46 Letters to the Editors © 2007 The Authors. Journal compilation © 2007 Blackwell Publishing Ltd. 1 A.A. Hyder & L. Dawson. Defining Standard of Care in the Devel- oping World: The Intersection of International Research Ethics and moves from an urban to a rural area, or remains in a rural area when he has the willful means to move to a more urban area, has implicitly chosen the pri- ority of the preference of the pastoral over that of proximity to intensive health care, which, as Hyder and Dawson properly state, usually is concentrated in more urban environs. How do we factor this implicit value preference in these circumstances? 5 Hyder and Dawson then go on to propose that it is the responsibility of the researcher to: stimulate the national professional community to develop guidelines prior to the conduct of health research, allowing for a discussion of many med- ical and technical issues prior to the start of research. 6 In an ideal world I say, again, ‘Fair enough.’ In an ideal world we would all be activists with the proper political, cultural, diplomatic, and financial skills so 5 Of course many poverty-stricken rural populations do not have these choices – they cannot easily migrate from one political or urban/rural area to another. And, in some cases, they do not have a vote to influence the political allocation of resources. I make my point only to illustrate that a ‘national’ standard cannot be thought of as a monolithic entity unaffected by both political and personal decisions. 6 Hyder & Dawson, op. cit. note 1, p. 151. as to stimulate debate and effect the implementation of de jure standards. But is this truly the place of medical researchers? Most medical researchers are unschooled and incapable of fighting this war, espe- cially in foreign locales. Even if they have the skills, how far do they have to go? Must they obtain con- sensus agreement before implementing a research protocol? Or is something less than consensus ade- quate? Is this an efficient use of researcher resources? How much do we bioethicists need to work out the ethics of this kind of implementation before we can even answer these questions? 7 Locus of control of allocation of resources is more important than formal political structures (i.e. national vs. local), and medical researchers often may not be resource-equipped to ‘stimulate the national professional community.’ 8 If we are to have meaningful debate about standards of care through recognition of cultural, political, and economic implementation we need to factor in these and other variables. 7 S. Rennie & F. Behets. AIDS Care and Treatment in Sub-Saharan Africa – Implementation Ethics. Hastings Cent Rep 2006; 36: 23–31. 8 Hyder & Dawson, op. cit. note 1, p. 151. Blackwell Publishing Ltd.Oxford, UKDEWBDeveloping World Bioethics1471-8731Blackwell Publishing Ltd. 20062006••••••••Letter to the EditorLETTER TO THE EDITORLiza Dawson and Adnan A. Hyder Address for correspondence: Adnan A. Hyder, MD, MPH, PhD, Assistant Professor, Department of International Health & Phoebe R. Berman Bioethics Institute, Johns Hopkins University Bloomberg School of Public Health, 615 North Wolfe Street, Suite E-8132, Baltimore, MD 21205 USA. ahyder@jhsph.edu UNDERSTANDING THE ‘DE JURE’ STANDARD OF CARE FOR RESEARCH: A REPLY TO FAUST LIZA DAWSON AND ADNAN A. HYDER Faust makes the point that many national standards for health care are not fulfilled at the local level due to a failure of commitment of resources, and states that this reflects a valuing of health care by the society in question; therefore, he urges us to con- sider this standard as the relevant standard. 1 He points out that London’s analysis includes social, cultural and economic factors in the consideration of the de jure standard – but he has conflated the de Health Systems Analysis. Developing World Bioeth 2005; 5: 142–152; H.S. Faust. Is a National Standard of Care Always the Right One? Developing World Bioeth 2007; 7: 45–46.