Ethics of Scarcity or the Scarcity of Ethics

Ethics of Scarcity or Scarcity of Ethics is a journey into child health research with implications on the broader field of ethics of health research in the Global South. In contrast to other books on the topic, Ethics covers a wide terrain from micro-ethics to macro-ethics, conservative realism to radical realism, and immediate causes to systemic, root causes.

Ethics is written in a clear and engaging style by Dr. Karim F Hirji, a retired Professor of Medical Statistics, who was catalyzed by his participation in a study that utilized chest circumference to identify low birth weight babies. Hirji is an award winning biostatistician who has led research projects and taught in the United States, Norway and Tanzania. In Ethics, Hirji presents a critique of research methods that fail to confront the economic and political structures underlying the health issues faced by the people of the Global South.

Ethics begins with a sanguine interaction between two pediatricians and the author at the Muhimbili National Hospital in Dar es Salaam, Tanzania. Their exchange leads to the design, conduct, analysis and publication of  a study that tackles a need to identify low birth weight babies in areas where weighing scales are not available. At the outset, the study is deemed a scientifically valid and ethically laudable undertaking. Yet, later revelations raise questions about its ethics and rationale. These doubts compel Professor Hirji years later, to reevaluate his own study and undertake a comprehensive survey of the literature on low-birth-weight studies from a systemic perspective.

Hirji determines a fundamental flaw in the low birth weight studies in that they accept the notion of scarcity of resources, a notion that he presents as ethically and factually dubious. The low birth weight studies fail to examine the misuse and abuse of resources that often lie at the root of the health maladies in the poor nations. The authors of the low birth weight studies do not question the priorities of nations that invest in large military budgets but not key items like weighing scales in rural clinics. The low birth weight studies, including his own, bypass these fundamental issues and instead seek a proxy measure to replace direct weighing. Hirji finds that not only is the general the scientific quality of the reviewed studies substandard, but also deems that their adherence to the tenets of the Nuremberg Code of research on human subjects wanting.

Ethics is an exposé of how health research in the poor nations superficially address or ignore fundamental features of the societal context that cause scarcity. Hirji illustrates this through examples, including the double standard of western researchers whose ethical focus is informed consent, while ignoring the broader moral issues of governments that violate human dignity with impunity. On the question of informed consent, consent from the authorities is taken as a valid substitute for individual consent.  Ethics calls on researchers to avoid elitist conceptions of ethics and probe the root causes of health maladies, address systemic problems, ask critical questions and genuinely respect human dignity when undertaking health studies.