have shifted towards low and middle-income countries over two decades.
is faster, costs are lower and populations are less likely to have taken other treatments.
That last advantage is the ethically uncomfortable one, because it is a consequence of poor access to care.
A patient with no alternative treatment is an excellent research subject and a person under pressure.
carries most of the ethical weight and does the least reliable work.
Studies of comprehension find that many participants believe they are receiving treatment chosen for them by a doctor.
The word trial translates badly, and the concept of translates worse.
Consent obtained through a form signed in a second language records a procedure rather than an understanding.
The question is sharper still and has divided research ethics for thirty years.
A should receive the best available treatment, and the phrase available conceals the dispute.
Available where, and to whom, decides whether a trial is a gap or measuring within it.
Post-trial access is the provision most often promised and least often delivered.
A community that carried the risk of a trial frequently cannot afford the drug that the trial validated.
Several funders now require an access plan as a condition of the grant, which shifts the question earlier.
Local ethics committees are the other structural answer and are unevenly resourced.
A committee reviewing two hundred a year with no paid staff approves most of them.
Funding those committees is cheap, unglamorous and almost never included in a trial budget.
Ethics in practice is largely a question of who is paid to say no.