In crafting our paper on addressing the ethical challenges in HIV prevention research with people who inject drugs,1 we had hoped to stimulate further discussion and deliberation about the topic. We are pleased that three commentaries on our paper have begun this process.2 3 4 The commentaries rightly bring up important issues relating to community engagement and problems in translating research into practice in the fraught environments in which PWID face multiple risks. These risks include acquisition of HIV as well (...) as criminalisation, stigma and lack of access to needed healthcare, prevention and social services. We take this opportunity to respond to the excellent points raised by the commentators. All of the commentaries support our emphasis on robust community engagement with PWID and other stakeholders in designing and conducting HIV prevention research, but urge us to go farther. Wolfe highlights the difficulty of even engaging with community members in oppressive settings, where authorities severely restrict civil liberties of PWID so that even discussing issues related to drug use and enforcement may place individuals at risk. To overcome such limitations, he appropriately suggests interviewing confidentially those who have previously been detained in closed settings as part of the community engagement process. Similarly, Wolfe observes that critical issues can be overlooked with a narrow focus on study procedures if contextual factors before, during or after a study are ignored. For example, he cites the risk of overdose for study participants who have been abstinent during a study and subsequently resume injecting when the study concludes. These kinds of risks may not be obvious …. (shrink)

Medicine interacts with the social, legal and political elements of life. For example, UK homelessness leads to a reduction in life-expectancy of around 30 years.1 This issue is a daily reality for practicising clinicians. In research and research ethics, vulnerable groups, including the socially vulnerable, are frequently excluded from research. While there are good reasons for this, it can mean exclusion from benefits as well as from risks. In our feature article this month, Dawson et al make a compelling and (...) nuanced case — and a practical proposal — for designing research protocols for HIV prevention measures that allow for the inclusion of people who inject drugs without compromising their safety from a legal and social perspective as well as a medical one. Along the way, they reference some of the public health damage caused by legal and social policy. To take one example: ‘if police beatings were eliminated in Odessa, Ukraine, HIV incidence among PWID would decrease up to 19% over a 5 year period’.2 For those of us in the university sector, measuring ‘impact’ has become a major, and sometimes controversial, way that our output is judged. This paper highlights the real-world importance of research impact as well as the kinds of difficulties researchers face. A series of commentaries probe the practical proposal put forward in the paper by Dawson et al. Lavery applies Rittel and Webber’s concept of ‘wicked problems’ to the dilemmas facing researchers in this context: > Wicked problems have 10 defining characteristics: they are not amenable to definitive formulation; it is not obvious when they have been solved; solutions are not true or false, but good or bad; there is no immediate, or ultimate, test of a solution; every implemented solution is consequential, it leaves traces that cannot be undone; there …. (shrink)

“Wicked” problems are characterized by intractable complexity, uncertainty, and conflict between individuals or institutions, and they inhabit almost every corner of medical ethics. Despite wide acceptance of the same ethical principles, we nevertheless disagree about how to formulate such problems, how to solve them, what would _count_ as solving them, or even what the possible solutions _are_. That is, we don’t always know how best to implement ethical ideals in messy real-world contexts. I sketch an implementation framework for medical ethics (...) that can help clarify wicked problems and organize further ethics research toward their resolutions. This framework describes the procedural variables that work alongside substantive ethical ideals to deliver ethical decisions in complex real-world situations. Using controversial GM mosquito research as an example, I illustrate how the generalizable relationships between the variables clarify emerging ethical guidelines of research governance and provide a pathway to extend these guidelines in a way consistent with our ethical intuitions across a wide range of research and public health ethics. (shrink)