Ethics in psychosocial and biomedical research – A training experience at the Interdisciplinary Center for Bioethics ( CIEB ) of the University of Chile 1

This paper reviews the experience in training Latin American professionals and scientists in the ethics of biomedical and psychosocial research at the Interdisciplinary Center for Studies in Bioethics (CIEB) of the University of Chile, aided by a grant from Fogarty International Center (FIC) – National Institutes of Health from 2002 to 2011. In these 10 years of experience, 50 trainees have completed a 12-month training combining on-line and in-person teaching and learning activities, with further support for maintaining contact via webmail and personal meetings. The network formed by faculty and former trainees has published extensively on issues relevant in the continent and has been instrumental in promoting new master level courses at different universities, drafting regulations and norms, and promoting the use of bioethical discourse in health care and research. Evaluation meetings have shown that while most trainees did benefit from the experience and contributed highly to developments at their home institutions and countries, some degree of structuring of demand for qualified personnel is needed in order to better utilize the human resources created by the program. Publications and other deliverables of trainees and faculty are presented.


Background
The University of Chile, the oldest public university in Chile and the most accredited research institution in the country, ranking among the most productive and solvent in the Region of the Americas and the Caribbean, has pioneered in the establishment of new fields of inquiry.Bioethics was among them.
The Interdisciplinary Center for Studies on Bioethics (CIEB) was established in 1993 (1) and in 1994 it entered into collaboration with the Regional Program on Bioethics established by an agreement between the Chilean Government, the University of Chile and the Pan American Health Organization (PAHO).The latter, with several burocratic vicissitudes, lasted until March 2010.
Throughout its existence, CIEB has been instrumental in promoting the dissemination of bioethical discourses and practices in the website www.bioetica.uchile.cland through the indexed, peerreviewed journal Acta Bioethica (ISSN 0717-5906), published with support from PAHO until 2010 and from 2011 onwards in electronic format (www.actabioethica.cl).CIEB also edits books, congress proceedings and monographic issues of Acta Bioethica, freely available at the websites.
CIEB also participates in seminars, congresses, and workshops in Latin America, the USA, and Europe and conducts research projects supported by private and governmental sources, such as the Ford Foundation, the Rockefeller Foundation, the US Department of Energy, the Chilean Research Commission, the Alexander von Humboldt Foundation and the US National Institutes of Health (NIH).This paper reviews one long lasting project supported by the National Institutes of Health (NIH) through grants from the Fogarty International Center in collaboration with other Institutes.For 10 years, from 2002 thru 2011, the emphasis has been placed on training selected professionals and academics from Latin America and the Caribbean in biomedical and psychosocial research ethics.
Ethical considerations affect quality of research and opportunities for collaborative work.In many Latin American countries informed consent, responsible conduct of research, risk assessment, protection from harm, privacy and confidentiality, equitable opportunities for subjects, and avoidance of stigmatization (among other issues) are still more a matter of compliance with donor agencies than a felt need of the scientific community.A combination of face-to-face and distant training within the same cultural community has proven appropriate for dealing with these issues.Ethics is always local, despite the fact that research may be considered a universal intellectual enterprise.

Social roles: clinician and/or researcher
Scarcity of personnel, professional traditions, and restricted funding are responsible for confusion between the roles of caregiver and researcher in many Latin American settings.Pervasive "therapeutic misunderstandings" (1,2), inadequate notions of "standard of care", different contextual interpretation of guidelines stemming from other cultures, and discrepancies between researchers from different countries/traditions/professions militate against a unified view of the research enterprise that could be applied to improve quality and train scholars.This training program confronted trainees with real-life examples of research in specific contexts and/or in response to felt needs of populations and institutions.Special emphasis given to public health topics and anthropological analysis was dictated by the priorities of healthcare systems in the continent and the multicultural, pluralistic environments in which researchers must act.

International collaboration: essential scientific dialogue
Increasing globalization of the research enterprise and the need to enter into meaningful dialogues for good results make it imperative to develop local capacity.The challenge is not only to increase sound scientific production.It is to establish a pattern of collaboration that not reproduces power relations frequent in other spheres (such poor nations.The cost of conducting research is less than in advanced countries.Poor countries offer large patient pools for diseases, thus ensuring rapid recruitment and reduction of time for completing trials.Regulations are weak or nonexistent, and lack of qualified policymakers and scientists create an imbalance between what is offered to communities and the actual benefits in terms of manpower development or economic support.Public awareness about the need to ethical control of research is imperative.

The know-do gap
Another aspect that merits consideration is the so called "know-do gap".While information is available on many health-related issues, its conversion to policy and practical measures is delayed precisely in those countries where its application would make a difference in living conditions.This is not only a matter of economic importance.Its ethical dimension arises from the fact that resource-poor countries-or some privileged groups within them-consider that they have the right to enjoy the highest possible standard derived from scientific progress.Only a cadre of professionals conversant with the state of the art in research and also aware of the value-laden nature of scientific knowledge can enter into a dialogue with experts and lay people regarding the appropriateness and timeliness of investments in the conversion of data into practice.On the other hand, an equitable distribution of the benefits derived from scientific research is a matter for ethical reflection by the scientific community, policymakers, and public at large.

Research: cultural implications and responsible conduct
Research is a context-dependent, patterned cultural process.Some activities called research in less developed countries would not qualify as such in scientifically alphabetized countries.Social demand for research (as different from need or desire) continues to be low in Latin America, as reflected in resource allocation, social recognition, and employment opportunities.sume positions of leadership nationally and internationally in addressing the ethical and social issues of global health research.Since this research is inherently multidisciplinary and interdisciplinary, students from a growing range of disciplines directly or indirectly related to health seek training, thus producing a heterogeneous group whose members not necessarily share the same ethos of service or are not sufficiently committed to the relationship between science and ethics in the creation and application of knowledge.There are also wide cultural variations regarding the social implications of scientific research, the roles of researchers in the community, and the expectations regarding social impact of science and technology.
The training program developed by CIEB aimed at consolidating and expanding an "ethically sustainable" research agenda in a globalized context by training groups of professionals able to participate as researchers, policymakers, advisors to legislators, and mentors for new generations of academics.It is recognized that ethical oversight of research is best performed locally; avoiding mistrust and dependence (sometimes associated with foreign funding and foreign institutions) the autonomy of the groups and institutions was sought.

Research accountability
Research is an activity not widely performed in the Latin American continent.Scientists and scholars represent a privileged minority and many of its members feel that they belong to elites whose contribution to science and technology may be hampered or otherwise limited by ethical oversight.All along, the emphasis on accountability of researchers and research has been a permanent feature of our training effort.

Approaches and experiences
After successful application (about 30 applicants annually), five to six trainees were selected each year for courses and activities at CIEB, with an international faculty.Table 1 presents a listing of trainees with their professions, country of origin, and other relevant information.The program was as economics) or the irrational fight against "foreign" influence (characteristic of some political discourses).A constructive contribution of Latin American science requires sound ethical oversight systems, good quality training, and awareness of the needs and expectations of the populations.Even if our trainees were not in the forefront of research, their expanded vision of the situation and the awareness of the goals of research in its proper context would help improve the translation of evidence-based facts into value-based actions

Human diversity: challenge and opportunity
Research ethics curricula face the challenge of multiethnic and multicultural contexts existent in Latin America, whose indigenous population averages 11% but varies widely from 80% in Bolivia, 60% in Guatemala and 40% in Peru.Even language diversity is a factor hampering research, particularly in the field of social studies and public health.Stigmatization has been found to affect genomics research in populations and the need for a "culture fair" approach to data gathering and interpretation is as an ethical an imperative as the need to respect dignity or request consent.The notion of "ethical sustainability", essential in our continent-wide work, stresses what international documents identify as essential in the pursuit of science at the service of development.UNESCO Universal Declaration on Bioethics and Human Rights, among other documents, underscores the vulnerability of resource-poor populations and the ethical imperative to avoid the typical "safari research": researchers from affluent societies behave as "data hunters" and disregard opportunities for real collaboration.Our emphasis on a selfgenerating faculty and permanent dialogue was an exercise in "counter-alienation" of researchers and an invitation to make real the "bi-directional" character of all ethical dialogue.The sustainability of this effort is ensured by the empirical, albeit anecdotal, evidence we have gathered during the conduction of the program.The danger of a group that is closed and immune to criticism is not supported by our experience.These factors justify the need for highly trained professionals from developing countries to as-institutionalization of bioethics, structure and functions of ethics committees, anthropology and bioethics, and other topics selected on the basis of personal interests and available teaching resources.Trainees participated in sessions of research ethics committees, had opportunity to interact with international scholars visiting the CIEB and were requested to select a topic to be dealt with in depth as a final exercise of in-´person period.These essays were presented in evaluation sessions, graded, and constituted publications in accredited journals or presentations at seminars, workshops, or congresses, attendance to which was sometimes covered by special allowances from the program.
A list of publications produced by trainees and faculty during the period 2002-2011 is presented in the Appendices.
During the first two years of the program, along with formal training and delivery of the above mentioned contents, other activities were programmed.Among them was exposure to group dynamics and direct experience with emotional manifestations in group sessions.This activity demanded some effort on the part of faculty and trainees and although results were enlightening, the practice was abandoned in view of resistances voiced by some participants.
The training period at CIEB was mainly devoted to work in groups under the leadership of a faculty member, avoiding any resemblance to an asymmetrical relation of the type mentor-trainee or tutor-trainee.

The covert dimension of the curriculum was to illustrate practically the dialogical nature of the bioethical enterprise and the development of bioethical discourse through open manifestation of ideas.
Among the guiding principles implemented, the following can be mentioned: • Methodical pluralism."Solutions" given by different disciplines to ethical dilemmas depend on methods, that is, ways of formulating, interpreting, and solving problems.The power of a profession derives from its being able to identify "real" problems and provide appropriate solutions.The teaching of sta-advertised through standard academic channels (websites and flyers).Former graduates constituted a good source of information for new applicants.The selection process involved analysis of previous activities, publications and other deliverables, and support from home institutions in order to keep a position or provide development opportunities after training.The acceptance rate was on average 15 to 20 %, depending on the number of good applicants.
The program underwent changes.At the beginning, no virtual (on-line) component was present and trainees were hosted at the CIEB, University of Chile, for nine months; three additional months spent doing work in a country different from the country of origin.Thus, useful contribution to the development of ethics committees and ethics regulations was possible in Peru, Dominican Republic, and Costa Rica.In the ensuing years, with the introduction of virtual learning modules adapted from the CITI program developed at the University of Miami and the Fred Hutchinson Cancer Center, Seattle, Washington4 , a period of virtual training was introduced before the inperson, face-to-face portion of the program.This period served for providing a common ground for all successful applicants, homogenized the language and familiarized trainees with the topics and terminology to be employed in the courses offered at CIEB in Santiago.The in-person period at CIEB was reduced to three months of full time commitment.The virtual phase served as a baseline for comparison with knowledge and attitudes at the end of the training period; it was used also as a teaching device: trainees were requested to develop modules of their own and contribute to the improvement of the virtual course.
During their stay at the CIEB in Santiago, Chile, trainees were exposed to a wide range of contents and training experiences.Courses were offered on the philosophical foundations of ethics, the history of bioethical thinking, the applications of bioethical discourse to research questions, statistical reasoning as it pertains to ethical formulation of methods, bioethical problems arising in medical and psychosocial research, qualitative and quantitative research methods, health economics, the subject matter of testimonies collected after the experience was finished.

• Improvement of communication skills. Trainees
were exposed to a variety of approaches for improving written and oral communication, and special training sessions were devoted to the design and development of websites, listserv lists, slide presentations, oral reports and written materials.This was essential given the different training experiences of participants and the need to represent ideas and attitudes to wider audiences.This portion of the training experience also served to highlight moral problems associated with scientific communication and thus introduce participants to a crucial aspect of research integrity.• Tolerance and the ability to listen.Al though implicit, the notion that a crucial competence necessary for a successful implementation of bioethical discourse is tolerance and the capacity to listen to discrepant or adversary views was reinforced throughout the training period and was continued in the aftermath of the face-to-face experience, when networking activities at the home institution were supported and followed.
When the training period was completed, participants were requested to write down formal and publishable papers and to prepare an activity in their home country or at their institution of origin, to which a faculty member was invited.Thus, continuity of effort was assured and support from the home institution assessed.

Evaluation of program and outcomes
A complete assessment of impact may require an extended time to complete and should probably consider aspects well beyond immediate effects on research ethics.Multiplying effects of the experience through the work and effort of participants probably need years to show manifest outcomes in research practice, policymaking, and committee work.These could be more qualitative than quantifiable in terms of publications, policies, or other deliverables.
tistical methods, participant observation, qualitative and quantitative approaches to data acquisition and presentation was aimed at reinforcing the idea that no good science (in the ethical sense of good) can be obtained without careful attention to method.In addition, the multi-leveled and complex nature of scientific/ethical problems was underscored by stressing different approaches to problems.• Perspectivism.Not to be confused with moral relativism, the presentation of different perspectives is essential in creating an adequate environment for democratic and fact-producing dialogue.This included an openness to all facts related to a problem or to decision-making, illustrating a "culture of dialogue" that is of the essence of bioethical practice in committees and commissions.Deliberation was pursued in an attempt to generate conclusions "sine ira et studio" but well grounded on argument.• Open-mindedness.This ideal of interaction was sought after by encouraging manifestation of personal preferences and emotionladen material related to case analyses.Success was measured by requesting a personal evaluation from trainees after the completion of the face-to-face period.• Cultural sensitiveness.The interdisciplinary nature of our effort was accompanied by the effort to underscore what is meant by a truly transcultural approach.Contact with anthropological thinking was provided by professional anthropologists who illustrated their methods and data with examples drawn from the cultural and the health fields.Their methods and approaches were considered valuable by trainees and helped to create awareness of the multiethnic and multicultural character of Latin American societies.The relevance of this knowledge for a culturally fair bioethics was stressed all along.• Attitudinal change.Although an ambitious goal not always easy to attain, it was expected that after the training period, attitudes toward problems, ethical dilemmas, and current or possible solutions could undergo changes.Again, this was reflected in self evaluations made by trainees and faculty and was sulted in network programs, continued support, and evaluation meetings, the last of which was held in September 2011 in Lima, Peru.
One important lesson learned from the experience was that the program did make a difference in the careers and outlook of participants.This not always found expression in their daily routines, for most of them continued performing duties and having responsibilities very similar to those previous to the learning experience.Many of them were able to install and develop ethical review committees and improve ethical oversight in their environments.In evaluation meetings, however, reports of difficulties associated with their contribution were common.This fact does not diminish the importance of this type of training but underscores the fact that the incorporation of competent human capital to the institutions depends on appropriate conditions in the countries of origin.The process of accepting bioethical practices and modes of thinking takes time.We are working in an environment of "trial and success" and "trial and error" periods.Measured by the structuring of functioning processes at trainees´ home institutions or the development of regulations and activities in their countries, the program has shown different degrees of success.Individual factors and institutional variables account for different outcomes.Important has been to maintain contact and develop networking activities that reinforce the sense of leadership derived from the successful completion of the training experience.In some quarters, the support by a US institution was considered negative and criticism was voiced, suggesting that the program was a way of imposing a politically laden view of the research enterprise.Needless to say, such criticism is not worth of consideration but exists.The plain fact that the program was conceived and carried out by a Latin American institution with a representation of all views should suffice as counterargument.
There are fundamental issues uncovered by this ten-year experience with ethics of psychosocial and biomedical research in Latin America.One is the very notion of research.Standards of scholarship and university training are not uniform The effects of the program can be evaluated at the individual, the institutional, and the national levels.
Faculty members served as tutors and provided advice and support to trainees throughout the training period and afterwards.Evaluation consisted in written reports and feedback to participants on their degree of commitment, collaboration with the long-term goals of the program, and written productions.
Individuals participating in the program provided feedback on their perceptions and accomplishments at the end of each term and their opinions proved valuable for reformulating aims and methods.Their publications attest to a wide range of interests and issues.The evaluations made by faculty members of participation, interest, and attitude change indicate that most of the goals of the program, at the individual level, were achieved in about half the members of the teaching experience.The program itself was modified in accordance with suggestions and ideas provided by participants.
At the institutional level, the effects can be summarized in the development and implementation of training programs, ethics committees, and structure modifications.They are indicated in the appendices.An expected outcome would certainly be an improvement in the quality of research from an ethical point of view.This, however, is difficult to assess with the information available.
At the national level the effects are more difficult to estimate.They depend in part on the personal influence each trainee may have in his/her local environment and in the recognition of the importance of research ethics by officials and public.

Lessons learned -the future of ethics training within the research enterprise in Latin America
As important as written materials, in and by itself a good demonstration of success and impact is the fact that both faculty and former trainees established an enduring collaboration which re-

A network for the advancement of a biocentric ethics
The experience gathered throughout the years has demonstrated that an ethical approach to science and technology, in the current state of development of disciplines, by necessity must incorporate specialized knowledge, be based on deliberation and dialogue, and depend on an organic and cohesive community.This community includes researchers, policymakers, politicians, administrators, students, and lay people.Since research is a cultural process shaped by expectations, hopes, and practices, it cannot be examined isolated from other aspects of social life.In point of fact, ethical oversight of research cannot be treated independently from the "ethical level" of the community at large.Political and administrative corruption, if present in a country and accepted as normal, cannot be irrelevant for the establishment of sound scientific practices.The notion of ethical sustainability suggests that any change in attitudes, goals, and practices must be based on sound argument and endure over time.
A sustainable effort depends critically on the establishment and maintenance of communities: Epistemic communities (or cultures), Practice communities and Moral communities.These communities not necessarily overlap, although it might be expected that the moral one embraces the others and includes knowledge and its applications.A biocentric ethics is not simply another form of applied ethics.It represents a change in the paradigmatic construction of the moral universe.Not only does it go beyond the classical anthropocentrism in the formulation of moral imperatives.It is knowledge on how to produce, expand, and apply knowledge.It is also an indication that the very foundation of welfare and progress includes a joint consideration of goals and means.Goals formulated as culture and civilization.Means legitimated by discursive practices respecting persons, living beings, and environment, accepting diversity and agreeing on basic principles of communality.In order to achieve this long-term goal, adapted to the historical peculiarities of a world region, our contribution depends on dialogue and common discourses.Re-throughout the continent.This affects the way in which ethics is considered.Sometimes we had the impression that to insist on the ethical oversight of scientific practices was misguided, considering that the idea of what research really is was fuzzy or nonexistent in some contexts.In point of fact, research was confused with other activities, such as surveillance or industry-guided clinical trials; social science research projects were not considered in need of ethical evaluation due to their presumed low risk.These misunderstandings may need some time to disappear and require an in depth-analysis of cultural practices.An exploration of what research really is in different cultural settings constitutes an interesting field of enquiry.Some aspects of this cultural difference in conceptualization and of the difficulties in devising appropriate methods to tackle with ethical issues were addressed by the Program on Bioethics of the Pan American Health Organization (PAHO), a collaborative effort of the Chilean Government, the University of Chile through CIEB, and PAHO, which was operative from 1994 through 2010 (3,4).The history and development of science funding in Latin America is a much needed enterprise and should be pursued alongside training in ethics and integrity.
Faculty members were drawn from different institutions and academic environments.It can be said that the experience was also valuable for them.Despite the fact that interactions were not always easy and that professional expertise sometimes made it difficult to interact with other members of the team and with trainees, everybody benefited from the effort in ways sometimes unexpected.
The interfaces with juridical systems, knowledge of funding procedures for research, disclosure of sometimes hidden or unknown prejudices were results from the experience of interacting with other professionals or members of specific groups.
Frontier researchers still mistrust ethical oversight and this may be due to a faulty implementation of it, lack of adequate development of ethics committees or vested interests.The effort is worthwhile, the project has been rewarding to carry on, and the need is still growing.
the institutions that make it possible (especially the University of Chile) and to the funders (NIH-Fogarty, the Alexander von Humboldt Foundation, among others).
search ethics is just a part of culture, and culture is life in common.The establishment of a network of users of the bioethical discourse has been an important mission of CIEB and will continue to be in the future.Thanks are to be expressed to

Table 2 :
Long-Term Trainees Interdisciplinary Center for Studies on Bioethics, University of Chile Fogarty Project who completed 1 year training on ethics of biomedical and psychosocial research (including coursework, research and practice, diploma degree conferred).Scientific and Hospital Ethical Review Committees, Health Research Regulations, Professional ethics codes, Ministry of Health, National University San Carlos, OPS Guatemala, April, 2010.(trainee Valencia HA., advisor: E. Rodriguez, K. Lagos).16.Workshop: Seminar ethics of research and scientific ethical review committees, Pontifitial Catholic University, Quito Ecuador, October 2005 (trainee: Rodriguez K., advisor: R. Mancini).17. Workshop: Seminar Ethics of Research Regulations & Scientific Integrity in Latin for former trainees, September 2011, National Institute of Health, Lima, Peru: Evaluation Meeting of the CIEB Fogarty Program.18. Workshop: Seminar Ethics of Social Research, School of Transborder Studies, Arizona State University, November 2011 (trainee: Garcia-Perez MH.).19.Workshop: Ethics of research, Health Care Services, Ministry of Health, April 2012 (trainee Marimon-Diaz Y.).20.Workshop: How to present a project to the scientific ethical review committee, for researchers Dentistry Department University of Chile, April 2012 (trainee: Torres, M.A., advisor: E. Rodriguez).Ayala-Jara Carmen I.: Progress ethics of research at National University of Trujillo, Peru.-Cardozo, Carmen A.: Activities carried out in ethics of research National University of Colombia.-Castro-Romero, Julieta I.: Strengthening and experience of scientific ethical review committee of Public Health National Institute, Mexico.-Diaz-Santana, E.: Analysis of the development of ethics of research regulations Dominican Republic.-Espinoza P., Vilma E.: Scientific ethics of health research committees situation at Honduras.-Gamboa-Bernal, Gilberto A.: Ethics of research regulations at Colombia.-Garcia-Rupaya, Carmen R.: Ethics of research curricula development Dentistry Department Cayetano Heredia Peruvian University, Peru.-Garbi-Novaes, Maria R.: Development Scientific Ethical Review Committee Health Secretary Federal District, Brazil.-Lara-Alvarez, Cesar F.: Ethics of Biomedical and Psychosocial Research.-Lara-Alvarez, Cesar F.: Scientific Ethics of Research Committees Functioning and Regulation Guidelines.-Moncayo, Lilian P.: Development process of science and technology, bioethics component, Public Health Ministry, Ecuador.-Mondragon-Barrios, Liliana: Development ethics of research Program National Institute of Psychiatry Ramon de la Fuente Muñiz, Mexico.-Moreno, L.: Ethics of research regulations at Peru. -Ormaeche-Macassi, Melvy: Rights to freedom of determination towards development, participation, consulting and consent in the process of building rights to guarantee indigenous populations health.-Ospina-Muñoz, Doris E.: Bioethics and Biolaw.-Pavon, Sandra: Vulnerable populations in mental health.-Rodriguez S., Katya: Ethics of research development at Ecuador.-Valencia-Marroquin, Hilda E.: Ethics of research experience at San Carlos University, Guatemala.Scientific Ethics of Research Committees Functioning and Regulation Guidelines.-Litewka, Sergio: Pan American Bioethics Initiative.Collaborating in the development of ethics of research training programs.-Lolas, Fernando: Ethics of research future developments.