In 1997, Chile had the highest rate of Caesarean section in Latin America (40 per cent), though the procedure should not account for more than 15 per cent of births, according to the World Health Organisation. To look at the association between private health insurance and the high rate of Csections (women covered by the national health fund are much less likely to undergo C-sections) the authors conducted in-depth interviews with obstetricians and pregnant women and also analysed 540 interviews with women post-natally, and reviewed their medical notes. Private health insurance requires an obstetrician’s care. “Conflicting demands arise from complex peripatetic work schedules and the need to provide personalised care for private patients. These are resolved by liberal use of caesarean section, which permits maximum efficiency in use of time. The prevailing business ethos in health care encourages such pragmatism among those doctors who do not have a moral objection to non-medical caesarean section.”
In this contribution to the current international debate on the ‘standard of care’ for testing new interventions in medical research, the authors reject as simplistic the idea that this standard must mean the best proven treatment — this may be both unachievable and insufficient. The real question is: what are the researcher’s moral responsibilities, given the context in which research is conducted? It is proposed that research must actively address the “social, political and economic forces that widen global inequities in health”. This approach to research ethics gives less weight to international research guidelines, and more to the development of a ‘broad moral agenda’ which will come from recognising the potentially exploitative nature of research, and insight into economic policies which increase disparity and affect people’s health. Among the requirements for “moral progress in international health research” are: ensuring that researchers understand the social, economic and political context in which they work; ensuring that trials are directly relevant to — and benefit — the researched country’s needs, evaluating in advance whether the study finding can and will be incorporated into the local health system; and ensuring that the research does not deepen existing disparities.
What does the draft sequence of the human genome mean to India? This editorial describes the scientific milestones of this project, the different approaches of privately and publicly funded groups in the collaboration, and some implications in terms of possible drugs and diagnostics. In India, one area of research has been inherited diseases. “The vast diversity of India with its relatively reproductively isolated populations is a storehouse for studying the genetic determinants of biological response.” Work is also ongoing in agriculture, parasite research, and so on. “India is scientifically well placed to benefit from the developments of the HGP, especially with the help of bioinformatics and the private sector. However, it remains to be seen how much of this capability will be harvested in a way that benefits society.”
Hysterectomy is too often seen as the only answer to a variety of gynaecological problems, despite improvements in imaging, and the existence of other surgical and medical alternatives. This article describes the procedure’s risks in terms of mortality and morbidity, its limited indications, conservative alternatives, and when it is not warranted. “As hysterectomy carries significant risks and can have a markedly negative impact on quality of life, the patient must be given the most complete and objective information possible, and her preferences must be taken into account in the therapeutic decision.”
The rich genetic variation in Indian society suggests that there is great scope for genetic research in this country. While some of this research could benefit the local community, the commercial possibilities of such work will bring for-profit companies into the picture. In 1998, the government of Iceland signed an agreement with a private company, deCODE, giving the company permission to use the medical records of this population valued for its genetic homogeneity. The project has been opposed on the grounds that it has not been debated publicly, that it denies access to academic researchers, that measures to protect privacy are inadequate, and individual discretion to opt out is an inadequate substitute for individual consent.
While the agreement relates to the use of medical records, DeCODE’s primary purpose is to collect and analyse DNA samples for commercial purposes, and the author discusses issues related to genetic research in detail. Some points: medical-records research is different from DNA-based research, community consent is needed but may not be a sufficient ethical requirement, and international standards for consent to research should apply to genetic research.