlarging this sense of responsibility not only requires a heightened sense of altruism. It indeed also implies a more enlightened sense of self-interest. As Benatar argues: “Crucial to a new approach will be the recognition that it is not merely altruism that is called for, but rather a long-term perspective on rational self-interest in an increasingly interdependent world.” (Benatar 2001, p. 91). Improving the health status of developing countries makes both moral and strategic sense. What is required is the avoidance of unnecessarily pessimistic or optimistic caricatures about globalization.

Realism that avoids these caricatures is called for. It is a realism that:

Accepts the inevitability of globalization
Accepts that free markets are the basis of growth in the world economy but that these markets are often, because of the growth of multinational conglomerates, not free
Promotes international deliberation in which the nature of the inequalities is recognized and imaginative measures are constructed to alleviate the plight of the worst off
Promotes the strengthening of capacity in the developing world to better provide for its own needs (Benatar et al. 2003, pp. 134–135)

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