may seem of secondary significance. Nonetheless, the research subjects were
indeed exploited - the researchers used them to further their own interests - and
it is easy to point out why the exploitation in this case was unethical: the research
participants were coerced to participate, they were harmed and received little or
no benefit, and the researchers treated them as mere means rather than as ends in
themselves, as Immanuel Kant put it ( 1998 , p. 45 [4:438]). The researchers
took unfair advantage of the participants' vulnerabilities.
What is it, then, that distinguishes morally unacceptable exploitation? Some
argue that exploitation is wrong because it is coercive (Schwartz 1995 ). If the only
way for a pregnant woman in a developing country to access antiretrovirals in
order to prevent the transmission of HIV to her unborn baby is to take part in a pla-
cebo-controlled trial, 7 despite the existence of a proven standard of care, 8 then one
could say she has been coerced into enrolling. 9 Exploitation occurs here when one
party takes advantage of another by making them an offer they cannot refuse; they
are then coerced to accept simply because they lack alternatives. (We shall return
later to the topic of lack of alternatives.) In the case of the penicillin research in
Guatemala, the coercion extended to direct and physical force. Others argue that
exploitation is wrong because it treats human beings as means rather than ends
(Wood 1995 ), that is, it instrumentalizes them. Yet others claim that exploitation is
wrong because it disadvantages the vulnerable (Macklin 2003 , p. 475).
Learning from the above, political scientist Robert Mayer has presented a new
analysis of exploitation, which we are going to use here (Mayer 2007 ). Mayer dis-
tinguishes three forms of exploitation.
In type 1 exploitation, exploiters fail to benefit other parties at all, even though
they ought to. This type of exploitation is best exemplified in free riding. Free rid-
ers benefit from public goods, which are indivisible and non-excludable, without
contributing their fair share. Usually this behaviour results in increased burdens
on others and/or inferior public goods. For instance, somebody might evade taxes
but still use health services funded through general taxation. The relative burden
of financing the health service is then higher on others and/or the service is not as
well resourced as it might otherwise be. Free riders thereby obtain wrongful gains
(access to health care) when fairness requires that they ought to contribute to the
costs of that public good.
In type 2 exploitation, exploiters do not benefit others sufficiently. In this
case of exploitation an exchange takes place, but it does not benefit both parties
fairly, and one party gains disproportionately. We can all imagine straightforward
7 A placebo-controlled trial involves some participants being given a medicine with active ingre-
dients, for instance a new drug against malaria, while others, known as the control group, are
given a sham, a placebo treatment, which is expected to have no effect. Neither the participants
nor the researchers know who has received which treatment until after the results are analysed.
8 A proven standard of care is a treatment that already exists for the illness under consideration.
Hence the ethical demand to test any new drug against an existing one that is known to be effec-
tive, rather than a placebo, is part of the 'standard of care' debate.
9 For a discussion of the exploitative character of such studies see Annas and Grodin ( 1998 ).