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It was on a dreary night in November that I beheld the accomplishment of my toils. With an anxiety that almost amounted to agony, I collected the instruments of life around me that I might infuse a spark of being into the lifeless thing that lay at my feet … by the glimmer of the half-extinguished light I saw the dull yellow eye of the creature open; it breathed hard, and convulsive motion agitated its limbs (Shelley, 1969).1

The modern human rights movement, like American bioethics, was born from the devastation of World War II. The multinational trial of the major Nazi war criminals at Nuremberg following World War II was held on the premise that there is a higher law of humanity (derived from natural law rules based on an understanding of the essential nature of humans), and that individuals may be properly tried for violating that law. Universal criminal law includes crimes against humanity, such as murder, genocide, torture, and slavery. Obeying the orders of superiors is no defense: the state cannot shield its agents from prosecution for crimes against humanity.

No other region of the world has suffered from such devastating epidemics in the recent past than sub-Saharan Africa. HIV/AIDS poses the worst single health threat on the continent and approximately 28.5 million of people infected with HIV/AIDS are in sub-Saharan Africa, yet, less than 8% have access to treatment. As African countries start or continue to expand their HIV/AIDS treatment programs with the assistance of international donors, they are facing several ethical and health policy challenges, including difficult decisions on how to ration available treatment, the high cost of drugs, the complexity of treatment regimens, the inadequacy of health and delivery systems, the lack of knowledge about treatment, and the threat of drug resistance.

Research sponsored by entities in developed countries, but conducted in developing countries, has recently been the focus of academic debate, international declarations and media controversy. Much of this attention has focused on whether the trials are exploitative and if so what should be done to avoid exploitation. This chapter takes Alan Wertheimer's principles of mutually advantageous transactions and applies them to the question of exploitation in international research. In this chapter, I develop an analysis of exploitation and apply this to the hypothesis that some pharmaceutical companies who run drug trials in developing countries wrongfully exploit the trial participants.

In an essay titled, “In Harm's Way. AMA Physicians and the Duty to Treat” (Clark, 2005), I argued that a physician's duty to treat, at personal risk, followed not only from the language, history, and precedents of the American Medical Association's Code of Ethics, but that such a duty was sound in morally relevant ways. A key element in the soundness of the argument was that such a duty had contractual features that were inherent in an implicit social covenant.

With the recent outbreak of Severe Acute Respiratory Syndrome (SARS) and on-going concerns about influenza and the use of pathogenic organisms as weapons, the management of outbreaks of contagious diseases has recently taken on a new urgency (Barbera et al., 2001). However, the public health law concerning disease outbreaks is still based on the perspectives, and often the words, of the early twentieth century, when most public officials saw little option but to take a very authoritarian approach to the protection of the public's health. Over the past 40 years, the jurisprudence of involuntary non-criminal incarceration, for example for the treatment of tuberculosis or as a result of mental disease, has changed dramatically, as basic concepts of due process have been incorporated into the process of civil commitment (Gostin, Burris, & Lazzarini, 1999). There is, therefore, a pressing need to rethink the approaches traditionally taken to the control of infectious disease outbreaks to address this gap between the old assumptions of plenary power to act in the public's interests and the rights of individuals threatened with state actions (Davis & Kumar, 2003). It is a canard sometimes used to justify authoritarian actions that the public responds to emergencies by losing control and panicking; indeed it is the consensus of social scientists that people in emergency situations tend to be more cooperative and more generous toward others than they may normally be (Smith, 2001; Clarke, 2002). If anything, it is my reading of such experiences as the bomb attacks on London during World War II (Harrisson, 1989) that it is the poorly prepared and under-supported public officials who are most likely to act in unproductive and socially divisive ways during public emergencies.

Physicians are instrumental to our national defense against epidemics, whether natural or bioterror-related. Broadly speaking, they are obligated to help rapidly identify threats, prevent the spread of disease, and care for infected patients. Each task presents ethical challenges, including the need to address access to care, balance the medical needs of individuals and communities, and ensure that health professionals continue to treat infectious patients in spite of the risk they present. If physicians can acknowledge these duties and meet these challenges, they have an opportunity to strengthen medicine's public trust and professional identity.

Objectives: To discuss whether, during an influenza pandemic, public health authorities could be ethically justified in implementing a mandatory vaccination program directed at health care professionals.

Methods: Ethical analysis is carried out by examining arguments that can be made in favor or against such a mandatory measure and by seeking a reasonably balanced position between them. Arguments under consideration are based on the duties of health professionals and public health authorities, the consequences of their actions and on other ethical principles. The importance of relevant empirical data is stressed without any attempt to review or analyze them systematically.

Results: Mandatory vaccination of some health care professionals during a serious pandemic of influenza can be justified, but only under certain limited conditions.

Conclusions: In the throes of an influenza pandemic, health care professionals (and to a variable degree, other health care workers) have an ethical obligation to accept influenza vaccination if it is reasonably safe and effective. The ethical responsibility of public health authorities is to limit the impact of a pandemic on the population by all reasonable means, which clearly includes the appropriate use of vaccine. Consequently, the vaccination of health care staff can be made mandatory under certain conditions. However, a critical objection to this conclusion, which upholds that a voluntary vaccination program (an ethically much less problematic intervention) is just as effective, needs to be addressed.