In the course of the debate, critics
of the placebo-controlled trials were sometimes accused of "ethical imperialism"--that
is, of seeking to impose their ethical standards on countries that had made
their own judgments on the merits of the trials, based on their particular needs.
Many of those who made this charge were health officials and clinicians from
developing countries. The host countries in sub-Saharan Africa had played an
active role in designing the trials, they said, and were not merely the pawns
of sponsoring nations.
In a letter to Satcher and Varmus,
which they quoted in their New
England Journal of Medicine article, Edward Mbidde, chairman of the
AIDS Research Committee of the Uganda Cancer Institute, wrote: "These are Ugandan
studies conducted by Ugandan investigators on Ugandans. Due to lack of resources
we have been sponsored by organizations like yours. . . . It is not NIH conducting
the studies in Uganda but Ugandans conducting their study on their people for
the good of their people." Furthermore, these critics maintained, the clinical
trials had been carefully examined by ethical review committees in the sponsoring
and host countries; they conformed to international standards, yet were tailored
to suit the realities of medical care in their communities.
Many of the researchers and health
officials from sub-Saharan Africa who responded to the criticism of Lurie et
al. questioned the depth their understanding of conditions in their countries,
sometimes in harsh terms. Writing in the New York Times on September
28, 1997, Danstan Bagenda and Philippa Musake-Mudido, a biostatistician and
a pediatrician, respectively, from Uganda, asserted:
Those who can speak with
credibility for AIDS patients in Africa are those who live among and know
the people here or have some basic cross-cultural sensitivity. We are suspicious
of those who claim to speak for our people, yet have never worked with them.
Callous accusations may help sell newspapers and journals, but they demean
the people here and the horrible tragedy that we live daily.
Critics of the trials in sub-Saharan
Africa dismissed both the charges of ethical imperialism and the defense of
the ethical review process that preceded the studies. Regarding the latter,
they questioned the disinterestedness of the review, both at home and abroad,
particularly in view of the substantial research money at stake.
Moreover, some argued, the researchers
and health officials who levied charges of ethical imperialism were not necessarily
advocates for the poor citizens of their nations. The term, "ethical imperialism,"
Angell points out, was not a new one, but rather "an old argument in new clothes."
Ten years earlier, she had written an editorial on the issue in The New England
Journal of Medicine, when questions arose about the appropriateness of seeking
informed consent from women in some developing nations, where their husbands
or village chiefs normally spoke for them. Then, as now, she and others argued
that the charge of ethical imperialism obscured a more insidious danger to developing
countries: ethical relativism, which opened the door to exploitation of the
vulnerable peoples of the Third World.