Abstract
Self-harm using poison is a serious public health problem across Asia. As part of a broader effort to tackle this problem, medical research involving randomised clinical trials are used to identify effective antidotes among patients who have ingested poison. On the basis of ethnographic material collected in rural hospitals in Sri Lanka between 2008 and 2009, this article describes the conduct of trials in this unusual and difficult context. It outlines three subject positions crucial to understanding the complexity of such trials. At one level, self-poisoning admissions might be thought of as abjects, that is, stigmatised by actions that have placed them at the very limits of physical and social life. They have seriously harmed themselves in an act that often leads to death, marking the act as a suicide. Yet, this is the point when they are recruited into trials and become objects of research and experimentation. Participation in experimental research accords them particular rights mandated in international ethical guidelines for human subject research. Here the inexorable logic of trials and morality of care meet in circumstances of dire emergency.
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Notes
When discussing clinical trials, critical attention is usually focused on pharmaceutical company sponsored trials carried out in mid-level and developing countries, which bring increased risk of exploitation and abuse of trial participants (Petryna, 2007, 2009). In this article we are interested in those initiatives, usually funded under humanitarian initiatives, which attempt to cut into the 90/10 gap – 90 per cent of biomedical research funding is used for conditions that afflict 10 per cent of the world's population (COHRED, 1990).
The highly influential Belmont Report identified vulnerable populations as ‘racial minorities, the economically disadvantaged, the very sick, and the institutionalized’ (see Levine, 2004).
Although we would not wish to invoke the whole of Kristeva's psychoanalytic project in the context of Sri Lankan society, her conceptualisation of the ‘abject’ as being neither object nor subject has been helpful in developing the argument we put forward here.
Decontamination of the stomach was often spoken of as gastric lavage and/or forced emesis, which in practice usually meant making patients drink water mixed with sodium bicarbonate to induce vomiting. Patients might also be subject to flushing the stomach with water or given activated charcoal, or a combination of all of these. Despite the fact that the concepts were collapsed together like this, different practices have differing consequences on the patients’ conditions, and therefore clarity on what exactly has been done matters.
The appalling experiments carried out in the camps of the Third Reich, the Tuskegee trials that withheld medication from Black African men with syphilis long after they could have been treated, clinical trials carried out in prisons are just some examples of such events.
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Acknowledgements
We thank the UK Economic and Social Research Council grant no. RES-062-23-0215 for funding of the International Science and Bioethics Collaboration. The ideas presented here are ours and do not reflect those of our funders. This article would have not been possible without the insights, generous comments and support of a number of people. We thank Marilyn Strathern and Margaret Sleeboom-Faulkner for their intellectual contributions to this article and the ISBC-project. We also thank the blind reviewers of BioSocieties for their feedback and improvements on this article. Moreover, we acknowledge the contributions of audiences at University of Edinburgh South Asia Seminar Series in October 2009 and ISBC Colloquium End of Award Workshop in Cambridge in September 2010 where earlier versions of this article were presented. Several medical colleagues have been enormously helpful in developing this article and conversations with them have made it significantly better and accurate – our gratitude goes to Andrew Dawson, Nick Buckley and Michael Eddleston. Last, this work would have not been possible without the cooperation of the researchers and doctors that we studied and we thank them for their courage to be subjects of research themselves, and for the interesting conversations that followed.
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Sariola, S., Simpson, B. Precarious ethics: Toxicology research among self-poisoning hospital admissions in Sri Lanka. BioSocieties 8, 41–57 (2013). https://doi.org/10.1057/biosoc.2012.34
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DOI: https://doi.org/10.1057/biosoc.2012.34