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AZT treatment began when the women entered the study, which occurred between weeks fourteen and thirty-four of their pregnancies. Id. at 1174.Google Scholar

Levine, C., “Placebos and HIV: Lessons Learned,” Hastings Center Report, 28, no. 6 (1998): 43–48, at 44. To be sure, there is some artificiality to the stated cost of drug therapy. Companies may be able to price far above actual costs and exact monopoly profits for drugs under patent protection. Furthermore, public pressure has been successful in lowering the market price of important drugs. Nevertheless, it is clear that citizens of developing countries cannot afford drug treatments to the same extent as citizens of developed countries.CrossRefGoogle Scholar

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This example is based loosely on the Kenya Program of the Indiana University School of Medicine.Google Scholar

Some people might reject the view that a U.S. citizen's obligations to citizens and residents of the U.S. are greater than the citizen's obligations to people living in other countries (who are not citizens of the U.S.). However, as a matter of ethics and law, national borders matter. When Congress funds health care coverage for older persons, it acts ethically when it limits coverage to people living in the United States. Similarly, the constitutional rights of U.S. citizens and residents under U.S. law exceed those of noncitizens living in other countries. This distinction between local residents and people living in other countries reflects a number of considerations. First, ties of kinship matter. We recognize the interest of people in devoting more of their money and time to family members over strangers, to local non-profit organizations over non-profits in other cities or states, to co-religionists over members of other religions, and to countrymen and women over people who live elsewhere. In addition, when people share citizenship or residency with each other, they share in a collection of rights and responsibilities. Nonresidents do not bear most of the responsibilities of community membership, and they therefore do not bear most of the rights of community membership.Google Scholar

Some people might find the drug company example unethical on grounds of exploitation, but I do not think we can condemn businesses simply because they bring a resource from a less developed country to a more developed country. It is not in the interest of developing countries if they are prevented from sending their fruits and vegetables, oil and gas, or precious minerals to other countries in exchange for goods that cannot be produced in their countries. The exploitation concern is discussed at length later in this article.Google Scholar

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Some critics have questioned whether in fact the women gave true informed consent, and other critics have observed that many of the women suffered stigmatization when their HIV status became known. These objections are important, but they would apply to any research done in the same communities, regardless of whether a placebo control was used or whether the experimental therapy studied was destined for use in developing or developed countries.Google Scholar

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In fact, the less aggressive, less expensive course of AZT treatment substantially reduces the risk of HIV-transmission from mother to infant, though not as effectively as the more aggressive, more expensive course of AZT. Grady, C., “Science in the Service of Healing,” Hastings Center Report, 28, no. 6 (1998): 34–38, at 35–36.Google Scholar

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Placebo controls — even when there is an established therapy — also have value for other kinds of studies. When testing an experimental therapy, one can determine whether it is effective with a smaller number of subjects if the experimental therapy is compared to a placebo rather than to established therapy. Emanuel, E.J. Miller, F.G., “The Ethics of Placebo-Controlled Trials — A Middle Ground,” N. Engl. J. Med, 345 (2001): 915–19, at 916. For additional discussion of the justifications of placebo-controlled trials see Orentlicher, D., “Placebo-Controlled Trials of New Drugs: Ethical Considerations,” Diabetes Care, 24 (2001): 771–72.CrossRefGoogle Scholar

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