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Third World Bioethics

By Michael Cook

Poverty overcomes informed consent in India, where nearly 2900 people died in India during clinical trials of drugs between 2005 and 2012.

Bioethics has its own flavour in a tidy, law-abiding, wealthy country like Australia. Here we assume that, once approved, regulations and laws will be obeyed – and by and large, they are. Corruption, in other words, is uncommon. Not unknown, mind you, but Australia ranks seventh out of 194 in the Transparency International corruption index. Not too bad.

This defines the focus of our bioethics. Here doctors are trained to respect patients’ autonomy.

But corruption is endemic in the developing world, so much so that a bioethicist in India (which ranks 94th) contends that “corruption is arguably the most serious ethical crisis in medicine today”. So the focus has to be protecting patients from exploitation.

In a recent issue of the Indian Journal of Medical Ethics, Dr Subrata Chattopadhyay has asserted: “Quality care cannot be provided by a healthcare delivery system in which kickbacks and bribery are a part of life”.

Unhappily, Exhibit A of this system is the former president of the Medical Council of India (MCI), Dr Ketan Desai, a urologist who should have been a model of probity. He wasn’t.

Desai was a consummate political operator. His personal website described him as “an apostle of genuine imagination, innovation and creativity which has resulted in his enviable ascending to key positions in the world of medicine”.

But everyone knew he was corrupt – back in 2001 he had been removed from his position as the president of the Medical Council of India. Undaunted, he clawed his way back and was once again elected as president in 2009. This time he posed as an ethical crusader, and even banned doctors from accepting gifts from pharmaceutical companies.

Perhaps that was because he had kept the best for himself. It was through him that private medical colleges were accredited, the number of places could be increased and annual inspections were held.

He was so imaginative, in fact, that he got himself elected as president of the World Medical Association (WMA). Fortunately, he never advanced beyond president-elect, because the MCI informed the WMA that he had been deregistered, arrested and charged with accepting a bribe to accredit a medical college in the Punjab. The whole affair was highly embarrassing for the WMA.

If this happens in the stratosphere of Indian medicine, what is happening on the ground? Chattopadhyay thunders: “It is time to acknowledge that corruption in healthcare entails crimes against humanity. There is no room for complacency – history will not forgive physicians and bioethicists if they fail in their moral duty to safeguard the cause of ethics in medicine when it is necessary.”

He’s right. In a global village, everyone is implicated in developing world bioethics. Take two examples: international clinical trials and medical tourism.

Drug companies are increasingly outsourcing clinical trials to the developing world to escape rising costs and red tape. But in this environment the Western notion of a completely autonomous patient who gives informed consent after balancing the benefits against the risks is a dream. The subjects in trials are recruited with financial incentives, are probably illiterate, may be pressured by husbands, and may be intimidated by doctors of higher status.

Reports of exploitation are never-ending. Chattopadhyay claims, for instance, that nearly 2900 people died in India during clinical trials of drugs between 2005 and 2012, and that any compensation was paid in only 45 cases.

One area of the burgeoning medical tourism sector is surrogacy. A whole industry has grown up to service infertile and gay couples who are desperate to have children, but the women who bear the children are always poor, often illiterate, and sometimes pressured by greedy husbands. Western notions of autonomy simply do not apply here.

Local doctors seek to allay suspicions of their Western clients by asserting that these patients have been adequately compensated, that they have given informed consent and that the risks are minimal. But can they be trusted if the president of the Medical Council of India can’t be?

The point is not that doctors in India are corrupt and doctors in Australia are virtuous. The former is quite unfair and the latter is laughably naïve.

But it verges on criminal self-deception to accept the reassurances of medical services in poor and distant countries that everything is A-OK.

Michael Cook is editor of BioEdge, an online bioethics newsletter.