Who is my brother's keeper? (Original Article).

Quinacrine is a drug which in its country of origin is listed as "unapproved", and therefore cannot be employed as a female sterilising agent. Nevertheless, it has been introduced into Third World countries on the basis that the demographic benefits by far exceed the potential side effects, even when these include drug-induced cancerous growths. Under the title, "Good enough for the Third World", Cooley has published a defence of employing unapproved drugs in developing countries, starting off with the statement that a drug with "ill side-effects" is a lesser evil than no treatment at all for life-threatening diseases. (1) An argument of this kind, however, needs to be validated by those involved, not by outside observers.

To bolster such a lenient view towards unapproved drugs, a quasi-utilitarian principle is introduced: "An act is normally right for an agent only if the agent, after proper consideration, believes that it will produce at least as great utility as any alternative to the act". (2) An admittedly "agent-centered relativity" of this sort erodes the principle of patient autonomy and is especially suspect in intercultural relationships were agent and subject differ in their world-views. (2) Something of this attitude is revealed in the statement that: "[W]omen in these situations are desperate for a solution and they are willing to take the chance that it may give them cancer". (3) The author does not say if he knows this for a fact or is just guessing, which is more probable in view of his endorsement of the distribution of: "unapproved medical products, if individuals autonomously choose to be engaged in the enterprise even though they may not be as knowledgeable as some opponents would like them to be". (4) If distributors of a drug are allowed to be incompletely informed, there is little room for recipients to reach enlightened decisions.

The acceptability of negative side effects in relation to purported benefits is not to be decided by benevolent paternalism; rather, it is for public health policies and for the affected population to evaluate, especially if the argument of lesser evil is invoked. Whether it is preferable to avoid pregnancy at the risk of getting cancer can only be decided by the women to whom quinacrine might be offered, supported by local health care officials who must assess the rationale of this approach as compared to alternatives.

Local health care policies are not a proper subject for heavy external criticism, for outside scholars are not immersed in the contextual cultural and economic forces at issue. Besides, less developed nations do have cadres of professionals, both in the medical and in the bioethical fields, who should be capable of assessing and counselling their own authorities in these matters. (5 6) And yet, Cooley goes quite a bit further by suggesting that countries which have rejected quinacrine should not have done so, nor should they ban "any other product that people choose to use". Under this premise, the Food and Drug Administration (FDA) and equivalent regulatory institutions must be declared superfluous, which is absurd, or a double ethics standard must be accepted whereby developed countries continue to enjoy pharmaceutical protection that in underdeveloped nations ought to be lifted. And that seems to be the conclusion Cooley reaches: "Even if it turned out to be the case that the buying and selling of unapproved medical products is unethical, it does not follow that we are obligated to put an end to it". (7) Since one can legitimately wonder if such a statement would ever apply in developed nations, it seems that a double ethical fallacy is here being committed: to recommend policies of different moral probity, and to do so as a cultural outsider. In fact, Cooley's interventionism goes even further, for he explicitly disagrees with local authorities who for good moral reasons reject dubious medical practices.

RESEARCH STRATEGIES

At least four points of contention have been discussed …