In this blog post, we will examine why medical experiments banned in developed countries for ethical reasons are allowed in developing countries. We will discuss the boundary between science and ethics, and the double standards that exist.
In 1994, a medical study conducted in the United States attracted worldwide attention by suggesting the possibility of effectively preventing vertical transmission of HIV (human immunodeficiency virus), i.e., transmission from pregnant women to their fetuses. According to the study, long-term use of the antiretroviral drug AZT (azidothymidine) during pregnancy reduced the risk of vertical transmission of HIV by about one-third. This was a decisive step forward in preventing the spread of HIV and a hopeful result that could dramatically change the lives of infected pregnant women and their children.
Based on these significant results, US health authorities and the World Health Organization (WHO) recognized the need for follow-up experiments in a wider range of ethnic groups and environments. Accordingly, they supported follow-up clinical trials in several African countries. The main purpose of these trials was to confirm whether AZT could effectively prevent vertical transmission of HIV even when taken for a shorter period of time, based on the results of previous studies. The subjects of the trials were HIV-infected pregnant women in Africa, some of whom were given AZT and the rest a placebo to serve as a control group. The key to the trial was to compare and analyze the difference in transmission rates between the placebo group and the AZT group to confirm the effectiveness of shortening the duration of drug administration.
However, this experiment soon became the center of an ethical debate. In 1997, Marcia Angell, editor-in-chief of a prominent American medical journal, publicly criticized the immorality of the experiment, sparking a global outcry. She pointed out that even though AZT had already been proven effective, administering an ineffective placebo and allowing newborns to be born with HIV was ethically unacceptable. The experiment was considered a violation of basic medical ethics, which requires that all subjects be given established treatments.
This position was strongly supported by civic groups. They argued that “since AZT has already been proven to be an effective treatment, it should be provided as a standard treatment to all HIV-infected pregnant women,” and raised their voices, saying that comparative experiments using placebos were nothing more than unethical research that put patients’ lives at risk.
In response, the researchers took the opposite position and actively defended themselves.
They argued that even if the experiment had not been conducted, most African women would not have been able to obtain AZT due to poverty and poor health systems. In other words, the women who participated in the experiment were not placed in a worse situation than before. Rather, some women gained access to treatment through the experiment, which could be a positive change in areas with extremely low access to medical care.
Angel and civil society organizations dismissed this argument, pointing out that experiments using placebos have long been banned in developed countries such as the United States and Europe for ethical reasons. They emphasized that such double standards cannot be justified in medical research and clearly stated their belief that “medical ethics are universal values that transcend national borders.” They argued that applying different ethical standards between developed and developing countries is inherently unfair and that the commodification of human life in the name of science can never be justified.
On the other hand, the researchers emphasized that the experiment had been formally approved by the institutional review boards (IRBs) of each country and that all subjects had been fully informed of the content and risks of the experiment and had given their voluntary consent. They disagreed with the accusation that the experiment did not follow ethical standards, adding that health authorities in developing countries also supported the researchers’ position. Some health officials argued that unilaterally applying US or European ethical standards to Africa was nothing more than “ethical imperialism” and that flexible standards reflecting the realities and circumstances of each country were necessary.
This debate has gone beyond a mere academic or medical dispute and raised fundamental questions about global ethical standards and how they should be applied. Research funding agencies countered that placebo-controlled trials allow experiments to be completed in a shorter period of time with fewer subjects, arguing that developing effective treatments quickly is the best way to contribute to public health. Furthermore, they argued that if the trial were successful, governments would be able to provide HIV-infected pregnant women with AZT therapy at a much lower cost than before, claiming that this approach was both practical and effective.
In response, Angel and civil society organizations once again pointed out the essence of the problem. They emphasized that placebo-controlled trials are not necessarily required for this type of research and that the same scientific results can be obtained through ethically superior methodologies. In other words, it is entirely possible to use existing AZT treatment as a control group and compare it with the new shortened treatment. Furthermore, even if the shortened treatment were proven effective, at a cost of approximately $80, it would still be 11 times the average medical expenditure in Africa and therefore not a realistic alternative for the majority of pregnant women. The criticism was that it was not enough to find an effective treatment; it had to be a treatment that was actually accessible.
The heated debate continued for about four years, and finally, in 1998, the US health authorities announced new clinical results. They officially announced that taking AZT during the last four weeks of pregnancy reduced the rate of vertical transmission by half and ordered the discontinuation of the experiment. This was recorded as a representative case in which the conflict between scientific progress and ethical responsibility ultimately resulted in an ethical judgment.
This incident did not end with the suspension of a single experiment. Rather, it presented us with a fundamental dilemma facing modern medical research. How much can we sacrifice individual rights and ethical values for the greater good of scientific advancement and public health? In particular, what standards should we adopt to ensure the dignity of people living under the double burden of poverty and disease as human beings, not as subjects of experimentation?
Medicine is a tool for a better life, but the moment it becomes a means to an end, it loses its original purpose. The controversy surrounding the AZT experiment reminds us once again that scientific progress must always be balanced with ethics. We must continue to strive to create a medical research environment where the dignity of even a single life is not violated. And that effort must begin with “just procedures,” not “just purposes.”
