Image Credit: Maria Paula Calderon

by Bai Xiao 白皛

Read the Faculty Introduction.

As an influential figure in the history of Western literature, Ezra Pound marked the epochal transformation of English poetry at the beginning of the 20th century. Besides his pioneering theory of imagism, Pound is also known for his bold translation of ancient Chinese poetry and Confucian classics, through which he presented a highly positive and even glorious image of “China” to the Western world. Although many of Pound’s contemporaries belittled China only as “a vast potential market for American goods, American culture, and American democracy,” Pound’s unusual enthusiasm for the Orient helped usher in the second taste for China in the West after the Enlightenment (Divine 25). However, instead of presenting China in its true sense, Pound’s “China” is rather a myth created by the author himself. Pound’s works translating Chinese literature to English, notably the Confucian classics and Cathay, are more than a collection of involuntary inaccuracies mixed with intentional manipulations; more intriguingly, considerable assimilation and metamorphism of the Chinese ideology, submerged under the surface of his Chinese-related texts, distinguish his works from any conventional translations. To be more exact, Pound’s creative image of China in his “translations” shapes an effective myth of China, which he proposed as a medication to save the Western world from serious crises and degradation in the 20th century and to lead the West to a brighter future.

Studying China persistently for more than forty years, Ezra Pound spares no efforts in eulogizing China’s culture and ideology, fundamentally Confucianism, in his most exemplary works such as The Cantos. His interest in China was largely kindled by orientalist Ernest Fenollosa, who, in his “The Chinese Written Character as a Medium for Poetry,” expressed hearty admiration of China:

Their type of cultivation has been high. Their harvest of recorded experience doubles our own. The Chinese have been idealists and experimenters in the making of great principles; their history opens a world of lofty aim and achievement, parallel to that of the ancient Mediterranean peoples. (42)

It is noteworthy that at the root of this effulgent civilization, Confucianism became the cardinal representative of Chinese philosophy and ideology in Pound’s mind, with all the meritorious essence of Chinese wisdom aggregated in the Confucian canon. Confucianism constituted one of the major pillars in Pound’s prolonged development of The Cantos—from Canto XIII written as early as around 1920, which combines several important flashes of Confucian thought into one piece, to Canto LIII, the finale of his China cantos, which vigorously concludes the first 2000 years of recorded Chinese history with an allusion to Confucius’s honorable lineage.

Pound’s attachment to Confucius was not only intellectual but also personal. During those most gloomy days when he was confined at St. Elizabeths, he had James Legge’s translation of Confucian odes with him. Angela Palandri quotes Pound as saying, “This little book has been my bible for years, the only thing I could hang onto during those hellish days at Pisa…. Had it not been for this book, from which I drew my strength, I would really have gone insane” (qtd. in Flack 124n44). Here, we see the first glimmerings of Confucianism as a kind of medication, first for Pound himself, and, as he would later propose, one which could radiate healing throughout the West.

Although Pound appreciated China and made profound contributions in introducing China to the West throughout his life, his presentation of China largely remained a deficient myth due to his peculiar ideogrammic interpretation of the Chinese language. One of the biggest problems with Pound’s “China” was his lack of knowledge of Chinese, which caused him to deviate from the true meaning of original texts from time to time. An interesting moment in Pound’s journey of studying Chinese sheds light on his maverick view: when reading James Legge’s bilingual edition of the Four Confucian Books without a glossary in 1937, he professed, “When I disagreed with the crib or was puzzled by it I had only the look of the characters and the radicals to go on from” (Sun 111). Without knowing sufficiently the meaning of Chinese characters as organic entireties, he often focused on their graphic components.What became the paradigm of his ideogrammic approach was the juxtaposition of unrelated particulars to arrive at an imagined abstract meaning. However, subjective assertions about the Chinese language actually overemphasized the apparent forms of Chinese characters while neglecting the inseparability of all integrals in a character to convey abstract concepts. Pound’s approach incurred the illusion that someone without any knowledge of Chinese would be able to access the meanings of characters instantly by simply looking at these “semi-pictorials” (Fenollosa 43).

Such a subjective approach explains why Pound made mistakes in his translation of Da xue, commonly translated as The Great Learning but what Pound called The Great Digest. For instance, from his selected terminology before the text, he dismantles shen 慎 into its radical on the left, xin 心, meaning “heart,” and a fragment of its right segment, mu 目, meaning “eye,” which results in the interpretation of the whole character as “the eye (at the right) looking straight into the heart” (Pound, Great Digest 21). However, not only does he fail to recognize that the so-called “eye” is only a fraction of the right part zhen 真 (“truth”), but he also distorts the meaning of the whole character, which should denote “cautiousness.” In contrast to Pound’s ideogrammic analysis of Chinese, “Chinese characters, at least the vast majority of them” are “morphosyllabic—a heavy (if rather clunky and esoteric) term intended to convey the dual semantic-phonetic nature of the majority of the Chinese characters” (Williams 158-159). That is to say, most Chinese characters should not be taken as purely “ideograms,” but Pound might not have identified the phonetic segment of a character and imposed the meaning conjectured from the partial form to the overall understanding instead. Even if Pound did not bungle every Chinese character in his works, many of his cognitions about China are actually problematic, as a result of his unfamiliarity with unique characteristics of the Chinese language.

In fact, Pound’s ideogrammic myth of the Chinese language gives rise to his idealization of the Confucian ideology, which became a luminous component of his mythmaking. Let us take Pound’s interpretation of one key character in Confucian writing under scrutiny:  de 德, which is usually paraphrased as all kinds of virtue a human could possess in line with Confucian morals, including benevolence, righteousness, propriety, wisdom, sincerity, and so on. According to Pound, de refers to “the action resultant from this straight gaze into the heart” ideographically, and thus revealed specifically “the ‘know thyself’ carried into action” rather than general virtue (Great Digest 21). Strikingly enough, here Pound emphasizes the significance of self-knowledge, namely “know thyself,” over all the other qualities embedded in de, while there is no evidence at all that self-knowledge was given such a priority in the original meaning of the character. Though it might appear unintelligible at first sight, this uncommon illustration uncovers how Pound’s ideogrammic interpretation was subtly colored by the Confucian ideals. On the one hand, aligned with Pound’s translation of The Great Learning, Pound deemed Confucianism as a morally and ethically virtuous system that vitalized human nature through self-reflection and self-cultivation; on the other hand, Pound identified in The Great Learning that the ultimate catalyst of self-knowledge was rooted in gewu 格物, “sorting things into organic categories” in his own words, which resonated with knowledge of the laws of nature (Great Digest 31). Inspired by the Confucian classics he was working on, his ideogrammic method with a biased focus on specific components of characters helped further consolidate his Confucianism as a “totalizing philosophy” where Heaven (“nature”) went hand in hand with humanity (Zhu, “One-Principle Text” 397). His complimentary presentation of the harmony of Confucianism—both pointing inwardly towards the bottom of the heart and stretching outwardly toward  prodigious nature—significantly burnished his mythmaking of China.

For Chinese readers, Pound’s flawed image of China might seem quite bizarre; however, as Pound’s works on China were intended for his Western audience, this oriental myth functioned surprisingly well. Eric Hayot points out in his book Chinese Dreams: Pound, Brecht, Tel Quel that there have been long-term effects of Pound’s works on the Western view of China in so far as that “everything after him has to look like his work to seem ‘Chinese’” (21). Even though Pound was vulnerable to potential criticism on his deficient knowledge of China, the Western audience at his time was even more ignorant of China than he was. That is to say, “Pound [could] imitate and persuade with utmost economy not because he or his reader [knew] so much but because both [concurred] in knowing so little” (Steiner qtd. in Hayot 21). Considering the existing knowledge gap between the West and China, Pound ingeniously sorted out the most conspicuous elements closely related to the image of China—those luminous details “whose strangeness needed no explanation” for Western people (Hayot 23). His colossal handwritten Chinese characters standing out abruptly in his Cantos were among the best examples to render such percussive oddness. It is exactly the “cultural shorthand” “easily recognizable as ‘Chinese’” in Pound’s works that eventually “established the authenticity of the Eastern setting,” resulting in an enduringly appealing impression of China in the Western view (Hayot 21). By taking advantage of such a stylized conception of China from the Western perspective, Pound laid the foundation for effectively utilizing the myth to make his prescription later for what he perceived to be a  degraded modern Western society.

Entangled in the turbulence of the 20th century, Ezra Pound’s advocacy for China was  deeply rooted in the social environment of the Western world at that time, which galvanized his pungent depression and anxiety. It is quite noteworthy that among the tens of thousands of surviving ancient Chinese poems on various topics, the fourteen translations in Pound’s Cathay seem to be purposefully selected, concentrating on only a few themes such as war, exile, lovesickness, unwilling farewell, and nostalgia. The pervasive inner bitterness and loneliness shared by these motifs underscore Pound’s Chinese poetry with subtle pathos and mirror the poet’s torment during a desperate quest to salvage Western society.

From Pound’s point of view, the cardinal cause of Western society’s sickness was economic breakdown. With the cruelty of World War I still carved in mind, “Pound came to the conclusion that poverty and war result from the inequitable distribution of consumer purchasing power in a capitalist economy” through the control of credit from international private banking and usury (Farahbakhsh 1450). In other words, “the evils of unchecked capitalism,” featured in vicious rivalries of international capitalists, accompanied by recessive monetary policy and heavy taxes, was the culprit to blame for the severe disorder in the western society (Farahbakhsh 1450). In Pound’s Canto XLV, the repetition of sentences beginning “with usura” demonstrates Pound’s sharp denunciation of usury, a “sin against nature” and “CONTRA NATURAM” (229-231). Although he  seems to hold his discussion in the context of fifteenth century Italy and northern Europe, it was exactly usury, this determinant for the failure of the authoritative Medici bank, that was eroding modern Western society again. Such a pessimistic outlook on the economy also found its way to the Chinese cantos. When Pound describes the Spring and Autumn period in Chinese history in Canto LIII, he highlights, “Usurpations, jealousies, taxes / Greed, murder, jealousies, taxes and douanes,” which might be regarded as a vividly realistic portrait of the 20th century here—a startling metaphor of troubled times (274). This premonition of chaos made Pound perceive an urgent need for peace, welfare, and order, through which he aspired to “prevent a second international war” (Farahbakhsh 1451). However, this aspiration was difficult to achieve without the presence of strong leaders.

Pound re-discovered “China” from ancient legacies and found that its honored Confucian philosophy “offered the best hope for an enduring and just social order,” which turned out to meet exactly his needs (Farahbakhsh 1451). The idea of order and good national governance took up a key position in Pound’s image of China according to Confucian values. In Canto LIII, the tyrants who ruled by misdoings, like King Wang who intended to vary the currency “against council’s opinion, / and to gain by this wangling,” are all punished by anomalies from the wrath of heaven, for example, “never were so many eclipses” (273). In  sharp contrast, those virtuous emperors who followed Confucian teachings and governed with wisdom all achieve great success in their administrations, and are held in awe and commemoration by the people. For example, Pound sings his praises to one of the benevolent emperors explicitly:

                       Honour to Chao-Kong the surveyor.

                                      Let his name last 3000 years

                       Gave each man land for his labour

                                               not by plough-land alone

                       But for keeping of silk-worms

                                     Reforested the mulberry groves

                                     Set periodical markets

                       Exchange brought abundance, the prisons were empty. (LIII/268)

From this hymn, we can clearly assess that Pound witnesses, or rather “realizes” his propositions of a well-governed and prosperous economy in his representation of China. The gracious images of those wise emperors in ancient times also embody his other ideals of the right form of governor, by “keep[ing] down taxes” (LIII/267), “fitting words to their music” and ritualistic odes (LIII/262), giving people freedom to “make verses” and “play comedies” (LIII/270), and reigning by righteous law “of the just middle, the pivot” (LIII/269). More importantly, he makes his powerful appeal for the stability of the state and the well-being of the people through Tching-ouang’s weighty testament: “[T]his is my will and my last will / Keep peace / Keep the peace, care for the people” (LIII/267). Having suffered heartbreaking devastation after war, Pound believed he could turn to Confucius for remedies, in a similar way that he looked to the Odyssey in Canto I “in order to heal the wounds opened by the Great War” (Flack 105).

Order, calibrated to the Confucian teachings and beginning at the level of the individual, appealed to Pound. Confucius’s recurring reference to “order” underlines its significance:

                                      If a man have not order within him

                       He can not spread order about him;

                       And if a man have not order within him

                       His family will not act with due order;

                                      And if the prince have not order within him

                       He can not put order in his dominions. (XIII/59)

The uniqueness of “order” here consists in “the Confucian emphasis on the individual as the origin and expression of a society’s values,” with the on-going spiral of cultivation toward perfection originating from the individual and then extending to the sphere of family and society (Flack 106). This emphasis on individualism is further expounded in The Great Digest: “[F]rom the Emperor, Son of Heaven, down to the common man, singly and all together, this self-discipline is the root” (Pound, Great Digest 33). Everyone, whatever identity and social status he or she enjoys, must carry out a responsible surveillance of himself or herself first and foremost.Confucius’s call to establish order through good rulers first from internal strengths of individuals turns out  to be the best and the most innovative solution to external disorders and conflicts in the Western world, as Pound longed for effective “ideas which are intended to go into action” (Guide to Kulchur 34).

Apart from war and social disorder, the Western world was experiencing a profound spiritual degeneration at the turn of the 20th century as well. Under the intensive impact of industrial civilization and the age of machines, there was an increasing concern that human beings would gradually be alienated from nature by their materialistic desires and the fast-paced lifestyle of modern society. Pound was determined to summon human “nature” back with the help of Confucian China. According to Alireza Farahbakhsh, Pound strongly resisted the “debasement of human life within the contemporary conditions of bourgeois economics,” which “distorted the nature and purpose of work, time, and wealth” (1452). To tackle the predicament, “Confucius offers a way of life, an Anschauung or disposition toward nature and man and a system for dealing with both” (Pound qtd. in Zhu, “Pound’s Confucianism” 58). From the Confucian Chinese culture and values rooted in agricultural civilization, Pound attained a clean cut from what he thought of as the rotten industrial society and warmly embraced the beauty of simplicity and the charm of primitivism. In Canto XIII, when commenting on his pupils’ answers on how to become known, Confucius makes a perfect response: “‘They have all answered correctly, /‘That is to say, each in his nature” (58). Here Pound actually adapts Confucius’s sayings to express his enthusiasm for the natural, unstained state of soul. Similar to what Tian gracefully describes in Canto XIII—going swimming, flopping off planks, and playing mandolins in the underbrush— Pound’s ideal headed for a nobler mode of harmony, where edification was as gentle “wind over grass” (LIII/266). Sharply different from “the ‘stupidity’ of extreme asceticism born of hatred of the body” in Christianity, Confucian teachings on nature and spiritual life made good sense to Pound, giving him the useful treatment for curing the inward disease of the Western world (Romer).

Of course, it is no coincidence that Pound looked to China, particularly ancient China, for his prescription for the Western world. Ultimately, this choice of “medicine” reflects the thinking behind his famous command to “make it new.” In Canto LIII, among all the Chinese characters Pound appended to his text, he places Confucius’s name, Zhongni 仲尼, between two zhou 周, meaning “Zhou Dynasty.” It is true that there were exactly two Zhou Dynasties, the Western and the Eastern Zhou; Confucius lived in the restless Eastern Zhou. In his paper “Pound’s Quest for Confucian Ideals: The Chinese History Cantos,” Hong Sun raises the thought-provoking observation that “although the master himself lived in the Eastern Zhou dynasty, his heart went back to the good old days of King Wen’s Western Zhou and often lamented the demoralization of his contemporaries” (115). Pound’s romantic, nostalgic application of Confucianism to his time and place mirrors Confucius’s own nostalgia for a better, wiser society. Just like Confucius, Pound was anxious to give appropriate treatments for almost all social problems at his time, but “what he was seeking was not so much a revolution as ‘a renewal, a revivification of an old tradition’” (Firchow qtd. in Sun 116). Pound’s declaration of his looking to “an American renaissance” in “The Chinese Written Character as a Medium for Poetry” further proves his standpoint—“renaissance” instead of radical and thorough transformation. Interestingly enough, if we recognize that Greek and Roman antiquity served as the paradigm for reviving Western culture during the Renaissance in the 14th through 16th centuries, we can see the essence of Pound’s “renaissance” actually remained the same, except with “China” as the tool this time.

Through the lens of Pound’s works on China, it can be clearly seen that his presentation of China derives from his way of viewing “others” and the “self.” The mythicized image of China provided Pound a valuable opportunity to conscientiously reflect on the severe crises in the Western world during the 20th century. Some people may attack Pound’s distortion of China in his translations of Chinese classics, criticizing him as a bad translator; however, Pound never wanted to be treated as a literal “translator.” It is true that he may not have been a good or even qualified translator because of his lack of knowledge of the Chinese language, but he was definitely an excellent preacher of China and a voluntary ambassador of ancient Chinese legacies to the modern West; he made great efforts to bring “China” closer to Western people, though his image of China is still confined to an effective myth. Pound longed to “make it new”—a vigorous “remaking of the old” to catalyze the process of renewal of the West, and he was successful (Firchow qtd. in Sun 116). He would not feel satisfied to become only “a passive reflector of light from another culture”; instead, he took the mission of Prometheus, “an active agent not simply carrying forward the light of Chinese philosophy, but rejuvenating Western poetry with its ideals” (Sun 96). History is sometimes strikingly similar: from Voltaire during the Enlightenment period to Pound in the 20th century, the West always stumbled on its way to getting to know China, starting from myths and misunderstandings, but Pound clearly tries to initiate a leap. His mythmaking is an ambitious construction of his own world of China—a luminous one to make the Western world new with the flame of hope.

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Works Cited

Divine, Robert A. The Illusion Of Neutrality. The University Of Chicago Press, 1962.

Farahbakhsh, Alireza. “The Image of Confucius in Ezra Pound’s ‘Chinese Cantos’ (Cantos LII-LXI).” International Journal of Science and Research, vol. 5, no. 6, 2016, pp. 1450-1455, www.ijsr.net/archive/v5i6/15061601.pdf. Accessed 6 Nov. 2016.

Fenollosa, Ernest and Ezra Pound. The Chinese Written Character as a Medium for Poetry: A Critical Edition. Edited by Haun Saussy, Jonathan Stalling, and Lucas Klein. Fordham University, 2008.

Flack, Leah Culligan. “‘The News in the Odyssey is still News’ Ezra Pound, W.H.D. Rouse, and a Modern Odyssey.” Modernism/modernity, vol. 22, no. 1, 2015, pp. 105-124. Proquest, search-proquest com.proxy.library.nyu.edu/central/docview/1664944777/ fulltextPDF/2DDD390E3B434FB9PQ/1accountid=12768. Accessed 6 Nov. 2016.

Hayot, Eric. Chinese Dreams: Pound, Brecht, Tel Quel. University of Michigan Press, 2009. NYU Ebrary.

Pound, Ezra. Confucius: The Great Digest, The Unwobbling Pivot, The Analects. New Directions Publishing Corporation, 1969.

—. Guide to Kulchur. New Directions Publishing Corporation, 1952.

—. The Cantos of Ezra Pound. New Directions Publishing Corporation, 1996.

Romer, Stephen. “The great imitator: Ezra Pound may have been declared insane by an American court but, says Stephen Romer, the notion of ‘Mediterranean sanity’ that illuminates his best work still has lessons for his homeland.” The Guardian, 3 July 2004, www.theguardian.com/books/2004/jul/03/featuresreviews.guardian review12. Accessed 6 Nov. 2016.

Sun, Hong. “Pound’s Quest for Confucian Ideals: The Chinese History Cantos.” Ezra Pound and China, edited by Zhaoming Qian, University of Michigan Press, 2010, pp. 96-119. ProQuest ebrary.

Williams, R. John. “Modernist Scandals: Ezra Pound’s Translation of ‘The’ Chinese Poem.” Orient and Orientalisms in American Poetry and Poetics, edited by Sabine Sielke and Christian Kloeckner, Lang, 2009, pp. 145-165.

Zhu, Chungeng. “Ezra Pound’s Confucianism.” Philosophy and Literature, vol. 29, no. 1, 2005, pp. 57-72. ProQuest Central, https://search-proquest-com.proxy.library.nyu.edu/central/docview/220552581/fulltextPDF/5AA17F4AEDA430APQ/1?accountid=12768. Accessed 6 Nov. 2016.

—. “Ezra Pound: The One-Principle Text,” Literature & Theology, vol. 20, no. 4, 2006, pp. 394–410. JSTOR, doi:10.1093/litthe/fri037. Accessed 16 Jan. 2018.

Image Credit: Wang Zixin (Harry)

by Madison E. Pelletier

Read the Faculty Introduction.

Royal Navy Doctor James Lind is credited with conducting one of the first known placebo-controlled trials. In 1572, he divided a group of his scurvy-ridden sailors into six sections, each receiving a different treatment, ranging from citrus fruits to seawater. Two treatments were proven effective; the remaining four were fatal (Lemoine 1). Thus began a long and controversial discourse. A placebo treatment, in this case seawater, is described as a substance with “no specific therapeutic effect on a patient’s condition, but believed by the patient to be therapeutic” (OED). The randomized, double-blind placebo-controlled trial, wherein neither patients nor doctors know whether the administered treatment is inert, is considered the paragon of research methodology. Ethically, however, physicians seem to stand in violation of their Hippocratic duty to “do no harm” by randomizing their patients to placebo, particularly if those patients are harmed by their lack of treatment––if they die of scurvy, for example (Tyson). Despite the modern prevalence of placebo-controlled trials, it was not until 2008 that their official allowance was written into the Declaration of Helsinki, the foremost governing document for medical and research professionals. Article II.3 of the Declaration, in its most current form, declares, “In any medical study, every patient—including those of a control group, if any—should be assured of the best proven diagnostic and therapeutic methods” (World Medical Association). The debate has thus arisen: is it possible to simultaneously possess a control group and provide the “best proven diagnostic and therapeutic methods,” or has the West simply grown complacent in the face of immorality, because the trials are no longer conducted on its soil? When we examine placebo trials through the lens of Kantian moral philosophy and historical medical ethics, it becomes apparent that the speed of scientific progress has outstripped the development of societal values, both individually and internationally.

The utilitarian case for placebo-controlled trials is clear cut: if lessening the quality of treatment for a minority of test-subjects increases the likelihood of advancing medical knowledge, thus helping the majority, it is permissible. Furthermore, if a drug cannot be proven to be more effective than a placebo within a clinical trial, then it ought not be sold. Some supporters go so far as to suggest that, given the primary role of the physician as an alleviator of patients’ suffering, it does not matter whether a person is receiving a proven drug or an inert substance; a treatment is morally permissible so long as it improves the comfort of the patient (Specter). Opponents of the practice, however, point to studies proving that even when suffering is reduced under administration of a placebo, the patient’s physical health does not improve (Wechsler 124). This contradicts the assumption that the placebo effect can stand in place of a proven treatment. Internationally, the debate hinges on what is possibly humanity’s most enduring moral dilemma: ethics versus economy. By hosting trials in developing nations, pharmaceutical companies assert that they are able to both keep costs low and provide medicine to underprivileged regions. Opponents point out that Western standards of informed consent are all but impossible to uphold in such trials (Miller). Critics also cite countless failed experiments as evidence that corporations cannot be trusted with the lives of the world’s vulnerable populations. Public moralists and developing nations fear the worst, envisioning an unstoppable era of pharmaceutical neocolonialism.

The core principles of Kantian morals and medical ethics have long been intertwined. At the heart of each philosophy rest the concepts of autonomy and beneficence. Kant bases his autonomy on the fundamental belief that every human is a rational being deserving of dignity and respect from others. Because this reason is what gives value to all other things, it is, in and of itself, invaluable. This principle lays the groundwork for the Formula of Humanity as an End, which dictates that a human being “is not a thing and hence not something that can be used merely as a means” (Kant 4:430). Within a Kantian framework, a decision does not possess moral worth unless it is made autonomously, meaning that it is based only upon the rationality of its maker. If coerced by another, the decision-maker is rendered merely a means to achieve that other person’s end. Kant goes on to further qualify this principle, noting the difference between choices made autonomously and those made “heteronomously” (Kant 4:434). Heteronomous choices are influenced by outside forces, be they base, physical need or the coercion of another (Kant 4:435). A decision founded upon fear for one’s safety, need of money, or misinformation cannot be autonomous, as each of these requires the suppression of reason in favor of some other physical or mental faculty. Within medical ethics, Kantian autonomy is honed into the concept of informed consent. This requirement is written into the Declaration of Helsinki, which states, “After ensuring that the potential subject has understood the information, the physician or another appropriately qualified individual must then seek the potential subject’s freely-given informed consent, preferably in writing” (WMA). Within both frameworks, ends reached through the coercion or deception of another are categorically impermissible.

The concept of medical beneficence, though not as clearly outlined, is equally indivisible from Kantian morals. This principle stands at the heart of medical ethics; the Declaration of Geneva of the World Medical Association declares on behalf of physicians, “The health of my patient will be my first consideration,” and the International Code of Medical Ethics dictates that “a physician shall act in the patient’s best interest when providing medical care” (WMA). It is the fundamental role of doctors to care for their patients, and it is this role that links the principle of beneficence to Kant’s categorical imperative. Within the imperative, each citizen is ordered to act only upon a maxim which she would will to become universal law. If the universalization of the maxim would result in its own invalidation, the maxim is impermissible (Kant 4:423). When examined against this formula of universal law, the necessity of beneficence stands. Citizens place both their trust and their bodies in the hands of physicians, who are expected to “promote and safeguard the health, well-being, and rights of patients” (WMA). If it were to become universal law that these so-called caregivers acted against the best interest of their patients, the people would no longer employ their care, and the profession itself would cease to exist. It is with these two core values that each question within the bioethical discourse must be considered, and the debate surrounding placebo-controlled trials is no exception. By administering an inert substance in place of a proven therapy, physicians may be advancing medical knowledge, but by doing so, they render their patients as mere means to scientific discovery, as opposed to  rational beings deserving of care in their own right.

To begin discussion of the moral application of the placebo effect, one key misunderstanding must first be addressed. The placebo effect is the phenomenon observed when patients given inert substances, such as sugar or saline, report the same lessening of symptoms as their counterparts receiving the trial’s active drug. It is generally accepted that the placebo effect is a part of the body’s natural response to medication––when the brain believes it will soon receive a painkiller, for example, endorphin production begins independently in order to prepare for the effects of the medicine (Specter). Where public perception falls short of fact, however, is in equating subjective relief to objective medical benefit. In a groundbreaking study published in the New England Journal of Medicine, researchers found that placebo treatments were highly effective in the reduction of symptoms, yet showed no ability to cure the underlying medical issue causing those symptoms. This study was performed on participants with mild to severe asthma. Of the four trial arms, one received no treatment of any kind, one was given placebo acupuncture, one a placebo inhaler, and one group received an inhaler with active Albuterol, the most common treatment for asthma patients in the United States. Though both placebo groups reported roughly the same comfort-level as those given Albuterol, their lung function––measured by their performance on an FEV exhalation test––was not improved (Wechsler 123). This study highlights an important fallacy within the debate: that a patient’s increased comfort level necessarily means that they are healing. Proponents of placebo-usage argue that the health of a patient in the control group is improved by the placebo effect, thus absolving themselves of the moral responsibility to treat illness. The effect is not a miracle cure, however, and a saline injection will not treat hypertension any more than a sham inhaler improves asthmatic lungs. The doctors who administer these treatments cannot claim to fulfill their duty of beneficence, as a placebo group is not receiving the best care available. With this in mind, the debate becomes one of scientific detachment versus medical responsibility.

Western pharmaceutical corporations have, by and large, shipped their trials overseas, where both the cost and risks are lower. Corporate officials claim that Western standards of informed consent are upheld within the trials, but critics point out the sheer improbability of that statement. In a recent interview, Dr. Arthur Kaplan, director of the University of Pennsylvania’s Center for Bioethics, noted that pharmaceutical trials can no longer find sufficient participation for trials held in the West, because citizens simply “don’t want to be randomized to placebo” (Miller). Despite the unwillingness of their Western counterparts, pharmaceutical companies claim that each of their trial participants has given their own fair consent, with full knowledge of the trial’s methodology and potential treatment plans. Dr. Arand Rai, who was fired from his job at a hospital in Indore, India for raising ethical concerns, contests this statement. According to Rai, the doctors at his hospital specifically chose “poor, illiterate people who do not understand the meaning of clinical drug trials” to participate (Lloyd-Roberts). When a person in a developing nation is offered the opportunity to participate in a Western drug trial, it may very well be their only way to receive treatment for their condition. These people do not have the choice between participating in a potentially high-risk, experimental trial or going to their local doctor to purchase a proven treatment. They are at the mercy of the trial. Dr. Kaplan poses the question: “are [the participants] really giving you informed consent or will they sign up for anything that you show up with because they are desperate and have an overwhelming faith in anybody in a white coat?” (Miller). Again, consent that is gained through coercion and misinformation fundamentally cannot be autonomous; these patients, most of whom are poor, ailing, and scared, are acting upon their heteronomous, physical needs, and the abuse of such a situation is morally impermissible. Proponents of these trials have offered many solutions to this methodological failing, going so far as to propose a system of “community consent” wherein local leaders are tasked with both informing and consenting for their community (Weijer). This system, however, which seems to put poor women at disproportionate risk within male-dominated developing nations, would not increase the subjects’ autonomy, but detract from it. In her review of the oft-criticized maternal-fetal HIV transmission trials of the 1990s, researcher Paquita de Zulueta of Imperial College London notes the failings of such a system, and argues that “if individuals’ competence is vitiated by a lack of understanding, they should be afforded greater protection, not less” (304). If a patient’s ability to exercise their autonomy is compromised, it is the duty of the physician to bridge the ethical divide by acting beneficently on behalf of the patient, not the corporation.

Pharmaceutical companies may be in the business of saving lives, but they prioritize the success of that business above all else. It is failingly idealistic to expect that a multibillion dollar corporation will act according to the well-being of their trial participants when it is opposed to their pocketbooks; providing healthcare to the poor, though noble, is not inexpensive. The fifth version of the Declaration of Helsinki, released by the World Medical Association in 2005, had even expressly “prohibited the use of placebos in situations of local scarcity if the ‘best current method’ exists elsewhere” (de Zulueta 307). Since the Declaration’s revision in 2008, however, the use of placebo-controls has skyrocketed, and supporters argue that their obligation rests only in providing “the highest standard of care practically attainable in the country in which the research is being carried out” (Perinatal HIV Intervention Research). By this measure, the responsibility to provide care for participants in some of the world’s poorest regions is all but nonexistent. Vindicated by this line of thinking, administrators of pharmaceutical trials feel no responsibility to care for a community that is no longer profitable. De Zulueta notes the prevalence of HIV trials that, upon completion, leave their participants ostracized without treatment, without prospects, and without a cure (de Zulueta 290). Once these participants have served their purpose, they are worthless. In 2003, a trial of the mania drug Risperdal came under fire for its abuse of international health standards. The trial, conducted on poor citizens of Gujarat, India, took psychiatric patients off of their existing medicine, placing them into groups receiving either risperidone or a placebo drug. The placebo arm of the trial possessed 145 patients (Weyzig and Schipper). Given the high instances of acute and long-term morbidity associated with untreated mania, sources, such as the British Journal of Psychology, have called the trial “unethical and inhumane,” suggesting, “All future trials concerning the efficacy of a medication for acute mania should use an arm with one of the proven medications as a comparator and not include a placebo arm” (Basil). A similar trial was conducted, with joint sponsorship from the UK Medical Research Council (MRC), Rockefeller Foundation, DfID (Uganda), GlaxoSmithKline, Gilead, and Boehringer-Ingelheim, in Uganda, Zimbabwe, and Côte d’Ivoire from 2003 to 2005. The trial, which tested Anti-Retroviral Therapy––used to slow the progress of the HIV virus––forced a group of patients off of their medication in order to test the effects of intermittent treatment. Though concerns were raised during the trial, attempts to re-administer ART drugs failed, and several members of the interruption group died (Weyzig and Schipper).

Trials such as these––and unfortunately these are only two of many examples––breed distrust of foreign entities abroad, making the work of truly beneficent groups all the more difficult. When administrators of these trials deny patients their life-saving medicine in order to satisfy the curiosity of Western scientists, the Hippocratic principle of nonmaleficence is all but disregarded and human lives are treated as nothing more than a means to medical discovery and financial gain (Tyson). This is not because corporations actively wish to do harm, but rather because they can afford to not do good. For every settlement a corporation must pay, such as the $175,000 payout Pfizer recently made to four of the eleven families whose children they killed in a clinical drug trial in Nigeria (“Pfizer: Nigeria Drug Trial Victims Get Compensation”), they stand to gain millions from the development of a successful new drug. It is clear that pharmaceutical corporations cannot be relied upon to “do no harm” (Tyson) to the more vulnerable patients they test. With this in mind, it is of the utmost importance that regulatory bodies, be they federal or non-governmental, take a stand against the abuse of vulnerable populations and force these corporations to incorporate beneficence into the caregiving process once more.

It is impossible to host a placebo-controlled trial abroad without violating the core ethical values of autonomy and beneficence. The Declaration of Helsinki’s “best proven diagnostic and therapeutic methods” are never given, and often even standard, local medical care is denied to participants. The myth of informed consent is little more than the abuse of a people who hold “the implicit assumption that health care professionals will always protect patient’s best interests, and provide effective treatment” (de Zulueta 310). These people are not in a position to make autonomous decisions; instead, their rationality is suppressed and their physical health exploited to ensure their enrollment in potentially dangerous medical experiments. Not only do the trials take advantage of this assumption of beneficence, but they fail to deliver even the most basic care inherent in that duty. Multinational pharmaceutical corporations have been caught time and again disregarding the health, safety, and dignity of their patients in order to maximize their profit margins. Within the framework of both classic Kantian morals and the modern medical ethic, it is clear that the use of placebo-controlled trials in the developing world is an impermissible abuse of vulnerable populations. The lives of the world’s poorest citizens cannot to be used merely as a means to provide a product for their Western counterparts. They are humans, and they deserve better than what has been forced upon them.

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Works Cited

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