Ethical Considerations in International Nursing Research: A Report ...

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Ethical considerations in international nursing research 123accountability in the field of nursing and related disciplines. The ICNE promotesinternational research, the development of ethics teaching, cross-cultural discussionand understanding, and ethical interprofessional and interagency cooperation.It runs regular conferences and seminars. This is the first of a series ofarticles produced by ICNE’s teams of researchers and working groups.The goals of this article are to identify ethical issues that nurse researchers andresearch ethics review committee members should consider regarding nursingresearch extending across national boundaries, and to stimulate discourse. Ourhope is to move towards a broad consensus among nurses of all nations on normsof ethical conduct in international nursing research. The present discussionproceeds as follows: (1) specifying the scope of consideration; (2) reviewingtheoretical issues that frame the topic; (3) defining initial conditions for researchto be considered ethical; and (4) examining research protocol design and procedureconsiderations.Scope of considerationMost recent efforts to examine issues in international research ethics in somedeveloped countries focus on medical research. The executive summary of the USNational Bioethics Advisory Commission’s (NBAC) report, Ethical and policy issuesin international research, specifically states ‘the Commission’s attention was focusedon the conduct of clinical trials . . . in particular those trials such as Phase III drugstudies’ (p. ii). 1 In the UK, the Nuffield Council on Bioethics report, The ethics ofclinical research in developing countries, lists the scope of research considered:clinical trials of new drugs, vaccines and diagnostics, or improved clinical managementstrategies . . . basic clinical research studies on the natural history of a disease, the functioningof the body or on behaviour . . . Epidemiological studies may be aimed at identifyingrisk factors (p. 3). 2Although not excluding research of primary interest to nurses, these reports areclearly focused on medical research. A recent more comprehensive report fromthe Nuffield Council, The ethics of research related to healthcare in developing countries,does more to recognize the need to broaden consideration beyond clinicaltrials, stating:In the developing world, research to find new or improved medicines and vaccines isoften given high priority . . . but research to find better ways of delivering existingproducts and services to those in need is often equally or more important (p. 5). 3However, this Nuffield report still does not deal specifically with nursing.This article addresses international nursing research, that is, research whereinvestigators and participants are from different countries, rather than researchtargeting populations by race or ethnicity. Although cultural differences betweenresearchers and participants are often an essential consideration in internationalresearch, it is not the only consideration. Furthermore, situations whereresearchers from one culture study persons from a distinctly different culturewithin national boundaries occur frequently in multi-ethnic countries like the USAand South Africa, or in countries with indigenous populations such as Australiaand Finland. When research is conducted within national boundaries on minorityNursing Ethics 2003 10 (2)
124 D Olsen et al.populations, there is a commonality of law and there may be a greater sharedcommon sense of norms regarding authority and social goals.There are many categories within the broad designation of internationalresearch, distinguished by different combinations of researchers and participantsfrom developed and developing countries, and by varying types of collaborativearrangement between researchers, sites for recruiting, and origins of sponsorship.Some types of research that cross national boundaries have a higher potential forethical difficulties than others. The two factors that determine the level of ethicalconcern are the degree of cultural difference between the involved countries andthe potential for exploitation. Therefore, studies with principle investigators froma more developed country who are recruiting participants from a less well-developedcountry are of greater concern than collaboration between researchers ofsimilarly developed countries collecting data for purposes of comparison, becauseof the greater potential for exploitation.In the context of international HIV/AIDS research, UNAIDS identified factorsthat create conditions that make countries or communities potentially vulnerableto exploitation. These include: the level of the proposed community’s economic capacity; limited experience with, or understanding of, scientific research in the countryas a whole; limited local infrastructure, personnel and technical capacity for providinghealth care and treatment options; limited experience and capacity for conducting ethical and scientific review; an uncertain ability of individuals in the community to provide informedconsent, for instance, as a result of class, gender and other social patterns. 4Method and data-gathering techniques of particular concern to nurses, such asinterviewing, psychosocial intervention, participant observation, and otheranthropological techniques, may be liable to different types of problems to quantitativehealth care research. 5–7 Although qualitative research does not usuallyinvolve the risk of physical harm, it carries a greater risk of social and psychologicalharm, particularly from breaches of privacy. 8 For example, Upvall andHashwani 9 reported difficulties with informing participants in developing countriesbecause in qualitative research the direction the inquiry takes cannot be fullyanticipated in advance. Although it is becoming more accepted, qualitativeresearch has often received less attention by research review committees becausethe medical establishment has traditionally considered this type of research to beof lesser value. 10 Current ethical and legal guidelines, developed by the westernmedical establishment and designed to regulate clinical drug trials, are often apoor fit with the realities of the qualitative research and methods more frequentlyused in nursing. 11In a final note about the scope of consideration, we acknowledge a historicallylong view of potential problems. History is filled with examples of events widelyaccepted at the time, even enjoying a semblance of local approval, but which, inretrospect, are seen as exploitive. The most dramatic of these may have been theslave trade during the eighteenth century. Researchers and reviewers cannotalways be held accountable for the reactions of future generations but mustremain alert for instances when present thinking and evidence are ample toNursing Ethics 2003 10 (2)
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