标题：Justice and Fairness in the Kennedy Krieger Institute Lead Paint Study: the Ethics of Public Health Research on Less Expensive, Less Effective Interventions
摘要：The Kennedy Krieger lead paint study stirred controversial questions about whether research designed to develop less expensive interventions that are not as effective as existing treatments can be ethically warranted. Critics questioned the social value of such research and alleged that it sanctions a double standard, exploits participants, and is complicit in perpetuating the social injustice. In response, we demonstrate the propriety of conducting research on interventions that can be extended to the population in need by stipulating the limited conditions in which it is ethically warranted and providing fair terms of participation. We contend that the failure to conduct such research causes greater harm, because it deprives disadvantaged populations of the benefits of imminent incremental improvements in their health conditions. THE CONTROVERSIAL KENNEDY Krieger lead paint abatement study raised serious questions about the ethics of public health research and the relation between research and policies aimed at improving population health. 1 – 4 This study tested low-cost lead abatement procedures in housing in Baltimore to determine their effectiveness in reducing blood lead levels in children living in these houses. An impassioned debate has ensued about the role of public health researchers in improving health outcomes, reducing health inequalities, and promoting social justice. 5 – 10 Critics have questioned whether attempts to find interventions that are less expensive than the current standard of care, but also less effective than existing treatments, sanction a double standard, exploit participants, and are ultimately counterproductive by sapping the political will to provide the best health care possible. 11 , 12 However, research that seeks to discover less expensive interventions may be ethical under certain carefully defined conditions, and the failure to conduct such research is contrary to the interests of those most in need. The goal of public health is to improve the health of the population as a whole. 13 , 14 Because of the robust relation between socioeconomic status and the full spectrum of health indicators, many people have argued that significant improvements in population health can be achieved only by effecting substantial redistributions of wealth and access to social resources. 15 – 17 Programs that attempt to ameliorate conditions within the existing structure of social inequalities have often been faulted as Band-Aid solutions that merely perpetuate injustice. Thus, it is important to place the debate about the ethics of public health research in the context of a wider debate about competing conceptions of social justice and to sort out carefully the links between research ethics and the ethical obligations of society to reduce socioeconomic inequalities in order to improve the health and welfare of the poor. The Kennedy Krieger Institute (KKI) case is particularly instructive because it extricates controversial debates relating to standards of care that are now prominent in international health research from those confounding ethical concerns associated with delivering medical care in the context of doctor–patient relationships.
