Commentary
doi: 10.1111/1753-6405.12286
Ethical challenges in cross-cultural research: a student researcher’s perspective Jo Durham School of Population Health, University of Queensland
I
t is common for international public health researchers from countries such as Australia and New Zealand to undertake research in settings that are culturally different from their own. This may include for example, undertaking research in Indigenous communities; low or middle-income countries; able-bodied researchers conducting disability research; or urban-based students conducting research in rural settings. Undertaking research in different cultural contexts can reveal large differences in values and ethics between the researcher and the study population. Managing these differences can be challenging, and researchers are often required to make judgements in complex situations for which there are typically no simple solutions, and where they may have limited understanding of the socio-cultural and political environment.1-5 These challenges relate to a range of factors including different practices and worldviews, differences in sociocultural norms, power asymmetries and different understandings of research ethics and principles.6,7 It is at least partly for these reasons that research proposals are submitted to ethics committees to provide protection and ensure fair benefit sharing of research participants. Knowledge of research ethics and the ability to demonstrate ethical choices, values, and practices in decision-making is a fundamental competency for public health graduates.5,8 The Australian National Statement on Ethical Conduct in Research Involving Humans9 and a number of other well-developed ethical guidelines exist for researchers and ethical review committees. Inevitably, however, these ethical frameworks can only provide guides to resolving the ethical questions that may arise in cross-cultural research.1,4,8,10,11 This paper considers some of these ethical challenges within the context of an International Health doctoral student from an Australian
2014 vol. 38 no. 6
University undertaking research in the Lao People’s Democratic Republic (Lao PDR), a lower to middle-income country and oneparty state in SoutheEast Asia. The purpose is to highlight some of the potential challenges novice public health researchers commencing research in different cultural contexts may face as they move through the process of applying required research procedures in real world contexts, and learning in concrete terms the real human interactions and lives at stake in the research process. The overall intent is to contribute to the debate on how students can prepare themselves for crosscultural research and how supervisors and ethics review committees supervising and reviewing cross-cultural research can prepare themselves to be better guides for their students.8 In an increasingly globalised world, this is of particular importance in professional programs that are multi-disciplinary and methodologically diverse, such as public health. The paper is divided into three sections. First, I describe the research setting to contextualise the paper. Next, I illustrate a number of incidents from the fieldwork, which best reflect the ethical challenges faced. In particular, I discuss my experience of obtaining ethical approval and how tensions arose over the interpretation and application of the ethical principles in practice. I conclude by describing the implications for the ethics review committees, supervisors and doctoral students undertaking public health research.
The research and its setting The overall research design was a concurrent, mixed method cross-sectional survey. The aim was to investigate the impact of the removal of unexploded ordnance (UXO) on household livelihoods and well-being. These UXO include potentially lethal unexploded cluster munitions, bombs and mortars that remain in the ground – a result of substantial
bombing during the Vietnam War.12 The research setting was three primarily rural districts, identified as being among the poorest and most UXO-contaminated in the country.13-16 I had worked in Lao PDR and the UXO sector for many years and this provided entry to the field and some understanding of the research context. While not fluent in Lao, I had adequate conversational Lao language skills. I worked alongside a Lao national coresearcher who, although initially from a rural UXO-contaminated village, had migrated to the city and completed tertiary level study, and was proficient in English. Thus the coresearcher was in many ways also an ‘outsider’.
Obtaining ethical approval I initially discussed my research and shared my research proposal with the National Regulatory Authority (NRA) for the UXO sector in the Lao PDR who provided a letter of support for the research. The NRA is the appropriate Lao national authority to provide approval for such research. I subsequently applied for ethics approval from the Australian university where I was enrolled. During this process, I questioned the relevance and appropriateness in the research context of some of the questions and rules contained in the guidelines. For example, I knew many of the participants would be illiterate and not have access to electricity. I questioned how providing the email address and telephone number of an ethics officer in Australia to whom participants could address any concerns, provided any form of protection for participants. I was informed, however, that this was non-negotiable. Instead of being used as an opportunity for a more substantive discussion on ethical research in different cultural environments, the response effectively closed the opportunity for discussion. I therefore duly included the details of the ethics officer on the participant information sheet. In this way I completed the ethics application form almost as a formality; an additional hurdle to surmount. Questions were diligently answered, putting to one side the fact that some questions were irrelevant to the context. No one on the ethics committee asked if the research was also being reviewed by an ethics review committee in Lao PDR. Whether any members of the review committee had been to rural Lao PDR or undertaken research in similar contexts was not disclosed. The underlying message seemed to be that the review committee
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knew what was in the best interests of the participants.
Fieldwork and ethical challenges One of the challenges I faced once in the field was adhering to the principle of respect for persons – a fundamental ethical principle – as conceived in western-based ethical guidelines. An example of this is the obligation to obtain informed consent.11 The three elements of consent are: it must be given voluntarily without having been subjected to coercion undue influence or inducement; it must be informed (i.e. the participants must understand voluntariness, purpose of research, any risks or benefits and how research will be used and the right to withdraw); and it must be given by a person competent to do so.10,17 Determining to what extent the consent given by participants met these criteria was a challenge. The voluntary nature of participation was discussed with participants. However, I questioned whether participation was really voluntary and if participants genuinely felt able to refuse. This was partly because of the status conferred on an international researcher and partly because respondents were program recipients and thus had a sense of obligation to the program. In addition, as is customary in Lao PDR, I had first sought the permission of the village head to conduct the research. While this facilitated entry to the community, it may have created an obligation for participants and I was concerned that agreement may be given as a sign of respect and out of deference to the village head. I was also concerned about my ability to assess to what extent participants – who often lacked formal education and had low levels of literacy – had a proficient understanding of what their participation entailed, including how the research would be used. In consultation with the local co-researcher, I provided the information verbally and gained verbal consent, and repositioned the formal signed component of the informed consent process to after the interview. While there was no evidence of participant discomfort, ultimately, I could not determine the extent to which participation was genuinely voluntary and the extent to which participants understood the research and the possibility of them refusing to participate. Other studies have highlighted the challenges in securing genuine informed consent in low-income countries. They have
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argued that the concept of informed and voluntary consent is inherently culturally bound, is based on western values of individual autonomy, self-determination and freedom, and may not translate across cultures.11,18-22 This may particularly be the case in a collectively oriented culture such as Lao PDR and a hierarchical, one-party state. As Macklin points out, in western societies where research ethics have evolved, the self is typically seen in individualistic terms of ‘I’, whereas in collective societies, one’s sense of identity may be seen as ‘we’, intimately connected with the realisation of a common way of life, the reproduction of valued social practices and the sense of community, with one’s sense of identity inextricably bound up with social relationships. Macklin and colleagues21 argue that, in such contexts, individual consent can be seen as a violation of accepted social norms. In such contexts, respectfulness may mean respecting the needs not only of individuals but also of the families and communities to which they belong.11 The notion of confidentiality is founded on the principle of respect for autonomy. Rarely, however, was confidentiality – as conceived in Australian universities – maintained. Interviews took place under a tree in the village or on the balcony of a person’s home, as determined by participants. Such places cannot be considered private spaces. Frequently, other family members and neighbours would come along to listen. In the village context, it was not considered necessary for other people to ask permission to join us or come onto the balcony of the interviewee’s house. The village head was present in some cases. A challenge here was whether or not to insist on confidentiality as described in the ethics application. To have asked these additional people to leave, however, would have been culturally inappropriate and a source of embarrassment for the research participant. These ‘breaches’ of privacy and confidentiality were not considered as such in the village setting, and interviews were often conducted in this collective space. As a researcher, I was often uncomfortable with the presence of others during the interview, especially the village head, whom I knew could shape the way in which participants exercised individual agency and expressed their views, because of his or her position of power. However, as a guest in the participant’s home, I did not have the
right to ask these other people to leave. The challenge here was that as a researcher, I was obliged to protect participant confidentiality and obtain the best quality data; on the other hand, I was obliged to respect the social norms of a being a guest in that context.19,23 In this research, issues discussed were not usually of a sensitive nature but, in cases where the research is of a more sensitive nature, protecting participant confidentiality is essential and novel strategies need to be developed at the outset to protect confidentiality and maintain the dignity of the participant.24 Another challenge arose in the principle of responsiveness; that is, whether the research addressed key local health needs25 and had the potential to provide fair benefits to participants and/or local communities.26 While the issue being researched was crucial for program staff, I knew from my experience as a practitioner that often local communities felt they had more pressing needs than UXO contamination. Another challenge was deciding whether, and how, participants should be compensated for their time. My ethics proposal had stated there would no remuneration for participation. It was clear, however, that participation in the research had opportunity costs for the participants. Specifically, it prevented them from going to their rice fields until after the interview was concluded or meant they came back from their fields early in order to make our appointment. Finally, in consultation with the co-researcher, participants were given two bars of soap – which are valued in remote villages – at the conclusion of the interview. Participants were not informed of this until after the interview and after final, written consent had been obtained. While I did not think this acted as a form of coercion, I was not sure to what extent it compensated for the opportunity costs of participation.
Discussion In this paper, I have provided concrete examples of some of the ethical tensions experienced in the course of research while trying to apply the ethical guidelines derived from western universities in rural Lao PDR. These ethical tensions around autonomy, beneficence and justice are not new and have been subject of overlapping discourses.4,5,8,11,18,22,27-30 However, they are not always explicitly discussed in public health programs, where the teaching of research ethics is not universal. The research
Australian and New Zealand Journal of Public Health © 2014 Public Health Association of Australia
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Commentary
experience outlined in this paper led me to question whether these ethical guidelines are a form of cultural imperialism, involving “the universalization of a dominant group’s experience and culture, and its establishment as the norm”31 suggesting universal values and an underlying moral ‘truth’ in a pluralistic world, or whether there are differences in moral practices across cultures. The justification and appeal to ‘universal values’ contained in ethical guidelines are based on the view that there is an unchanging normative order31 but it can be difficult to justify, as becomes evident in value conflicts between researchers constrained by ethical guidelines while conducting research in different moral and cultural contexts.19,27,32 In adhering to ethical guidelines derived from western-based institutions, I found it almost impossible to avoid asking whose moral values were being privileged. The requirements laid out in western procedural ethics arguably assume that experiences, perspectives and meanings held in the western world are universal, neutral and normative.11,31,33 Yet, while I wrestled with some of these challenges, I also felt that the underlying values of respect for persons, beneficence and justice were just as salient in this context as they are in western societies, although the way in which these principles were interpreted and applied were different. In other words, while ethical guidelines provided me with important principles to guide the research, the way in which these guidelines are interpreted may not be universal. Ultimately, once in the field, I had to make relatively autonomous, situated decisions based on ethical principles and local context and culture. Such factors are not neatly captured in an ethics application form. The opposite of universalism is ethical relativism. Ethical relativism holds that the extent to which an action is right or wrong depends on the moral norms of the society in which it is practiced. From this position there are no universal moral standards that can be applied to all peoples at all times: something is right if it is consistent with a society’s customs. If taken to extremes, ethical relativism would lead to acceptance of the Nazi experiments in the Second World War and other notorious cases whereby the rights of vulnerable populations have not been protected.11,34-39 Ethical relativism serves to remind us, however, that different societies have different beliefs that are deeply influenced by culture, and thus ethics in any
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particular research setting are contextually dependent.11 This suggests the need for a more nuanced view between universalism and ethical relativism that posits that there are fundamental ethical values and principles that all cultures recognise to some extent, at least implicitly, although they may be open to different interpretations with ethical values relative to culture.21,40,41 For example, in this research, the concept of respect for persons is deeply embedded in the culture but the collectivist nature of the society means that the common western interpretation of autonomy may not apply. Another example is how the western concept of privacy of information and physical space is one that is not recognised in everyday life in rural Lao PDR. This does not mean, however, that there are no cultural norms related to the respect of personal boundaries. Macklin argues that there are different levels of ethical significance. Some relate to how humans treat each other and others are accepted forms of politeness rather than universal ethical principles.40 These different levels can provide a middle ground between ethical universalism and ethical relativism.40 As illustrated earlier, privacy may be a culturally relative value. While confidentiality as conceived in western-based ethical guidelines may have been breached in the research presented here, the ethical principles of respect for persons and do no harm were not.40 On the other hand, while the research did not cause any obvious harm, the opportunity costs for participants were unclear – for example, in terms of lost productivity. Despite there being no evident harm in this research, an understanding of the research context and power relations is crucial in adhering to the principles of respect for persons and do no harm. For example, ensuring privacy and confidentiality is essential where the research includes collecting information related to stigmatised behaviours or other sensitive or personal issues such as gender based violence.24 In contexts where the prevailing cultural norms do not facilitate maintenance of privacy and confidentiality, or where permission is required from powerful gatekeepers, innovative strategies are needed to allow for privacy wherever the participant is approached.24 Thus, protecting the welfare of participants requires culturally sensitive attention to issues of context in finding just solutions to ethical challenges.42 From this
perspective, ethical research is likely to be based on the dialectical interplay between judgements in terms of local considerations, guided by ethical principles, with each being interpreted and reinterpreted in light of the other.43 International public health research that does not observe the highest ethical standards will be at risk of losing the trust of a community and its integrity.5,8,20 Indeed, some have argued that the current process of ethical review may limit researcher’s ability to engage in ethical reflexivity throughout the whole of the research process.32 Research ethics committees should critically engage with student researchers to understand how researchers have applied the ethical guidelines in the context of their proposed research. However, this requires contextual knowledge that ethic committees may lack.32 When ethics committees review applications for research in contexts such as rural Lao PDR, for example, do they try and picture the potential participants and – if so – who do they see and where has their imagery come from? To help novice public health researchers develop the skills to undertake research that is sensitive to context, the ethical review process needs to be seen by students and their supervisors as a valuable part of the research process, rather than an administrative hurdle.5,11,33 Moreover, teaching must go beyond codes of research ethics.41 It should include supervisors engaging students in substantive discussions about the nature of ethical research in different contexts, exploring ethical principles throughout the research cycle, and embracing the local, specific, contextual and contestable challenges that are ‘ethics in practice’.5,27,33 Engaging with students in ethical issues as they arise in practice can help develop students’ ethical competence. In the space of ‘ethics in practice’, the possibilities of respecting justice and the autonomy, dignity and privacy of research participants – and the risks of failing to do so – lie with the integrity of the researcher, not in the procedural ethical review process.5,27 In contexts where researchers and research participants have disparate worldviews and uphold cultural norms that diverge from the philosophies and values of western-based ethics, such discussions may be crucial to ensuring ethical research, especially in public health programs where ethics coursework is not a requirement.
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This paper has highlighted the some of the personal conflicts and ethical tensions that researchers may face as they grapple with their ethical obligations to their participants. For those conducting research in crosscultural environments, the principles inherent in the ethical conduct of research: integrity; respect for persons; beneficence; and justice provide an important foundation for decision making. This includes careful consideration of context. For doctoral students who are applying for ethics clearance to conduct their research, and for their supervisors, the ethical process must be used as an opportunity for substantive discussions about the nature of ethical research in different contexts.
References 1. Liamputtong P. Performing Qualitative Cross-cultural Research. New York (NY): Cambridge University Press; 2010. 2. Mertens DM. Transformative mixed methods: Addressing inequities. Am Behav Sci. 2012;56(6): 802–13. 3. Piquemal N. Free and informed consent in research involving native American communities. Am Indian Cult Res J. 2001;25(1):65-79. 4. Verweij M, Dawson A. Public health research ethics: A research agenda. Public Health Ethics. 2009;2(1): 1-6. 5. Hunt MR, Godard B. Beyond procedural ethics: Foregrounding questions of justice in global health research ethics training for students. Glob Public Health. 2013;8(6):713-24. 6. Honan E, Hamid MO, Alhamdan B, Phommalangsy P, Lingard B. Ethical issues in cross-cultural research. Int J Res Method Educ. 2013;36(4):386-99. 7. Humphery K. Dirty questions: Indigenous health and ‘Western research’. Aust N Z J Public Health. 2001;25:197-202. 8. Fry CL, Peerson A, Scully A-M. Raising the profile of public health ethics in Australia: Time for debate. Aust N Z J Public Health. 2004;28:13-5. 9. National Health and Medical Research Council. National Statement on Ethical Conduct in Human Research. Canberra (AUST): NHMRC; 2007. 10. Mertens DM. Transformative Research and Evaluation. New York (NY): The Guilford Press; 2010. 11. Macfarlane B. Researching with Integrity London (UK): Routledge; 2009. 12. Durham J, Ali M. Mine risk education in the Lao PDR: Time for a public health approach to risk reduction? Int J Health Promot Educ. 2008;46(1):27-32. 13. Epprecht M, Minot N, Dewina R, Messerli P, Heinimann A. The Geography of Poverty and Inequality in the Lao PDR. Bern (CHE): Geographica Bernensia, Swiss National Centre of Competence in Research (NCCR) North-South, University of Bern and International Food Policy Research Institute (IFPRI); 2008.
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14. Committee for Planning and Investment. National Socio-Economic Development Plan (2006-2010). Vientiane (LOA): Lao Ministry of Education and Sports; 2006. 15. Handicap International. Living with UXO, Final Report, National Survey on the Socio-economic Impact of UXO in the Lao PDR. Vientiane (LAO): Handicap International; 1997. 16. Messerli P, Heinimann A, Epprecht M, Phonesaly S, Thiraka C, Minot N. Socio-economic ATLAS of the Lao PDR: An analysis based on the 2005 Population and Housing Census, Section E health and disabilities. Bern (CHE): Geographica Bernensia, Swiss National Centre of Competence in Research North-South Switzerland and Centre for Development and Environment, University of Bern; 2008. 17. Nuffield Council on Bioethics. The Ethics of Research Related to Healthcare in Developing Countries. London (UK): Nuffield; 2002. 18. Dugas M, Graham JE. Is consent for research genuinely informed? Using decision aid tools to obtain informed consent in the global south. J Glob Ethics. 2011;7(3):349-59. 19. Hamid MO. Fieldwork for language education research in rural Bangladesh: Ethical issues and dilemmas. International J Res Method Educ. 2010;33(3):259-71. 20. Ellis BH, Kia-Keating M, Yusuf SA, Lincoln A, Nur A. Ethical research in refugee communities and the use of community participatory methods. Transcult Psychiatry. 2007;44(3):459–81. 21. Macklin R. Double Standards in Medical Research in Developing Countries. New York (NY): Cambridge University Press; 2004. 22. Buchanan D, Sifunda S, Naidoo N, James S, Reddy P. Assuring adequate protections in international health research: A principled justification and practical recommendations for the role of community oversight. Public Health Ethics. 2008;1(3):246-57. 23. Yee WC, Andrews J. Professional researcher or a ‘good guest’? Ethical dilemmas involved in researching children and families in the home setting. Educ Rev. 2006;58(4):397-413. 24. Jewkes R, Watts C, Abrahams N, Penn-Kekana L, García-Moreno C. Ethical and methodological issues in conducting research on gender-based violence in Southern Africa. Reprod Health Matters. 2000;8(15):93-103. 25. London AJ. Responsiveness to host community health needs. In: Emanuel EJ, editor. The Oxford Textbook of Clinical Research Ethics. Oxford (UK): Oxford University Press; 2008. p. 737-44. 26. Millum J. Sharing the benefits of research fairly: Two approaches. J Med Ethics. 2012;38:219-23. 27. Guillemin M, Gillam L. Ethics, reflexivity, and ‘ethically important moments’ in research. Qual Inq. 2004;10(2):261–80. 28. Hyder AA, Dawson L, Bachani AM, Lavery JV. Moving from research ethics review to research ethics systems in low-income and middle-income countries Lancet. 2009;373(9666):862-5.
29. Kubanyiova M. Rethinking research ethics in contemporary applied linguistics: The tension b e t we e n m a c ro e t h i c a l a n d m i c ro e t h i c a l perspectives in situated research. Mod Lang J. 2008;92(4):503-18. 30. Pace CA, Emanuel EJ. The ethics of research in developing countries: Assessing voluntariness. Lancet. 2005;365:11-2. 31. Young IM. Justice and the Politics of Difference. Princeton (NJ): Princeton University; 1990. 32. Hammersley M. Against the ethicists: On the evils of ethical regulation. Int J Soc Res Methodol. 2009;12(3):211-25. 33. McAreavey R, Muir J. Research ethics committees: Values and power in higher education. Int J Soc Res Methodol. 2011;14(5):391-405. 34. Harpur P. Embracing the new disability rights paradigm: The importance of the Convention on the Rights of Persons with Disabilities. Disabil Soc. 2012;27:1-14. 35. Iacono T, Carling-Jenkins R. The human rights context for ethical requirements for involving people with intellectual disability in medical research. J Intellect Disabil Res. 2012;56 Part II: 1122–32. 36. Iacono T. Ethical challenges and complexities of including people with intellectual disability as participants in research. J Intellect Dev Disabil. 2006;31(3):173–9. 37. Freedman RI. Ethical challenges in the conduct of research involving persons with mental retardation. Ment Retard. 2001;39:130–41. 38. Beecher H. Ethics and clinical research. N Engl J Med. 1966;274:1354–60. 39. Macklin R. Universality of the Nuremberg Code. In: Annas GJ, Grodin MA, editors. The Nazi Doctors and the Nuremberg Code. New York (NY): Oxford University Press;1992. 40. Macklin R. Against Relativism: Cultural Diversity and the Search for Ethical Universals in Medicine. Oxford (UK): Oxford University Press; 1999. 41. Akabayashi A, Slingsby BT. Biomedical ethics in Japan: The second stage. Camb Q Healthc Ethics. 2003;12(03):261-4. 42. Benatar SR. Reflections and recommendations on research ethics in developing countries. Soc Sci Med. 2002;54:1131–41. 43. Hughes J. Ethical cleansing? The process of gaining “ethical approval” for a new research project exploring performance in place of war. Res Drama Educ. 2005;10(2):229-32.
Correspondence to: Dr Jo Durham, Faculty of Medicine & Biomedical Sciences, School of Population Health, The University of Queensland, Herston Road, Herston, Qld 4006; e-mail: [email protected]
Australian and New Zealand Journal of Public Health © 2014 Public Health Association of Australia
2014 vol. 38 no. 6
doi: 10.1111/1753-6405.12286
Ethical challenges in cross-cultural research: a student researcher’s perspective Jo Durham School of Population Health, University of Queensland
I
t is common for international public health researchers from countries such as Australia and New Zealand to undertake research in settings that are culturally different from their own. This may include for example, undertaking research in Indigenous communities; low or middle-income countries; able-bodied researchers conducting disability research; or urban-based students conducting research in rural settings. Undertaking research in different cultural contexts can reveal large differences in values and ethics between the researcher and the study population. Managing these differences can be challenging, and researchers are often required to make judgements in complex situations for which there are typically no simple solutions, and where they may have limited understanding of the socio-cultural and political environment.1-5 These challenges relate to a range of factors including different practices and worldviews, differences in sociocultural norms, power asymmetries and different understandings of research ethics and principles.6,7 It is at least partly for these reasons that research proposals are submitted to ethics committees to provide protection and ensure fair benefit sharing of research participants. Knowledge of research ethics and the ability to demonstrate ethical choices, values, and practices in decision-making is a fundamental competency for public health graduates.5,8 The Australian National Statement on Ethical Conduct in Research Involving Humans9 and a number of other well-developed ethical guidelines exist for researchers and ethical review committees. Inevitably, however, these ethical frameworks can only provide guides to resolving the ethical questions that may arise in cross-cultural research.1,4,8,10,11 This paper considers some of these ethical challenges within the context of an International Health doctoral student from an Australian
2014 vol. 38 no. 6
University undertaking research in the Lao People’s Democratic Republic (Lao PDR), a lower to middle-income country and oneparty state in SoutheEast Asia. The purpose is to highlight some of the potential challenges novice public health researchers commencing research in different cultural contexts may face as they move through the process of applying required research procedures in real world contexts, and learning in concrete terms the real human interactions and lives at stake in the research process. The overall intent is to contribute to the debate on how students can prepare themselves for crosscultural research and how supervisors and ethics review committees supervising and reviewing cross-cultural research can prepare themselves to be better guides for their students.8 In an increasingly globalised world, this is of particular importance in professional programs that are multi-disciplinary and methodologically diverse, such as public health. The paper is divided into three sections. First, I describe the research setting to contextualise the paper. Next, I illustrate a number of incidents from the fieldwork, which best reflect the ethical challenges faced. In particular, I discuss my experience of obtaining ethical approval and how tensions arose over the interpretation and application of the ethical principles in practice. I conclude by describing the implications for the ethics review committees, supervisors and doctoral students undertaking public health research.
The research and its setting The overall research design was a concurrent, mixed method cross-sectional survey. The aim was to investigate the impact of the removal of unexploded ordnance (UXO) on household livelihoods and well-being. These UXO include potentially lethal unexploded cluster munitions, bombs and mortars that remain in the ground – a result of substantial
bombing during the Vietnam War.12 The research setting was three primarily rural districts, identified as being among the poorest and most UXO-contaminated in the country.13-16 I had worked in Lao PDR and the UXO sector for many years and this provided entry to the field and some understanding of the research context. While not fluent in Lao, I had adequate conversational Lao language skills. I worked alongside a Lao national coresearcher who, although initially from a rural UXO-contaminated village, had migrated to the city and completed tertiary level study, and was proficient in English. Thus the coresearcher was in many ways also an ‘outsider’.
Obtaining ethical approval I initially discussed my research and shared my research proposal with the National Regulatory Authority (NRA) for the UXO sector in the Lao PDR who provided a letter of support for the research. The NRA is the appropriate Lao national authority to provide approval for such research. I subsequently applied for ethics approval from the Australian university where I was enrolled. During this process, I questioned the relevance and appropriateness in the research context of some of the questions and rules contained in the guidelines. For example, I knew many of the participants would be illiterate and not have access to electricity. I questioned how providing the email address and telephone number of an ethics officer in Australia to whom participants could address any concerns, provided any form of protection for participants. I was informed, however, that this was non-negotiable. Instead of being used as an opportunity for a more substantive discussion on ethical research in different cultural environments, the response effectively closed the opportunity for discussion. I therefore duly included the details of the ethics officer on the participant information sheet. In this way I completed the ethics application form almost as a formality; an additional hurdle to surmount. Questions were diligently answered, putting to one side the fact that some questions were irrelevant to the context. No one on the ethics committee asked if the research was also being reviewed by an ethics review committee in Lao PDR. Whether any members of the review committee had been to rural Lao PDR or undertaken research in similar contexts was not disclosed. The underlying message seemed to be that the review committee
Australian and New Zealand Journal of Public Health © 2014 Public Health Association of Australia
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Commentary
knew what was in the best interests of the participants.
Fieldwork and ethical challenges One of the challenges I faced once in the field was adhering to the principle of respect for persons – a fundamental ethical principle – as conceived in western-based ethical guidelines. An example of this is the obligation to obtain informed consent.11 The three elements of consent are: it must be given voluntarily without having been subjected to coercion undue influence or inducement; it must be informed (i.e. the participants must understand voluntariness, purpose of research, any risks or benefits and how research will be used and the right to withdraw); and it must be given by a person competent to do so.10,17 Determining to what extent the consent given by participants met these criteria was a challenge. The voluntary nature of participation was discussed with participants. However, I questioned whether participation was really voluntary and if participants genuinely felt able to refuse. This was partly because of the status conferred on an international researcher and partly because respondents were program recipients and thus had a sense of obligation to the program. In addition, as is customary in Lao PDR, I had first sought the permission of the village head to conduct the research. While this facilitated entry to the community, it may have created an obligation for participants and I was concerned that agreement may be given as a sign of respect and out of deference to the village head. I was also concerned about my ability to assess to what extent participants – who often lacked formal education and had low levels of literacy – had a proficient understanding of what their participation entailed, including how the research would be used. In consultation with the local co-researcher, I provided the information verbally and gained verbal consent, and repositioned the formal signed component of the informed consent process to after the interview. While there was no evidence of participant discomfort, ultimately, I could not determine the extent to which participation was genuinely voluntary and the extent to which participants understood the research and the possibility of them refusing to participate. Other studies have highlighted the challenges in securing genuine informed consent in low-income countries. They have
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argued that the concept of informed and voluntary consent is inherently culturally bound, is based on western values of individual autonomy, self-determination and freedom, and may not translate across cultures.11,18-22 This may particularly be the case in a collectively oriented culture such as Lao PDR and a hierarchical, one-party state. As Macklin points out, in western societies where research ethics have evolved, the self is typically seen in individualistic terms of ‘I’, whereas in collective societies, one’s sense of identity may be seen as ‘we’, intimately connected with the realisation of a common way of life, the reproduction of valued social practices and the sense of community, with one’s sense of identity inextricably bound up with social relationships. Macklin and colleagues21 argue that, in such contexts, individual consent can be seen as a violation of accepted social norms. In such contexts, respectfulness may mean respecting the needs not only of individuals but also of the families and communities to which they belong.11 The notion of confidentiality is founded on the principle of respect for autonomy. Rarely, however, was confidentiality – as conceived in Australian universities – maintained. Interviews took place under a tree in the village or on the balcony of a person’s home, as determined by participants. Such places cannot be considered private spaces. Frequently, other family members and neighbours would come along to listen. In the village context, it was not considered necessary for other people to ask permission to join us or come onto the balcony of the interviewee’s house. The village head was present in some cases. A challenge here was whether or not to insist on confidentiality as described in the ethics application. To have asked these additional people to leave, however, would have been culturally inappropriate and a source of embarrassment for the research participant. These ‘breaches’ of privacy and confidentiality were not considered as such in the village setting, and interviews were often conducted in this collective space. As a researcher, I was often uncomfortable with the presence of others during the interview, especially the village head, whom I knew could shape the way in which participants exercised individual agency and expressed their views, because of his or her position of power. However, as a guest in the participant’s home, I did not have the
right to ask these other people to leave. The challenge here was that as a researcher, I was obliged to protect participant confidentiality and obtain the best quality data; on the other hand, I was obliged to respect the social norms of a being a guest in that context.19,23 In this research, issues discussed were not usually of a sensitive nature but, in cases where the research is of a more sensitive nature, protecting participant confidentiality is essential and novel strategies need to be developed at the outset to protect confidentiality and maintain the dignity of the participant.24 Another challenge arose in the principle of responsiveness; that is, whether the research addressed key local health needs25 and had the potential to provide fair benefits to participants and/or local communities.26 While the issue being researched was crucial for program staff, I knew from my experience as a practitioner that often local communities felt they had more pressing needs than UXO contamination. Another challenge was deciding whether, and how, participants should be compensated for their time. My ethics proposal had stated there would no remuneration for participation. It was clear, however, that participation in the research had opportunity costs for the participants. Specifically, it prevented them from going to their rice fields until after the interview was concluded or meant they came back from their fields early in order to make our appointment. Finally, in consultation with the co-researcher, participants were given two bars of soap – which are valued in remote villages – at the conclusion of the interview. Participants were not informed of this until after the interview and after final, written consent had been obtained. While I did not think this acted as a form of coercion, I was not sure to what extent it compensated for the opportunity costs of participation.
Discussion In this paper, I have provided concrete examples of some of the ethical tensions experienced in the course of research while trying to apply the ethical guidelines derived from western universities in rural Lao PDR. These ethical tensions around autonomy, beneficence and justice are not new and have been subject of overlapping discourses.4,5,8,11,18,22,27-30 However, they are not always explicitly discussed in public health programs, where the teaching of research ethics is not universal. The research
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experience outlined in this paper led me to question whether these ethical guidelines are a form of cultural imperialism, involving “the universalization of a dominant group’s experience and culture, and its establishment as the norm”31 suggesting universal values and an underlying moral ‘truth’ in a pluralistic world, or whether there are differences in moral practices across cultures. The justification and appeal to ‘universal values’ contained in ethical guidelines are based on the view that there is an unchanging normative order31 but it can be difficult to justify, as becomes evident in value conflicts between researchers constrained by ethical guidelines while conducting research in different moral and cultural contexts.19,27,32 In adhering to ethical guidelines derived from western-based institutions, I found it almost impossible to avoid asking whose moral values were being privileged. The requirements laid out in western procedural ethics arguably assume that experiences, perspectives and meanings held in the western world are universal, neutral and normative.11,31,33 Yet, while I wrestled with some of these challenges, I also felt that the underlying values of respect for persons, beneficence and justice were just as salient in this context as they are in western societies, although the way in which these principles were interpreted and applied were different. In other words, while ethical guidelines provided me with important principles to guide the research, the way in which these guidelines are interpreted may not be universal. Ultimately, once in the field, I had to make relatively autonomous, situated decisions based on ethical principles and local context and culture. Such factors are not neatly captured in an ethics application form. The opposite of universalism is ethical relativism. Ethical relativism holds that the extent to which an action is right or wrong depends on the moral norms of the society in which it is practiced. From this position there are no universal moral standards that can be applied to all peoples at all times: something is right if it is consistent with a society’s customs. If taken to extremes, ethical relativism would lead to acceptance of the Nazi experiments in the Second World War and other notorious cases whereby the rights of vulnerable populations have not been protected.11,34-39 Ethical relativism serves to remind us, however, that different societies have different beliefs that are deeply influenced by culture, and thus ethics in any
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particular research setting are contextually dependent.11 This suggests the need for a more nuanced view between universalism and ethical relativism that posits that there are fundamental ethical values and principles that all cultures recognise to some extent, at least implicitly, although they may be open to different interpretations with ethical values relative to culture.21,40,41 For example, in this research, the concept of respect for persons is deeply embedded in the culture but the collectivist nature of the society means that the common western interpretation of autonomy may not apply. Another example is how the western concept of privacy of information and physical space is one that is not recognised in everyday life in rural Lao PDR. This does not mean, however, that there are no cultural norms related to the respect of personal boundaries. Macklin argues that there are different levels of ethical significance. Some relate to how humans treat each other and others are accepted forms of politeness rather than universal ethical principles.40 These different levels can provide a middle ground between ethical universalism and ethical relativism.40 As illustrated earlier, privacy may be a culturally relative value. While confidentiality as conceived in western-based ethical guidelines may have been breached in the research presented here, the ethical principles of respect for persons and do no harm were not.40 On the other hand, while the research did not cause any obvious harm, the opportunity costs for participants were unclear – for example, in terms of lost productivity. Despite there being no evident harm in this research, an understanding of the research context and power relations is crucial in adhering to the principles of respect for persons and do no harm. For example, ensuring privacy and confidentiality is essential where the research includes collecting information related to stigmatised behaviours or other sensitive or personal issues such as gender based violence.24 In contexts where the prevailing cultural norms do not facilitate maintenance of privacy and confidentiality, or where permission is required from powerful gatekeepers, innovative strategies are needed to allow for privacy wherever the participant is approached.24 Thus, protecting the welfare of participants requires culturally sensitive attention to issues of context in finding just solutions to ethical challenges.42 From this
perspective, ethical research is likely to be based on the dialectical interplay between judgements in terms of local considerations, guided by ethical principles, with each being interpreted and reinterpreted in light of the other.43 International public health research that does not observe the highest ethical standards will be at risk of losing the trust of a community and its integrity.5,8,20 Indeed, some have argued that the current process of ethical review may limit researcher’s ability to engage in ethical reflexivity throughout the whole of the research process.32 Research ethics committees should critically engage with student researchers to understand how researchers have applied the ethical guidelines in the context of their proposed research. However, this requires contextual knowledge that ethic committees may lack.32 When ethics committees review applications for research in contexts such as rural Lao PDR, for example, do they try and picture the potential participants and – if so – who do they see and where has their imagery come from? To help novice public health researchers develop the skills to undertake research that is sensitive to context, the ethical review process needs to be seen by students and their supervisors as a valuable part of the research process, rather than an administrative hurdle.5,11,33 Moreover, teaching must go beyond codes of research ethics.41 It should include supervisors engaging students in substantive discussions about the nature of ethical research in different contexts, exploring ethical principles throughout the research cycle, and embracing the local, specific, contextual and contestable challenges that are ‘ethics in practice’.5,27,33 Engaging with students in ethical issues as they arise in practice can help develop students’ ethical competence. In the space of ‘ethics in practice’, the possibilities of respecting justice and the autonomy, dignity and privacy of research participants – and the risks of failing to do so – lie with the integrity of the researcher, not in the procedural ethical review process.5,27 In contexts where researchers and research participants have disparate worldviews and uphold cultural norms that diverge from the philosophies and values of western-based ethics, such discussions may be crucial to ensuring ethical research, especially in public health programs where ethics coursework is not a requirement.
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This paper has highlighted the some of the personal conflicts and ethical tensions that researchers may face as they grapple with their ethical obligations to their participants. For those conducting research in crosscultural environments, the principles inherent in the ethical conduct of research: integrity; respect for persons; beneficence; and justice provide an important foundation for decision making. This includes careful consideration of context. For doctoral students who are applying for ethics clearance to conduct their research, and for their supervisors, the ethical process must be used as an opportunity for substantive discussions about the nature of ethical research in different contexts.
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Correspondence to: Dr Jo Durham, Faculty of Medicine & Biomedical Sciences, School of Population Health, The University of Queensland, Herston Road, Herston, Qld 4006; e-mail: [email protected]
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