The last 10 years of Bioethics in the English-speaking Caribbean - An Overview

1. The last 10 years of Bioethics in the English-speaking Caribbean - An Overview By Dr. Derrick Aarons - Physician - Bioethicist © Dr. Derrick Aarons 2004

2. Introduction: • The English-speaking Caribbean comprise 18 politically independent as well as British-dependent countries where English is the first language. These are: Antigua & Barbuda, Anguilla, The Bahamas, Barbados, Belize, Bermuda, British Virgin Islands, Cayman Islands, Dominica, Grenada, Guyana, Jamaica, Montserrat, St. Kitts-Nevis, St. Lucia, St. Vincent & the Grenadines, Trinidad & Tobago, and The Turks & Caicos Islands.

3. Introduction: • Together, these countries have a total population of 6 million people. • Currently, there are 3 medical schools affiliated with the University of the West Indies (Jamaica, Barbados, and Trinidad), and 3 off-shore medical schools affiliated with the United States.

4. Bioethics - The last 10 years…

5. 10 years ago…. • Health professionals in the English-speaking Caribbean were first introduced to the concepts and substance of Bioethics at the 1st Caribbean Workshop on “Health Care, Law & Ethics”which was hosted in Barbados, April 13-16, 1993.

6. 10 years ago…. • Attendees included representatives from PAHO/WHO, the University of the West Indies, Chief Medical Officers for some Caribbean Islands, Medical Council representatives, doctors, nurses, and persons in health administration.

7. 10 years ago…. • Topics presented included: - Health Care Law as an Academic Discipline - Medical Ethics – Caribbean Issues and Perspectives

8. 10 years ago…. • Topics presented: - Patient Rights - Legal rights and responsibilities of the health professional - Contemporary medico-legal issues

9. 10 years ago…. • Topics presented: - Medical Research - Fitness to practice: Doctor and the Law - AIDS and ethical issues: suicide, euthanasia and confidentiality

10. 10 years ago…. • Topics presented: - PAHO: Inter-American Network of Health Legislation - Termination of Pregnancy issues and practice

11. 10 years ago…. • Topics presented: - Setting up Clinical Ethical Committees - Teaching Ethics and Law - Coordination of regional councils

12. 10 years ago…. With the resulting increased sensitivity to the issues discussed, attendees at the workshop were urged to implement certain recommendations in the future: - The Faculty of Medical Sciences should include a formal course on Bioethics

13. 10 years ago…. Recommendations for the future: - Plan for PAHO to fund the establishment of a Centre on Health Law at a regional level

14. 10 years ago…. • Recommendations for the future: - More teaching of Ethics to medical and nursing students - Establish a Caribbean Medical Council

15. 7 years ago…. • In April 1997, PAHO’s Caribbean Program Coordinator convened the 1st sub-regional meeting on Bioethics. • In attendance were several Chief Medical Officers from across the Caribbean;

16. 7 years ago…. • .. and representatives from the University of the West Indies and the Caribbean Health Research Council (CHRC). • At this meeting: Clinical ethics, ethics and health legislation, and bioethics in public health were identified as important priorities.

17. Since then…. • A growing awareness of bioethical issues has been permeating the English-speaking Caribbean • In 1999, Trinidad & Tobago, Haiti, and the Bahamas were selected as sites for HIV vaccine trials

18. Since then…. • More recently, Jamaica has been identified as the next site in the Caribbean for HIV vaccine trial. • Consequent to such developments, health professionals as well as lay persons have been questioning the ethics of vaccine trials in particular and health research in general.

19. Since then…. • In the Caribbean, not all investigators have access to a research ethics committee, and communities have not had the opportunity to debate and reach consensus on ethical issues arising from research involving human participants.

20. Bioethics: The last 5 years... • Consequently, at the 44th Caribbean Health Research Council (CHRC) scientific meeting in April 1999, a symposium was held on “Bioethics in the Caribbean”at which Dr. Fernando Lolas, Director of the PAHO/ WHO Regional Program presented an overview of the program.

21. Bioethics: The last 5 years... • The meeting agreed to: - Convene a sub-regional workshop on Bioethics - Develop a proposal for a training program in research ethics for the Caribbean

22. Bioethics: The last 5 years... • The meeting agreed to: - Present a draft of this training program to the workshop, which – after input from the workshop participants, would be submitted for major funding.

23. Workshop: • Workshop on Ethics in Health Care and Research in the Caribbean – 23-25th Feb., 2000 – Port of Spain, Trinidad. • 46 participants representing a range of disciplines and interests from across the Caribbean were in attendance. These persons were in positions to make substantial contributions to clinical, public health, and research ethics.

24. Workshop: • Distinguished experts contributing to the workshop included: Dr. Derrick Aarons, Bioethicist, UWI, Jamaica Dr. James Drane, Clinical Ethicist, Edinboro University, Pennsylvania Dr. Christine Grady, Head – Section of Human Subjects Research, NIH, USA

25. Workshop: • Distinguished experts contributing to the workshop included: Prof. Alice Herb, Asst. Clinical Professor – Family Practice, State University of New York Health Science Centre Dr. Fernando Lolas, Director – PAHO/WHO Regional Program on Bioethics

26. Workshop: • Distinguished experts contributing to the workshop included: Prof. Ruth Macklin, Professor of Bioethics, Albert Einstein College of Medicine, N.Y. Dr. F. Zacharias, Program Coordinator on AIDS & Sexually Transmitted Diseases, PAHO

27. Workshop: • Themes: - Ethical Issues in Health Care and Public Health in the Caribbean - Models of Clinical Ethics Committees - Research Ethics Committees - Caribbean Ethics Network - Training in Health Care Ethics

28. Workshop: • Workshop Conclusions: - The Caribbean has an inadequate number of persons who have received training in research ethics - Too few ethical review committees in the Caribbean - An urgent need exists to provide such training in the Caribbean

29. 2nd Workshop: • Workshop on Ethics in Human Subjects Research in the Caribbean – 12-14th Feb., 2001 – Port of Spain, Trinidad. • 50 participants were provided intensive training in human subjects research ethics. Included were members of research ethics committees from the English-speaking Caribbean, the Netherland Antilles and Haiti;

30. 2nd Workshop: • …Individuals with skills or interests in research ethics in the sub-region, including the fields of clinical and public health medicine, academia, non-government organizations, and active researchers in the Caribbean.

31. 2nd Workshop: • Faculty included: Dr. Derrick Aarons, Bioethicist, UWI, Jamaica Dr. Francis Crawley, Ethicist, European Forum for Good Clinical Practice, Belgium Dr. Jose Esparza, tutor of 2-day training workshop in research ethics for UNAIDS

32. 2nd Workshop: • Faculty included: Dr. Fernando Lolas, Director – PAHO/WHO Regional Program on Bioethics Prof. Ruth Macklin, Professor of Bioethics, Albert Einstein College of Medicine, N.Y.

33. 2nd Workshop: • Themes: - Fundamentals of Human Subjects Research Ethics - Status of Ethical Review in the Caribbean - Establishment of Ethical Review Committee

34. 2nd Workshop: • Themes: - Application of Basic Ethical Principles - Research in Developing Countries: Standards of Care - Standard Operating Procedures - Establishing a Forum for Ethics discussion in Caribbean Countries: Caribbean Ethics Network

35. Bioethics: The last 5 years... • In 1999, a survey was conducted on the existence of Research Ethics Committees (RECs) across the 18 English-speaking Caribbean countries. 8 countries had such committees (with 1 country having 4 committees). At that time, these 11 RECs reviewed an average of 10 research protocols each year (with the numbers ranging from 1 to 25).

36. Bioethics: The last 5 years... • However, only 4 countries had a research ethics committee that was accessible to all research investigators regardless of their institutional affiliation. • Only 6 of these 11 RECs had a member with any training in research ethics. Further, of the 8 countries that had no REC, 7 believed that there was a need for one.

37. Bioethics: The last 5 years... • Also in 1999, 5 countries in the English-speaking Caribbean were represented at the UNAIDS Workshop on Research Ethics held in Brazil. The workshop was sponsored for countries who were or may become involved in research on the HIV/AIDS vaccine, and invitees comprised members of research ethics committees and specialists who might be involved in the HIV vaccine research.

38. Bioethics: The last 5 years... • Subsequent to these developments, in 1999, an Ethics Committee Handbook was written for the Faculty of Medical Sciences, UWI, in Jamaica . • During 1999 and 2000, the Faculty of Medical Sciences, UWI, in Trinidad and Jamaica developed and distributed Guidelines for the conduct of research with human subjects to all their departments.

39. Bioethics: The last 5 years... • In 2000, as a part of its health reform and re-structuring program, the Ministry of Health in Jamaica established an Advisory Panel of Ethics & Medico-Legal Affairs. • This Panel, in 2001,developed Guidelines for the conduct of research with human subjects across the island.

40. Bioethics: The last 5 years... • In 2003, the Panel conducted a Research Ethics Seminar for all Medical Officers of Health in charge of the parishes across Jamaica. These officers are now the first reviewers of research protocols across the island, with multi-center studies and proposed research involving more than minimal risk being referred to the Advisory Panel in the Ministry of Health.

41. Bioethics: The last 5 years... • The Panel has also developed Guidelines for the establishment of Clinical Ethics Committees in hospitals across Jamaica. However, these committees have not yet been established.

42. Simultaneous with all this… There has been an expanding interest in ethics and ethical standards: • 1 week of activities on Medical Ethics hosted by St. Vincent & the Grenadines in the eastern Caribbean (1996) • Ethical dilemmas in the management of terminally ill patients – Annual Conference, Jamaica Anaesthetist Assn. (1997)

43. Simultaneous with all this… There has been an expanding interest in ethics and standards: • Ethical Issues in the treatment of HIV-positive Mother to prevent Mother-to-child transmission – a training workshop, Ministry of Health, Jamaica (1999).

44. Simultaneous with all this… There has been an expanding interest in ethics and standards: • Bioethics: A new frontier – a Challenge for Policy-making, Law & Jurisprudence - A distinguished lecture to High Court Judges, Resident Magistrates, and Attorneys-at-Law in the Jamaican Justice System (1999)

45. Simultaneous with all this… There has been an expanding interest in ethics and standards: • Genes and their impact: Social, Ethical, Moral & Religious Issues – Annual Conference of the Scientific Research Council of Jamaica (2000). • The 10th Annual Research Day of Activities, UWI, Jamaica, was on Research Ethics (2001).

46. Simultaneous with all this… There has been an expanding interest in ethics and standards: • Human Cloning – The General Assembly of the Jamaica Baptist Union (2002).

47. Simultaneous with all this… There has been an expanding interest in ethics and standards: • Medical Ethics & the Doctor-Patient Relationship Course established in the M.Sc. (Family Medicine), UWI, Jamaica (2001), and in the Family Medicine Diploma program in Trinidad (2000).

48. Bioethics: The last few years… Expanding interest in ethics and standards: • The annual conference of the Medical Association of Jamaica includes at least one topic on ethics (clinical or medical). • The West Indian Medical Journal (WIMJ) published an Editorial on the Role of the Health Care Ethics Consultant (1997).

49. Bioethics: The last few years… Expanding interest in ethics and standards: • Since then, its has published a series on Bioethics: - Issues in Bioethics: Teaching Medical Ethics to health professionals - Issues in Bioethics: Ethics and Professional Responsibilities - Issues in Bioethics: Teaching Research Ethics

50. Bioethics: The last few years… Expanding interest in ethics and standards: • The Caribbean Health Research Council (CHRC) has included a chapter on Research Ethics in its Research Skills Workshop Manual (2003). • Radio interviews on many bioethical issues, e.g. cloning, in-utero diagnosis of diseases, euthanasia & physician-assisted suicide, ethical dilemma in harvesting semen from a deceased man for impregnation, etc.