Between participation and signature: a response to “Autonomy and risk in HPSR studies”

Health Policy and Systems Research (HPSR) is defined as the “production of new knowledge to improve how societies organise themselves to achieve health goals” (1: p 4); the focus of HPSR studies is on generating, using and disseminating research to strengthen health systems, particularly in low-and middle-income countries. There has been an increasing focus on defining HPSR clearly and on its ethical components and challenges, especially as this domain, is fundamentally different from biomedical /clinical research. One of the imperatives of HPSR is the “co-production of knowledge” (1: p 4) by the researcher, the communities involved, and healthcare providers; and this calls for shared responsibility and ownership, which is not an essential aspect of biomedical research

A few shades fairer, please

This piece critically reflects on the growing Indian desire for fairer shades of skin. While skin-whitening products vanish off store shelves, notwithstanding protests against such products, the event that generated a storm some time ago in the media was the Garbha Sanskar workshops. In these workshops, women were allegedly taught methods to purify their wombs and beget fairer (and taller) children. In this article I argue that not only is it simplistic to label this ideology regressive, but that it becomes rather difficult to criticise the sanskaris because of the “register” they employ, ie the language they use to rationalise and explain their actions. The sanskaris use the rhetoric of modern medical science to justify their methods, while the same science tells us that their logic is not scientific; consequently, we are stranded between a paradox and a dead-end. A step-wise, critical look at this discourse reveals how complex its nature is, especially its attempt to lay simultaneous claims to different (and contradictory) epistemologies. I offer no easy solution, for there is none. I map some of the complexities and contradictions of the scenario as a first step.

When fiduciary duty clashes with duty to the state

In their case study Cash and Castro discuss a situation where a physician’s duties to the laws of her land stand in conflict with her fiduciary duties to her patient. This present commentary is a response to the situation they describe, and it engages with the issue of conscientious objection in medicine, to argue that the ethical responsibility of the physician should be tilted in favour of the patient, especially when the laws of the land are regressive and harmful.

Assisted reproductive technologies: Conundrums and challenges

A few weeks ago, a leading multi-city IVF clinic published an advertisement in a leading news daily. The advertisement sounded ominous, “The longer you wait, the lower your chances” – it referred to one’s chances of getting pregnant. The subtext was far too easy to decipher: the content was thoroughly gendered and directed solely at women, particularly at career-oriented women who delay their marriages and childbearing plans far too long, supposedly lowering their fertility in the process. It also sounded benevolent in its attempt to warn these “erring” women. It is socially accepted that women are responsible for increasing the infertility rates in the country by their “poor, untimely, and problematic prioritisation of life choices”. while men produce sperm that are regenerative, a woman’s reproductive potential is perpetually on a decline; born with a fixed number of egg cells, she never produces any more in her lifetime. however, male infertility is an interesting area to delve into; 40–50% of total infertility is male factor infertility (MFI) (1)

Menstruation: a complex saga

In their letter, Singh and Thawani highlight the gender insensitivity of the government which, after declaring items such as sindoor, bindis and condoms as tax-free, opted to levy 12% tax on sanitary napkins, equating the napkin with items such as packaged dry fruits, fruit juices, cell phones and so on. While the new sanitary napkin tax is actually a drop from the earlier 14.5%, in a regime where all taxes were reconsidered and revised, the authors’ argument that sanitary napkins should have been exempted from tax is absolutely valid.

The social value of research: interrogating the paradoxes

The relation between science and society is, simply put, very complex. In the history of global bioethics, it is the Code of Nuremberg which foregrounded the acute ways in which biomedical/scientific research could (negatively) impact society; this 1947 Code became the point of reference for subsequent research concerning humans. The Code “required that medical experiments on human beings must have the potential to yield fruitful results for the good of society” (1: p72). The Declaration of Helsinki (DoH), 1964 reinstated this concern by stressing that “clinical research cannot be legitimately carried out unless the risks to participants are justified by the importance of the research” – invoking the idea of the “social value” of research. However, in these initial days, “social value” of research was interpreted more in terms of the moral balance of research, a balance to ensure that the benefits of research unambiguously outweighed its risks as far as its participants were concerned.

To believe or not to believe: the onlooker's role in cases of sexual boundary violations.

This triple-tiered 18-minute documentary explores the issue of sexual boundary violation (SBV) in the healthcare setting. SBV is a complex terrain and the evaluation of the incidents falling in its domain rely on the imperatives of objective, rational and legal decision-making as these incidents are often considered an individual’s subjective perception of a gesture, an activity or spoken words. Consequently, it is not uncommon to find those acting as decision-makers and the jury getting caught in the slippage between their perception of the accuser’s “perception” and the objectivity warranted by the law. In the process, the “reality”/”truth” of SBV gets lost.

What ails India's two-tiered healthcare system? A philosophical enquiry.

India’s two-tiered healthcare system (viz the public and private sectors) has been suffering from various ailments, and each sector has been criticised for its own set of deficiencies. Against this backdrop, this article explores whether there is any possible commonality between the two sectors, and suggests that the “common logic”, or common ground, is themodel of biomedicalknowledge, which forms the foundation of both sectors. It is to problems inherent in the “model of biomedical knowledge” that certain gaps in each sector can be traced. It isonly when we have identified the lapses at the root of the structures of each sector that we can plug the gaps in healthcare. The author suggests that it would be best to analyse the gaps through a philosophical enquiry, and to offer a probable solution, turns to the methodologies of care ethicsand feminist standpoint epistemology.

The "chance factor": responsibility, risk and ethics in medical practice.

Without lapsing into a black and white portrayal of the world of the bad doctor who is indifferent to his patients' well-being, Alik Sukh (Ethereal Bliss) evokes subtle nuances in exploring the issues of medical negligence and the doctor's responsibility.

Book review : Of snowstorms, swordfights and blood trails: the underbelly of clinical trials.

The world of clinical trials is ethically fragile. Huge amounts of money are at stake and a handful of people are privy to a lot of confidential information about the trials. This imbalance in money and knowledge sometimes results in an unholynexus. Known as insider trading, progress reports of a trial are sometimes passed on to investors so that they can augment or deplete their share in the investment before the trial results are officially made public. The person(s) passing on the information would also have vested interests in the profits. This unmitigatedly unethical practice is explored by the book, using the genre of a murder thriller.

Conference Report.

The IJME Fourth National Bioethics Conference (NBC), organised by the Forum for Medical Ethics Society (FMES), Mumbai, in collaboration with the University of Hyderabad, Hyderabad, and the Council for Social Development, Hyderabad, was held from December 6 to 8, 2012, in Hyderabad.