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",isbn:"978-1-83881-922-4",printIsbn:"978-1-83881-921-7",pdfIsbn:"978-1-83881-923-1",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"dcfc52d92f694b0848977a3c11c13d00",bookSignature:"Dr. Fiaz Ahmad and Prof. Muhammad Sultan",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10454.jpg",keywords:"Agricultural Engineering, Technologies, Application, Sustainable Agriculture, Information Technology in Agriculture, Food Security, Renewable Energies, Precision Farming, Smart Agriculture, Farm Mechanization, Robotics, Post Harvest Technologies",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"November 25th 2020",dateEndSecondStepPublish:"December 23rd 2020",dateEndThirdStepPublish:"February 21st 2021",dateEndFourthStepPublish:"May 12th 2021",dateEndFifthStepPublish:"July 11th 2021",remainingDaysToSecondStep:"2 months",secondStepPassed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Dr. Ahmad is a researcher in the field of agricultural mechanization and agricultural equipment engineering, in-charge of Farm Machinery Design Laboratory at Bahauddin Zakariya University, with expertise in modeling and simulation. He applied for two patents at the national level.",coeditorOneBiosketch:"Renowned researcher with a focus on developing energy-efficient heat- and/or water-driven temperature and humidity control systems for agricultural storage, greenhouse, agricultural livestock and poultry applications including HVAC, desiccant air-conditioning, adsorption, Maisotsenko cycle (M-cycle), and adsorption desalination.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"338219",title:"Dr.",name:"Fiaz",middleName:null,surname:"Ahmad",slug:"fiaz-ahmad",fullName:"Fiaz Ahmad",profilePictureURL:"https://mts.intechopen.com/storage/users/338219/images/system/338219.jpg",biography:"Fiaz Ahmad obtained his Ph.D. (2015) from Nanjing Agriculture University China in the field of Agricultural Bioenvironmental and Energy Engineering and Postdoc (2020) from Jiangsu University China in the field of Plant protection Engineering. He got the Higher Education Commission, Pakistan Scholarship for Ph.D. studies, and Post-Doctoral Fellowship from Jiangsu Government, China. During postdoctoral studies, he worked on the application of unmanned aerial vehicle sprayers for agrochemical applications to control pests and weeds. He passed the B.S. and M.S. degrees in agricultural engineering from the University of Agriculture Faisalabad, Pakistan in 2007. From 2007 to 2008, he was a Lecturer in the Department of Agricultural Engineering, Bahauddin Zakariya University, Multan-Pakistan. Since 2009, he has been an Assistant Professor in the Department of Agricultural Engineering, BZ University Multan, Pakistan. He is the author of 33 journal articles. He also supervised 6 master students and is currently supervising 5 master and 2 Ph.D. students. In addition, Dr. Ahmad completed three university-funded projects. His research interests include the design of agricultural machinery, artificial intelligence, and plant protection environment.",institutionString:"Bahauddin Zakariya University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Bahauddin Zakariya University",institutionURL:null,country:{name:"Pakistan"}}}],coeditorOne:{id:"199381",title:"Prof.",name:"Muhammad",middleName:null,surname:"Sultan",slug:"muhammad-sultan",fullName:"Muhammad Sultan",profilePictureURL:"https://mts.intechopen.com/storage/users/199381/images/system/199381.jpeg",biography:"Muhammad Sultan completed his Ph.D. (2015) and Postdoc (2017) from Kyushu University (Japan) in the field of Energy and Environmental Engineering. He was an awardee of MEXT and JASSO fellowships (from the Japanese Government) during Ph.D. and Postdoc studies, respectively. In 2019, he did Postdoc as a Canadian Queen Elizabeth Advanced Scholar at Simon Fraser University (Canada) in the field of Mechatronic Systems Engineering. He received his Master\\'s in Environmental Engineering (2010) and Bachelor in Agricultural Engineering (2008) with distinctions, from the University of Agriculture, Faisalabad. He worked for Kyushu University International Institute for Carbon-Neutral Energy Research (WPI-I2CNER) for two years. Currently, he is working as an Assistant Professor at the Department of Agricultural Engineering, Bahauddin Zakariya University (Pakistan). He has supervised 10+ M.Eng./Ph.D. students so far and 10+ M.Eng./Ph.D. students are currently working under his supervision. He has published more than 70+ journal articles, 70+ conference articles, and a few magazine articles, with the addition of 2 book chapters and 2 edited/co-edited books. 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As such, upcoming research will be of little value in either understanding corruption or curbing its consequences. Corruption is a universal global problem with detrimental effects on economic growth and performance [1], political stability, and societal integration [1, 2, 3]. Despite the dominant satisfaction of the correlation between a large set of variables and corruption, controversial results seem to be quite common due to differences in definitions [4, 5], sources [6], measures, research designs, models, cultures, types of corruption control [7], and period of studies [6, 7, 8, 9]. This general controversy is deeply applicable to the literature of journalism and corruption where several empirical and theoretical studies yield dramatically contradicting results. The existing literature lacks consensus on why it exists, its determinants, consequences, and more importantly, what makes it so differently widespread among cultures and countries [10].
In such a context, it would be important to develop a universal theory that embraces conceptual grounds of journalism and corruption. Yet, without considering the intricate interconnections between journalism and other related intervening variables of the higher socioeconomic levels/layers, such a theory would be misleading. Journalism is thought by many scholars to have an immense effect in controlling corruption. However, they do not know the conditions under which its performance brings about positive results in some countries while serving to protect corrupt policies and corrupt policy makers in some other countries. Journalism combats corruption through its content, freedom, structure, independence, ownership patterns, diversity, ethics, and professionalism, all of which demonstrate significant variations across cultures and nations. As a social institution, journalism does not work in a vacuum; its impact is heavily determined by both the nation system and international system environments in which it operates [11, 12, 13].
A multidisciplinary method, I argue, is the most appropriate approach to synthesize the key variables and underlying relationships across a set of published studies in a variety of disciplines to arrive at a theory of journalism-corruption determinants. A theory that discusses how multiple levels of determinants might be linked, or at least juxtaposed to yield a more comprehensive understanding of causes, and consequences of corruption and that can lead to more effective policy reforms. What I intend to do is to examine and move a body of knowledge forward to understand, interpret, predict, and finally help control the penetration of the most dangerous ill humanity has experienced since its establishment. The worst aspect about corruption is the nature of corruption itself. It takes so many different forms and covers such a variety of public and private activities that often is difficult for the common man or accountability agencies to detect what it really is. The corrupt officials are efficient at disguising their behaviors and covering over any traces. Moreover, it is very contagious. Corruption in one sphere of public or private domain quickly spreads to and penetrates in another like wildfire [14].
Corruption is an undeserved, unfair, unjust, immoral benefit resulting from positions of public trust and responsibility used for unworthy behaviors. It violates any notion of public responsibility on which the construction of democracy is built [14]. Despite the fact that corruption reality is compacted, complicated, diffused, and penetrated among all sectors and layers of the society, studies are often designed and carried out independently [15]. What complicates corruption research is that its causes in one discipline or level of analysis could be examined as a consequence in other discipline or level of analysis [8]. The single act of corruption within a small or big public or private corporation could be traced through several determinants within the corporation itself, the constitutional and legal system, structure of the economy, politics, culture, rule of law, in addition to historical roots of a given country in relation to colonialism, among many other factors and forces.
The suggested theory, then, will be designed in hierarchical levels in which the upper level, the macro level, is supposed to influence the lower level and so on. As Shoemaker and Rees argue, the hierarchy of influences model is useful for research in two important respects. First, any single perspective does not offer a comprehensive view, which is possible only when all levels affecting the variables under study are considered. Massive studies are conducted at a specific level, but findings are explained at higher levels. Second, merging multiple hierarchal levels of analysis provide distinct explanations and direct the attention to the interplay between them [16]. In addition, as most of corruption behaviors occur within the transaction process between actors at different systems within and sometimes outside a given country, the multiple hierarchal levels of study is, perhaps, the only suitable method that detects different causes behind the illegal behaviors. The suggested theory is in line with what many authors believe about corruption. Political corruption, for example, is rooted in the social structure. The state of willingness for political corruption depends less on the psychological or personality characteristics of the individual public servant, and more on the socioeconomic environment and institutional context in which the state and the market are constructed. Furthermore, readiness for corruption is not constant in a public official, and can actually vary over time within the same person depending on the context he/she is found [17].
Literature on corruption is mainly divided between research that emphasizes either the influence of structure (determinism), or the influence of agency (freedom), on human thought processes and behaviors. While agency stands for the capacity of an individual to freely make his/her own independent choice, structure refers to factors such as economy, institution, religion, history, social class, and culture that influence the choices of an individual [18]. The rational choice theory represents the foundation for studies adopting the influence of agency. The unit of analysis is the individual who chooses a specific course of action on a short term as a rational action to satisfy his/her self-interest. Though this school of thought provides good reasons to study the motivation behind the corruption behavior of public officials, it has its own limitations that make it unsuitable to explain the complexities of this behavior (for more details on the limitations of the rational choice theory, see Monroe, 1991) [19]. Therefore, scholars have turned to the structural factors to overcome the shortcoming of the individual-based theory of corruption. My approach is also informed by the argument made by Michael Johnston in his book: Syndromes of Corruption: Wealth, Power, and Democracy. He outstandingly criticizes the current corruption literature that either adopts cross-sectional analytical traditions often applying statistical measures and models to large numbers of countries or the case studies that focus the investigation on specific context. The two approaches have their limits that never allows to appropriate understanding of corruption. Johnston, instead, suggests a middle level of comparison—one that does not deny the benefits of these two traditions but links them together [20]. My conviction is that no one approach holds all advantages, and that every approach has its own limitations and shortcomings that require a combination of multi-systems/layers interactive approach. Corruption is extremely entrenched in the basic historical, political, and cultural structures. This approach is in line with a growing body of historical institutionalism stressing the importance of moving away from examining corruption as individualistic behavior to focus on the informal rules and routines that enforce individuals to act according to these norms [21, 22]. Historical institutionalism, in general, is an analytical approach that pays attention to the ways by which institutions shape and structure behaviors [23]. At this point, it would be useful to identify the phenomenon with which I am concerned.
Corruption as dependent variable here implies that things, behaviors, and policies are not what they ought to be. They have been deviant from the normal and expected paths. In the process of so deviating, the corrupt have unfairly and intentionally gained in some way that should not have happened or would not otherwise have occurred at the expense of everyone else, who, significantly, have thereby been disadvantaged [14]. The existence of corruption requires three elements to simultaneously coexist: first, the powerful person who has a discretionally power; second, an economic rent linked to this authority; and third, low probability of detection by the judicial system [24]. Klitgaard presents an elegant understanding of the determinants of corruption that views it as the ultimate output of the interaction between three pillars: monopoly power, discretion, and accountability. Its existence requires little or no accountability mechanisms, and presence of both imperfect competitive markets and discretion [25]. The corrupt behavior may be either passive or active. That is when the law is not totally or partly imposed or when the public official intentionally applies it selectively and unfairly to favor some persons or some organizations over others in the transaction processes [26]. In a corrupt country, public resources are more likely directed toward protecting the elite of the corrupt regime—the armed forces, the police, the executives, and other cliques of social control—as the regime seeks to perpetuate its control. This is why corruption is usually defined as the criminal misuse of power. A corrupt individual occupies higher social, political, and economic status [27]. Given this fact, it is expected that corruption precludes the socioeconomic development expenditure and widens the gap between the rich and the poor population [28].
In this context, it would also be useful to distinguish between grand corruption on the one hand and petty corruption on the other. The first has been defined as the misuse of public power by heads of state, ministers, and senior officials for private financial gain [29]. The second refers to bribes citizens pay to lower level officials to speed the delivery of services or to fasten the appropriate guidelines [30]. Obviously, the huge and rapidly growing literature around corruption bears a conceptual bias when it confines it to public sector and defines it from a state perspective. Reviewing literature of the conceptual framework of this key term in economy, sociology, political science, and so forth ignores the reality of corruption in private sphere [31].
In most of cross-country comparative studies, corruption indices of Transparency International (TI) are used to measure and compare corruption. This is a composite index including many other sources. Some studies used data from other individual sources, that is, the Political Risk Service (PRS), the Institute for Management Development (IMD), the World Bank and University of Basel (WB/UB), or the World Economic Forum (WEF). For a description of these sources, see Lambsdorff [32, 33]. An older source has been compiled by Business International [1]. In their studies on typology of corruption, Bussell [34] argued for not using one single shared typology across all analyses, as it is highly unlikely that a single typology will be sufficient for all research questions. Given the complex nature of corruption, they argued for a more practical, problem-driven approach. Corruption as Helman [35] argues is a derivative concept, meaning that it depends on a theory of the institution involved. In order to define corruption of an official or institution, one needs an explanation of how the official ought to behave or how the institution ought to function. Corruption can and is being measured through a wide variety of innovative approaches. It is appropriate to rely on a wide variety of different indicators, both subjective and objective, individual as well as aggregate, cross-country as well as country-specific. This is important to monitor results on the ground, assess the concrete reality of corruption, and develop anticorruption programs [2]. The variety of approaches through which corruption has to be defined and insufficiency of any or group of approaches may urge me to suggest a flexible definition for this phenomenon to mean what people perceive in a particular culture as corruption.
The levels of analysis in journalism-corruption determinants can be thought of as forming a continuum ranging from micro to macro, from the smallest units of a system to the largest. A micro level study examines corruption act as an activity practiced by an individual or a specific social institution occupies the lower level of the hierarchical influences. This could be a public official, a newspaper, or other journalism outlet that affects another firm or level. A macro level study examines social and political structures that exist in higher layers of the hierarchy. These levels operate hierarchically: What happens at the lower levels is determined by what occurs at higher levels to cause or deter the corruption behavior of an individual official or a particular system. For more details on how hierarchical levels of analysis work and guide research, see Shoemaker and Reese [16]. The rest of this chapter examines from several perspectives findings and explanations relating to determinants of corruption at different hierarchical levels. The main argument of “the hierarchical universal theory of journalism-corruption determinants” as introduced here perceives corruption act as an outcome of a continuous interaction between five hierarchical levels as shown in the graph below. They are: (1) journalistic level, (2) economic level, (3) political level, (4) cultural level, and (5) the international system level. In general, each level has many sublevels interacting with each other to bring about an effect on corruption that could be negative or positive, minor or major, and finally in one domain or multiple domains. It is understood also that the magnitude of lower level impact is weaker than that of the higher level. It is not expected, for example, that influence of journalism, as institution to be stronger than that of the political system or cultural system.
Given the discussions outlined in the preceding paragraphs, I will move through a sequence of four steps. The purpose of the first step is to identify the number and domains of the interacting hierarchal levels—as shown earlier—that sustain and/or restrain corruption. The second step aims at reviewing the empirical and theoretical studies that examine the main relevant variables and issues. The purpose of the third step is to present the generalizations summarizing the main findings. The fourth step intends to synthesize the main cross-border assumptions; a theory that creates linkages capable to explain corruption, predict it, direct the future studies, and finally contribute to reducing it (Figure 1).
The hierarchal universal theory of journalism/corruption determinants.
At this first level of the hierarchal theory, the revision will confine to conditions and functions of journalism that have distinct implications for corruption determinants, consequences, and policy reforms. In theory, conditions are different from functions, they are the elements and characteristics that enable or disable journalism as a social institution in the fight against corruption. Freedom, independence, and diversity are the main conditions of journalism that empower it to perform the functions of (1) watchdog, (2) accountability, and (3) agenda-setter. These conditions and functions relate to the existence of corruption, its diffusion and control.
A commonly held belief is that a free and independent press serves as deterrent to corruption due to its ability to detect corrupt behaviors and officials. A number of recent papers that consider the relationship between press freedom and corruption lend support to this conviction. Ahrend [36] finds that lower levels of press freedom are correlated with higher levels of corruption, a result that is supported by Chowdhury [37], Stapenhurst [38, 39], and Bojanic [40] who explained the positive effect of press freedom in the presence of democracy [40]. The overwhelming majority of empirical studies support the theoretical view that restrictions to press freedom lead to higher corruption and that political and economic restrictions are strongly and robustly related to corruption [41]. This view is totally supported in OPEC members where journalism was not serving as a check against corruption due to the restrictions imposed on its ownership and performance [42].
The most rigorous work in this respect is that of Brunetti and Weder [43] in which they use alternative measures for both the independent and dependent variables. They carry out several robustness checks utilizing two different press freedom indexes and four different measures of corruption, across countries as well as over time. The results show significant positive effects of press freedom on three of the four corruption control indices. Their results confirm the widely held belief that in countries where the press is mainly free from any sort of restrictions, corruption levels are likely to be low [43]. Though freedom of the press is a prerequisite to combat corruption, without citizens’ access to and participation in press content, its impact would be at its minimum. The results of Dutta and Roy’s study present empirical evidence that these two components of the press—freedom and access—complement each other in controlling corruption [44].
In a different thread of research, Graber [45] demonstrates that the press often deserve less recognition than previously believed for detecting corruption. Similarly, Vaidya [46] indicates that the government-press relationship in different parts of the world appears to suggest a more complex relationship. It might not serve as a watchdog for the public but might prefer to enter in a partnership with corrupt officials. However, not all forms of restrictions to press freedom are strongly correlated with corruption. More specifically, it appears that it is the political pressures that have a slightly stronger effect on corruption [46]. Lindstedt and Naurin [47] contend that in order for transparency to alleviate corruption, the audience should receive the information made available through transparency and they must have the capacity to hold corrupt officials accountable. Transparency on its own has no or little impact to prevent or control corruption.
In this context, two competing views on the relation between perception of corruption and actual corruption deserve more elaboration. The first view sees that higher levels of corruption’s perception led citizens to hold their governments accountable through democratic mechanisms and, specifically, the electoral process. This view hinges on the assumption that higher perception of corruption corresponds to a higher level of actual corruption, and that press is independent and the public uses its power to punish the government. Perception is a function of press coverage for corruption in real world and the role of the press will be to decrease it [48]. The second view implies that heightened perception of corruption can increase its actual level by publicizing the view of corruption as a normal activity and therefore lower the threshold of inhibition for others to engage in the same kind of behavior. Proponents of this view argue that more perception of corruption threatens state legitimacy and creates credibility and trust crises in the state [49].
In fact, existing literature as a whole emphasizes the significant impact of the free press as a highly effective mechanism of external control on corruption because it works not only against extortive but also against collusive corruption [43]. Extortive corruption as explained by Brunetti and Weder [43] happens when the government official has the discretionary power to refuse or delay a service in order to extract a rent from the private agent in the form of a bribe. The collusive corruption occurred when the official and the client have mutual interests and the two partners benefit from the transaction. Generally, press freedom is highly correlated with low levels of corruption, but its effectiveness is only related to collusive corruption [43]. Free press is a prerequisite for investigative journalism, which in turn is a fundamental mechanism contributing to both vertical and horizontal accountability. Journalism as institution would be of little value in curbing corruption unless it is free, independent, and plural. Leaders of international economic bodies such as the World Bank have paid attention to the importance of press freedom as the core of the equitable development [50]. This positive attitude has coincided with publication of several articles that demonstrate a strong correlation between a free press and low corruption levels across countries [50]. Ahrend [50], for example, provides a strong empirical evidence indicating that causation runs mainly from lower levels of press freedom to higher levels of corruption.
The free press investigates wrongdoing, feeds the public sphere with the consequences of corruption behaviors and forms public opinion. This emphatically pressures the governmental bodies especially the judiciary to hold corrupt officials accountable [51]. As a result, in democratic countries, corrupt officials are forced to resign and lose their power. This significant role takes place where a combination of free press, democracy, and rule of law exists. Evidence on such a collaborative role is presented by Hamada, Abdel-Salam, and Elkilany who find that the interaction of press freedom, democracy, and rule of law reduces corruption. Furthermore, they obtain that the effect of rule of law is not contingent on freedom of the press; rule of law affects corruption both in countries where the press is free and where it is unfree [52]. In a similar vein, Besley and Prat [53] test and verify their model, which links a number of characteristics of journalism industry, namely concentration and ownership and obvious political outcomes, namely capture, corruption, and turnover. The model is based on three propositions: (1) media pluralism works against capture, (2) independent ownership minimizes capture, and (3) media capture lessens political outcomes. They conclude that laws of press freedom are not sufficient to protect journalism from government interference. Consistent with this, Djankov finds that countries with greater state ownership of the press have less freedom, fewer political rights for citizens, inferior governance, and less developed capital markets [54]. In general, press freedom and democratization have a symbiotic relationship. Both go hand in hand, and where democracy exists, press assumes its free and critical evaluation of wrongdoing and vice versa. What is not clearly known is the conditions under which these two close variables interact. Historically, a free press requires its independence from the state and the private sector, a kind of independence that enables it to act as an indirect check on corruption that would otherwise flourish in the absence of competitive environment. By creating a diversified atmosphere absorbing different views and enriching a free public debate, journalism sustains political and economic competition, the necessary condition for a clean economic and political environment with a minimum level of corruption [38].
It has long been recognized that journalism plays a key role in curbing corruption. This is because of its fundamental role in enabling citizens to monitor the actions of the government officials. This, in turn, rationalizes the voting behavior of the citizens to the extent that they can punish the corrupt and unresponsive governments. Literature offers two models linking journalism to corruption. The first has been developed by Stromberg [55] focusing on the impact of journalism on policy issues including corruption. The main concept of the model implies that when voters are deprived from free flow of journalism information, they are not likely informed citizens, and the government is more likely to allocate resources that do not serve the interest of people. It also sets policies that are associated with higher rents and corruption [55].
Besley and Prat [53] present the second model in which voters who have been informed by a free press can vote corrupt officials out of office, but where, at the same time, corrupt politicians can capture and silence the press. The latter deprives citizens of any possibility to form an enlightened voting, and hence increases the likelihood for corrupt government officials to continue in office. The model is in line with a long tradition of many political thinkers including Rousseau, Smith, Hobbes, Locke, Madison, Jefferson, and Mill who have argued that press freedom is a prerequisite for citizens to make rational and knowledgeable decisions about public affairs [8]. Regardless of these two models, there are two ways through which journalism fights corruption: tangible and intangible. The first role is apparent when public office-holders are accused, or forced to resign after their crimes are exposed to public space. Investigative journalism that defends social and ethical norms, and intensifies competition, works as an indirect check against corruption [38]. Unlike legislative, executive, and judicial bodies, journalism, as a fourth estate, has no specific means to sanction mismanagement of public officials [56]. Corruption flourishes in the presence of cooperation among horizontal institutions of the state. The independent press can replace cooperation by disputes when it highlights corruption behaviors and thus create unfavorable atmosphere that eradicates corruption [38]. Through the watchdog function of journalism, three patterns of policy effects are generated: The first occurs when the government bodies discuss the problems raised by the press and take the procedures to present solutions. The second takes place if sanctions are applied against persons or institutions as a result of corruption or wrongdoing. The third happens when the parliament made changes in laws and legislations as a response to the investigate reports [57].
The critical role of investigative journalism takes place when it exposes the government’s record to external scrutiny and critical evaluation, and holds authorities accountable for their actions [58]. Several studies offered empirical evidence [43] that watchdog role of journalists enhances the transparency of government actions and decisions, hinders misuse of public office, malfeasance, and thus reduces corruption [43, 58]. As Bovens argues, public accountability is a relationship between an actor and a forum, in which the actor has an obligation to explain and to justify his or her conduct, the forum can pose questions and pass judgment, and the actor may face consequences [59]. Traditionally, theorists of public accountability assume that governmental accountability incorporates a combination of vertical and horizontal institutions [60]. Vertical accountability describes a relationship between unequals where powerful superior actors hold less powerful inferior actors accountable or vice versa [61]. Forms of this type of accountability include electoral accountability, civil society, and journalism. Enlighted voter participation can punish the corrupt officials and replace the incumbent by electing a new government. The free press empowers voters and makes them aware of the corrupt behaviors and incumbents. As a result, they become more knowledgeable and their ability to hold elected officials accountable for their policy decisions enhanced. A variety of models also confirm the fact that policy distortion is a result of ill-informed citizens [62]. Horizontal accountability implies the power of checks and balances exercised by equals [60] where the three authorities of state-executive, legislative, and judiciary monitor each other. As an empirical investigation of this issue, Camaj [63] found that the free press has a greater indirect effect on corruption when coupled with strong institutions of horizontal accountability than when coupled with high electoral accountability. The main contribution of the free press to democratic governance lies in its ability to sustain political accountability [64].
If free press pressures public officials to be answerable for their behavior, forces them to justify their actions publically, and informs the citizenry about such investigations, then it necessarily contributes to holding them accountable [64]. This happens through either its original informational role in which it identifies corruption acts and initiates the investigations or through a subsidy informational role in which it republishes the facts and information provided by other traditional intermediaries [65]. By the original and secondary informational roles, press contributes to horizontal and vertical accountability [64]. The problem arises when the public in many countries lacks interest in politics and motivation to participate in elections. Here, the free press’ role is to hold the governors accountable—not to the public, but to the ideals and rules of the democratic polity itself [66]. This is particularly important given the fact that accountability mechanisms are fragile in many countries [67].
In such countries, social media provide an alternative that triggers accountability mechanisms in a large state-controlled press, limited political competition and censorship of traditional media [68]. Yet, social media role has to be accompanied by users’ interest in acquiring knowledge about corruption, their skills to process it adequately, and their motivation to participate in actions to change the corrupt behaviors [69]. Social media have tremendous power in turning public officials into symbols of wrongdoing, regardless of legal judgment and sanctions [67]. The preceding discussion shows that the mere existence of journalism does not mean anything unless it has access to sources of information and the ability to enlighten the public with what went wrong [70]. By doing so, press coverage influences norms, values, and cultures, which in turn can lead to transformation in politics, economy, and governance [71]. This cultural change happens over time as a cumulative effect of continuous coverage of the press and through the cultivation of new standards of behaviors. Press is a crucial actor in the process of changing norms toward more transparency and accountability. By changing perceptions of what is right and wrong, the press can lead to less or zero tolerance for corruption [71]. On the other hand, if journalism complies with the power of corrupt officials, ignores their intended failure and mismanagement, a culture of corruption tolerance prevails and it will be socially acceptable [72].
A strong association exists between free and independent press and corruption. The causation runs from higher level of free and independent press to lower corruption.
A strong relationship exists between restrictions to press freedom and corruption where more restrictions lead to higher corruption.
Higher public perception of corruption due to freedom of the press and political competitiveness may not lead to controlling of corruption, unless civil mechanisms of accountability work properly. Alternatively, this situation may intensify the actual corruption as it delegitimizes the corruption behavior and views it as normal activity.
The political forms of restrictions are more effective in determining corruption than the economic or any other form of restrictions.
Press freedom and democracy are complements rather than substitutes in the fight against corruption.
The effect of press freedom in reducing corruption is magnified by the existence of democracy.
The watchdog role of the press hinges on the plurality of ownership patterns, diversity of views, and its credibility.
The watchdog journalism can contribute to the early public identification of corruption in which news analysis and information are made available to the public and authorities. It also has a secondary informational role through which it can republish information from other intermediaries.
Press freedom may have a greater indirect effect on corruption when interacted with strong mechanisms of horizontal accountability than when interacted with effective electoral accountability.
Transparency is an important, yet insufficient, factor to curb corruption and it does not prevent corruption if accountability agencies are weak.
More internet and digital media freedom decreases level of corruption only in democratic countries.
Social media improve vertical accountability more in countries where traditional journalism are captured and censored.
The impact of the level of free press in curbing corruption depends on the level of democracy. It is very effective in well-established electoral democracies, but less effective in newly established democracies, and it has little or no efficacy in a weak electoral democracy.
To a great extent, the level of corruption is an outcome of the degree of both monopoly and discretionary power that officials exercise. The two types of monopolies exist in highly regulated economies and definitely in developing countries where administrative rules and regulations are mainly imperfectly defined and overwhelmed by a weak rule of law. Corruption environment is also characterized by ineffective accountability and weak watchdog mechanisms. Empirically, more discretionary power and regulations equal more corruption [73]. Hence, effective strategies to control corruption have to simultaneously work on reducing officials’ monopoly power, their discretionary power, and strengthening their accountability through enabling the watchdog mechanisms [38]. Prior studies provide evidence that competitive economies are less corrupt than economies where domestic firms are protected from foreign competition. The results suggest that the policies aiming at making markets more competitive could play a role in controlling corruption [74]. This approach to corruption control suggests that increasing competition may be a way to reduce returns from corruption activities. Yet this argument is over simple as economists still have not fully identified the conditions under which an increase in competition will effectively reduce corruption [75].
In a similar thread of research, public choice theorists argue that corruption rates are directly corresponding to the degree of monopoly that public office officials have over a specific bureaucratic sphere. In contrast, a negative relationship exists between accountability they bear and the rate of corruption [76]. Since officials in autocracies have monopoly power and discretionary power without any form of accountability, the risk of punishment associated with corruption is often zero [77]. However, consolidated autocracy differs from lenient autocratic governance as it applies rigid regulations that raise the cost of corruption practices to the extent that illegal bureaucratic corruption is often minimal [78].
In a different line of research, democracy and economic freedom prove to be real determinants of corruption. Meanwhile, there is not enough knowledge about how the interaction effect between democracy and economic freedom occurs or under which conditions the interaction represents a cure for corruption. Countries such as Hong Kong and Singapore exhibit a very low level of democracy and a very high level of economic freedom and at the same time have a very low level of corruption. On the other hand, in spite of India’s high level of democracy and low level of economic freedom, it experiences a very high level of corruption. Thus, it is of interest to ask how these two factors, that is, democracy and economic freedom work together in this process [79]. The answer to this question comes from the investigation of Saha and Gounder who found that the interaction effect of democracy and economic freedom has a significant impact on controlling corruption. But the relationship is complex; democracy increases corruption at lower levels of economic freedom, yet in a full mature democracy, corruption is significantly lower [80]. This is consistent with other studies indicating that corruption control is more likely if an economic development is attained first, with democracy following more gradually [81].
Any discussion of economic determinants of corruption has to answer the questions of privatization, public sector wages, government regulations, democracy, and level of economic development. Privatization may have its clear economic advantages, but unfortunately, its impact on corruption is unclear. What happens is the shift of corruption from the public to the private sector. What was formerly taken from state-owned enterprises can then be extorted from private firms. Surely, the public sector corruption is certainly higher, for many reasons, than the private sector. At the top of these reasons is the wages where low public sector wages stimulate corruption among public sector workers [82]. By the same token, it is likely that corruption correlates positively with the degree to which government regulations are vague and lax [83]. In contrast, Treisman found corruption is lower in economically developed well-established liberal democracies, with a free press, and a high quota of women in governmental institutions, and an open and competitive global trade history [84]. The logical question here is under what conditions this result takes place. Does economic development reduce corruption? Alternatively, does corruption impede economic development? To what extent are both determined by some other factors? The general verified finding illustrates that when countries grow rich, they become less corrupt [85]. In other words, corruption is significantly correlated with the level of economic development (1999), a condition that makes policy reforms unmanageable. A country cannot wait forever to attain the economic development in order to control corruption [86].
The preceding debate tells us that differential effect of corruption is a neglected topic. For example, China has been able to grow faster than so many countries while being ranked among the most corrupt countries. Why corruption is less dangerous in China? Or would China have grown even faster if corruption was lower? These kinds of questions have received scant attention and need more investigations [87]. The same debate has to be raised with regard to democracy-corruption relationship and to any other variable that is likely to affect corruption or be affected by it directly or indirectly. A more common and relevant predictor of corruption is the size of the government and state legitimacy. Bigger and illegitimate governments allow more bureaucracies and less legislative oversight and more corruption [26, 88]. Nevertheless, it is not only the size of the government that explains the level of corruption but also whether the big government is democratic. The big size of government reduces corruption if democratic values and institutions prevail. In contrast, it expands corruption if it is undemocratic [89].
Countries that experience higher levels of rents also have higher levels of corruption, with other things equal.
Decentralization of the government, its size and intervention in the market are important, but not sufficient, factors determining corruption.
Competition lowers the rents of economic transactions and therefore decreases corruption as motives to extract rents consequently decrease.
Economic development reduces corruption indirectly through the quality of education and rationalization of decision-making, which maximizes the cost of the corruption behavior.
Equal distributions of wealth mattered more than wealth itself as means of controlling corruption.
Administrative environments that are characterized by vague performance standards tend to have high levels of corruption.
Administrative environments that are dominated by meritocratic recruitment and promotion tend to have low levels of corruption.
A judiciary system where corrupt bureaucrats can be effectively charged reduces the potential rewards of corruption and thus minimizes its level.
The big size of the government does not lead directly to corruption; the relationship is strongly affected by existence of democracy that marginalizes the effect of government size.
The link between autocratic systems and corruption is complex, where tolerant autocratic governments create favorite conditions for bureaucratic corruption, consolidated autocracy tends to deter corruption.
The widely accepted definition of corruption as the abuse of public office for private gains reflects an ideological bias against state activity where national private sectors and global private business experience corruption as well.
I will discuss the prior literature of political level—similar to other levels—along two parallel tracks: the political theoretical frameworks of corruption and the empirical findings of political cross-national comparative studies. Both tracks will be simultaneously presented in a way that contributes to building the hierarchical universal theory of journalism/corruption determinants. Obviously, the most commonly examined political issue is democracy and democratization where the available evidences tentatively indicate the association between higher political competitiveness, democracy, and lower level of corruption; however, this effect is not linear. Some authoritarian countries actually experience slightly less corruption than countries at intermediate levels of democracy. Even authoritarian regimes do not have similar effect with regard to corruption behavior. Dictatorial regimes are significantly more corrupt than single-party and military regimes [90].
Following the transitional phase where countries enjoy more political competitiveness, they tend to be less corrupt [74]. The general idea is that partial, young democracies or countries that experience the transition to consolidated democracy perform worse than authoritarian regimes and much worse than full or older democracies [37, 91]. In support of this ideal view, Montinola and Jackman provide evidence that moderate levels of democracy do not reduce corruption if compared to autocratic regimes. After the transition period to democracy ends, democratic practices do curb corruption [10]. Consistent with this evidence, Ensung suggests that democracy in general decreases corruption with the exception of the early stages of the political liberalization that witnesses higher levels of corruption. His explanation assumes that it is the societal indicators of each society that determine how much democratic reforms can curb corruption [92]. In parallel, with these studies and results, political parties and its strength were also found to be deterring mechanisms. But, corruption prevails in the transition toward modernization where political parties are absent or have no influence on the public involvement in political decision-making [93]. In general, political parties have been found to be behind the prevalence and spreading of corruption as they may reduce the risks of corruption acts [94]. From a political point of view, what influences corruption is not only democracy-related issues, but the overall social, political, and judicial institutions of a given country [20]. Corruption is no more than a contest between those who benefit and those who lose from this illegal and abnormal practices. These two partners reflect the socioeconomic structure in any society. Political changes, therefore, do not curb corruption unless they redesign the balance of power in favor of fighting corruption [140].
The overall result accordingly suggests a failure of the conceptual association posed between democracy and the reduction of corruption [95]. Yet, there exists a complementarity effect of democracy and press freedom. Democratic institutions are much more effective in controlling corruption if the press is free, and free press can only be effective if politicians are accountable to the public [37, 96, 97]. Based on cross-country and panel data, Kalenborn and Lessmann show that conditionality matters, in the sense that press freedom is an important conditioning variable concerning the influence of democratic elections on corruption. Results of their study suggest a collaborative effect of democratic reforms and freedom of the press to provide unbiased information to the voters. Only in countries with high press freedom, voters are able to examine the corrupt behavior of politicians [98]. In this respect, scholars highlight three key democratic institutional factors that deter corruption: first, an increased number of veto players in the form of multiple legislative houses, independent executive branches, and constitutional courts; second, heightened transparency that enables exposure of corrupt behavior and activates vertical and horizontal accountability; and third, strong and large ruling coalitions that disable monopoly [99]. Similarly, data indicate that democracy empowers electorate to remove leaders from office and thus mitigate the impeding effect corruption has on economic growth. Therefore, leaders of many democracies refrain from growth-damaging corruption because they are afraid of punishment at the upcoming election [100, 101].
Based on the preceding discussion, it is obvious that press freedom and democratization have a cooperative relationship. As countries become more democratic, the critical investigative role of the press is intensified. Subsequently, press role in curbing corruption increases [102]. Empirical studies that are based on cross-sectional analyses confirm that free press role is intensified if it is accompanied with powerful horizontal political institutions able to hold corrupt official accountable. The most obvious agency is the independent judiciary system that works to sustain the critical role of the press. The picture, then, is that no single factor can fight corruption alone. This fight requires a collaborative role of all accountability mechanisms [63, 103]. The picture, now, will be more confusing if we know that democracy may have dual effects on perception of government corruption. Results obtained from the study of democracy and citizens’ perception of government corruption find a significant relationship between macro institutional democracy and micro individual perceptions of government corruption. When conditional effects of rationality including both instrumental calculations and intrinsic values on corruption perceptions were considered, the opposite effect exists. Democracy reduces the perception of government as corrupt [104].
The main reason for the inconsistency among scholars can be partially explained in the light of the multidimensionality of the concept of “democracy” or “democratization.” Whereas free and competitive election deepens corruption, other aspects such as freedom of speech, free press and civil liberties control it. To tackle such issues, Hung-En Sung examined democracy-corruption relationship using the three major statistical forms in social sciences (linear, quadratic, and cubic) utilizing up-to-date data covering a larger number of countries. In general, he finds that democratization reduces corruption [92]. As well documented, the level of corruption is more likely to decrease in countries with strong democratic institutions, for many reasons. Democracy mitigates the negative consequences of corruption when it allows the voters through election to expel politicians who engage in corrupt practices [100]. Democratic governments, accordingly, facilitate economic growth and receive the political support they deserve. However, in many cases democratic governments can exploit democratic institutions, and manipulate a network of political support through buying the votes and providing bribes to voters [105].
The comparison between democratic and dictatorial systems extends to cover election campaigns. Researchers prove that since elections are often accompanied with the need to buy votes and bribe voters, it is likely that democratic systems are more vulnerable to corruption than military, authoritarian and autocratic system. For sure, the incentive to finance political campaigns might be a good reason to the prevalence of corruption that never exists in dictatorial governments [106]. For me, this argument may need another look at the definition of corruption itself. Dictatorial political systems that threaten the freedom and dignity of human beings are the worst form of corruption regardless of whether they accommodate elections. Though the corrupt behavior of democratic election campaigns is unjustifiable, it is very naïve harm if compared to the negative consequences of the military and dictatorial systems that deprive citizens from their freedom and dignity. What is the privilege one can earn if he/she lost his dignity and personal freedom? What is the positive economic advantage the whole society can enjoy, if its citizens and institutions live under a dictatorial regime suppressing their basic human rights including the right in life? The narrow approach to political corruption is, then, misleading and has to consider dignity, human freedom, and self-determination issues.
Electoral rules, as another political dimension, are also not alike in their effect on corruption. Results suggest that the ballot structure, district magnitude, and the electoral formula have a strong influence on political corruption [75]. However, countries with higher electoral participation irrespective of the rules according to Adsera and his colleagues have lower levels of corruption [107]. In a similar vein, literature extensively examined the impact of political institutions and specifically political accountability mechanisms on good governance and corruption. Three main features have been identified in the political system that heavily affect corruption: the degree of competition in the political system, the existence of checks and balance mechanisms across different branches of government, and the transparency of the system. Results show that political institutions are extremely significant in determining the level of corruption: democracy, parliamentary systems, political stability, freedom of the press are all associated with lower corruption [108].
There is no direct and straightforward relationship between political competitiveness and corruption. The level of corruption is higher in countries with intermediate levels of political competition than in fully democratic or authoritarian countries.
The influence of the electoral institutions on corruption depends on the plurality voting system that enables higher level of the individual accountability.
Prevalence and persistence of corruption depend on the interaction between three major factors: (1) a discretionary power that enables an authority to tailor the policies and regulation in a discretionary way, (2) extraction of rents by the abuse of the discretionary power, and (3) lack of or weak horizontal and vertical accountability agencies.
Political stability does not influence corruption directly. It leaves its effect on both the quality of political institutions and the efficiency of judicial authority, which decrease the degree of compliance with regulations.
Literature does offer contradicting results of the causal relationship between party system and corruption. High political parties’ competition may cause corruption and corruption may heighten political parties’ competition.
The likelihood of corruption development increases where state capability in the areas of law enforcement and control is imperfect especially in times of social and political transformation.
The institutional historical contextual approach to political transformation provides evidence that democratization does not serve as a mechanism against corruption.
Democracy may reduce corruption indirectly through the creation of voters’ enabling environment that allows them to remove corrupt regime from office.
In general, democratization lowers the level of corruption; however, an increase in corruption is expected during the early stages of democratization.
The effect of democratization in curbing corruption depends largely on the integrity of the society and the strength of both the state and society.
In many cases, corrupt governments manipulate government bodies and officials to the extent they can gain the public support through illegal networks.
The cultural level analysis of corruption means that it is rooted in the long-term historical structural determinants that reside beyond the current occurrences and events. It also acknowledges the fact that corruption results from noneconomic and nonpolitical factors that include cultural and religious determinants. Thirdly, it indicates that attitudes toward corruption vary across cultures. Where some cultures totally reject corruption, some others may justify it. As Alejandro Moreno states, justification of corruption is based on different cultural basis. It is highly accepted in post-Communist societies, followed by Latin American and South Asian countries [109]. This result bears some implications to the link between the degree of permissiveness toward corruption, which has a cultural reference, and level of democracy. It says that justification of corruption is wider in nondemocratic cultures than in democratic ones. Finally, the cultural level analysis directly or indirectly implies some sort of ethical violation to the norms as accepted standards and behaviors that stand for ideals of good and virtue [110].
Education, for example, has been proven to be a real cause behind reduction of corruption [111]. It shapes other factors responsible for promoting honesty, and a sense of identity with the entire country rather than with specific cliques or groups [112]. In addition, higher levels of education has been found to generate greater levels of wealth and equality for countries, both of which are associated with lower levels of corruption [113]. Sociologists in contrast to political scientists, economists, and journalism scientists focus on cultural variables including trust in public institutions and a generalized trust as a social capital, dominance of religious values versus nonreligious values, unequal distribution of power and wealth, acceptance of nepotism, level of education, role of religion, and many other cultural factors.
Cultural values are very difficult to change over time and thus as Hofstede explains are uncontrollable and it is unwise to fight corruption through a cultural change process [114]. Based on his results, Husted draws a profile of the corrupt society as one that enjoys high power distance, high uncertainty avoidance, and high masculinity [86]. Power distance is the extent to which powerless people perceive and accept the unequal distribution of power in a culture. In such a culture, the inferiors rely on their superiors in the form of paternalism, which is a main cause of corruption in a society. Uncertainty avoidance refers to the extent to which members of a culture feel threatened by unpredictable environment where corruption can be seen as a way to minimize uncertainty and avoid threat. Masculinity refers to, among other things, a materialized society where the basic measure of success is money as opposed to interest to the quality of life. The more the society is materialized, the more tendency it has to corruption [86].
Religion as a cultural component defining societies receives little attention as a determinant of corruption with radically contradicted results. It is my conviction that all religions prohibit corruption and view it as a dangerous crime, but the eventual impact of the religion depends on its ability to shape social norms and the role of the latter to control behaviors, especially, those in power. In her study, Shadabi uses data of 174 countries in 2010 and all of the economic and noneconomic control variables were considered in its cross-sectional estimations. The results show that religion has no effect on corruption [115]. The neutral position of religion in the fight against corruption has to be extended by more comparative studies across religions. Does Islam, for example, have the same neutral effect similar to Judaism and Christianity? What about Hinduism and Buddhism? Do they have the same neutral effect on corruption? Are disbelievers or seculars more or less corrupt than believers? I do believe that the neutral effect of religion is due to the fact that corruption is committed more by the elite, those who hold the authority, who are less committed to the religious values if compared to the religious grassroots who are the victims.
Interestingly, is the effect of women’ participation in government on corruption where higher rates of women’ involvement in politics lead to lower levels of corruption. The justification is given by two different studies conducted by Robert Gatti and associate and Swamy and associates. Both suggest that women have on average a less tolerant attitude toward corruption [116, 117]. The problem with cultural factors is that it changes slowly and the value system may take decades to bring about very little changes. As such, it is very difficult to rely on cultural changes to fight corruption. Culture consists of orientations to action in particular ways. People acquire cultural values through lifelong socialization. Therefore, if a society experiences dramatic changes in terms of its politics and economy, the persistent cultural values may hamper the expected impact of economic and political liberalization on corruption. Communism, for example, had produced a culture of corruption to the extent that the entire populations had been socialized into values and traditions making corruption an integral part of their life style. Those cultural heritages of communism were unlikely to merely disappear with the new political values that produced them [118]. This obvious problem does not deny the role of culture in determining corruption and its decisive influence. Society is built on norms. Norms are standards of anticipated behaviors that also control the way we interact with each other. Our behavior is mainly influenced by our perception of norms. Our rejection or acceptance of the corrupt behavior depends largely on the norms that cultivate our worldview [71]. Another relevant cultural determinant is income inequality that creates an atmosphere in which corruption develops and flourishes. Whereas the rich have many opportunities to enter into corrupt behaviors and abuse their power to gain personal benefits, the poor struggle to stand against the rich. The ultimate result is the production of public policies that favor the interests of the powerful elites at the expense of marginalized people. The relationship of income inequality with corruption is complex. On the one hand, corruption intensifies inequalities in income distribution [119] and on the other, income distribution inequality significantly increases the level of corruption [120]. The empirical evidence of the influence of inequality comes from the study of Jong-sung and Khagram who found that inequality is as significant as economic factors in determining and explaining corruption [121].
There is an association between the levels of trust among the people and the level of corruption. Higher trust leads to lower corruption.
Religion has a neutral effect on corruption, with other things equal.
All religions prohibit corruption; yet, its potential impact is little and insufficient as a single factor in the matrix of corruption fighting.
Level of corruption is more affected by the long-lived sociocultural structures than the current state policies.
Increasing level of education without well-developed civil monitoring institutions leads to higher level of corruption as it increases agents’ rent-seeking capacity.
Income inequality is likely to be a significant and no less central determinant of corruption than economic and political factors.
Empowerment of women through increasing female participation in politics and decision-making circles would result in less corruption.
The conventional wisdom says that the natural cure for corruption is the existence of competition, which is a natural product of international openness. In perfectly competitive markets, outcomes of economic revenues are not subject to the exploitation and manipulation by market actors and thus there is no room for corruption [122]. The standard expectation is that more openness through international trade curbs corruption because states competing globally have to have the norms and culture of global business environment, mainly the rule of law, accountability agencies, and transparency to attract business [123]. The empirical analysis of the relationship between trade openness and corruption is rare. Ades and Di Tella find that corruption is higher in countries where domestic firms are protected by natural and administrative barriers to trade [74]. Similarly, Larrain and Tavares provide evidence supporting the negative effect of openness on corruption, that is, more openness leads to less corruption [122]. Sandholtz and Gray reach the same conclusion when they provide evidence supporting their hypothesis stating that greater degree of international integration lowers levels of corruption. They analyze data from 150 countries that support the justification of the role of international integration in importing cultural norms that deter corruption and alters the costs and benefits of engaging in corrupt acts [124].
In a parallel vein, other empirical findings lend significant support to the positive relationship between openness and good governance [125, 126, 127, 128]. Statistical analysis proves that openness to foreign trade significantly hinders corruption [126, 129]. However, the size of the effect is very small. A real difference to a country’s level of perceived corruption would require a substantial integration in global trade rather than a little change [130]. One measure of competitive pressures is the integration of a country into the global economy. If competition reduces corruption, then increased openness to international trade and investment should go along with less corruption [8]. According to an empirical study, it has been found that globalization is a powerful weapon against corruption only for middle- and high-income countries, while for low-income countries it has no significant impact. For such countries, fighting corruption requires additional global action aiming at the reduction of poverty [131]. There are good reasons for why globalization minimizes corruption as it exposes the globalized country to anti-corruption norms. The international networks of Western countries transmit the anti-corruption values to countries connected to globalization [124]. Sandholtz and Gray report that the more international organizations a country belongs to and the longer it has been a part of the major international institutions, such as the United Nations, the General Agreement on Tariffs and Trade/World Trade Organization (GATT/WTO), and the International Monetary Fund (IMF), the lower its level of corruption [124]. There is no doubt that social and political openness enhance information availability to a number of new players in politics. Yet, according to the study of [91] Charron, impact of social and political openness on corruption is conditioned by domestic factors.
In a slightly different thread of research, Mukherjee concludes that greater economic globalization does not reduce bureaucratic corruption. However, he argues that this finding does not necessarily deny the importance of global trade engagement. Rather, it reflects that curbing corruption is not only an outcome of integration in global economy that stems from a nexus of complicated and hierarchical bureaucracy [132]. Consistent with this view, Gatti tested the conventional wisdom that international openness reduces corruption by analyzing whether the presence of obstacles to international trade and capital flows is correlated with higher level of corruption and found no evidence to support his hypothesis. Instead, his conclusion states that the main impact stems from the incentives of collusive behaviors between the two partners: individuals and customs officials, rather than from the restrictive trade policy that lowers the openness and foreign competition [127]. Another international factor that seems to affect the level of corruption is the colonial heritage. Studies show that countries that were British colonies have significantly lower perceived corruption. This is because most former British colonies have common law systems [130]. In the light of the debate of global trade and corruption, it seems that the only verified result of international openness and corruption is simply it depends on the wider cultural and sociopolitical context.
The most dangerous international source and determinant of corruption, I argue, is the double standards employed by the United States and other powerful European countries against the weak and developing countries. If corruption as Gerald Caiden argues takes place when things are not what they ought to be [14], then, violation of international law by any state should be seen as corruption. In this context, the Israeli occupation of Palestine since 1948 right now with full support of United States and several European countries is by definition the worst form of corruption [133]. Within the past 70 years or so, Israel has occupied Palestine and was permitted to invade and attack numerous neighboring countries with full support of the United States and several European countries, without any true positive interference from the U.N or Security Council [134]. The illegitimacy of the Israeli occupation provides the legal justification for defending and interpreting all other issues pertaining to the dilemma of the Palestinians, including all acts of resistance since they are in line with the right of self-determination [133].
In a similar vein, Karen Del Biondo provides evidence that there have been double standards in the EU’s reactions to the violations of democratic principles in 10 African countries. The similar violations of democratic principles by Eritrea, Ethiopia, Kenya, Chad, Niger, Nigeria, Rwanda, Guinea, Côte d’Ivoire, and Zimbabwe received dissimilar reactions to protect the self-interested objectives of the EU [135]. An up-to-date example of the international corruption according to my suggested definition is the intervention of USA and several European countries to suppress the Arab Spring revolutions. The serious consequences of such interference are reflected in the decline of press freedom and civil liberties, lack of rule of law and accountability agencies which, in turn, worsen the level and magnitude of corruption. In other words, the systemic corruption of the developing countries could be partially attributed to foreign policies of some Western countries that seek to serve their own interests at the expense of the rights of the marginalized peoples of the East. Hindering democratic transformation in developing countries under any justification may not serve the developed countries themselves. Corruption is one of the main causes behind poverty, unemployment, poor quality of life, depression, and all social and political and economic problems the whole society, especially youth suffer from [136]. What I like to stress is the fact that some of Western countries through their foreign policies that work against the aspirations of peoples of developing countries toward freedom, democracy, and dignity increase corruption in such countries, which eventually harms the West. Supporting nondemocratic governments equals defending corruption as dictators make no distinction between their own wealth and that of their countries [24]. Nondemocratic governors are above the law and cannot be held accountable. As such, the best international policy for fighting corruption is to promote real democratic systems that respect the rule of law, enhance accountability, press freedom, civil liberties, and social and economic justice.
Adding the international domain in the analysis of corruption is obviously justified by the current research that has tended to be fragmented. Scholars often exhibit little familiarity in areas of research other than their own fields [24, 137, 138]. As a result, progress in explaining this cancer or coronavirus pandemic that is damaging the fabric of any hope for stability, democracy, and welfare will continue without a real cure. I therefore, suggest that the starting point is to reconsider a new definition of corruption embracing the dynamic collaboration among the five hierarchal layers with emphasis on the highest level, the international. I also assume that: (1) The double standards policies of some powerful Western states are in stark contrast with any international anti-corruption policy the World Bank, IMF and other international and regional organizations adopt to fight corruption. (2) The incredible illegal support of USA to Israeli’s occupation of Palestine is the main source of corruption in Arab countries that delay projects of political and economic development over seven decades with the hope to free Palestine. Unfortunately, their efforts in the two fronts lead to a big failure. (3) Western countries’ position against the aspirations of developing countries for freedom, rule of law, dignity, and democracy perpetuates the systemic corruption and helps export terrorism and migration to the West. (4) I, therefore, presume that emphasis on the missing part of corruption studies, the international dimension, will provide a perfect insight on how to understand the mechanisms through which corruption works. It is a vicious cycle through which causes of corruption trickle down from the upper to the lower level and to the bottom, journalism as depicted in the graph of the hierarchal universal theory. The ultimate result of this cycle is a type of journalism that enters into strong and permanent alliance with corrupt and dictatorial governments. Journalism is a key factor affecting vertical and horizontal accountability institutions. Not only this, but it defends the wrongdoing of corrupt officials and serves against any peaceful means to change them or hold them accountable. Since, corruption as reviewed here is an economic, political, and cultural issue expressing a big failure of the whole society, journalism performance also decreases the risks and costs of corruption and publicizes the impunity culture that tolerates the corruptible.
The corrupt journalism serves mainly to suppress diversity, particularly, the opposition voices while maintaining and strengthening its ties with corrupt alliances, supporting monopoly, discretion and attacking accountability. This analysis illustrates to a large extent the penetration of journalism influences into the fabric of the three major ingredients of formula of corruption suggested by Klitgaard who see corruption as monopoly + discretion – accountability ([25], p. 75).
Globalization exerts a powerful impact on decreasing corruption in high- or middle-income countries; however, it has no impact in low-income countries.
A substantial opening to foreign trade is required to lower corruption significantly, while a marginal shift does not make a difference.
The level of corruption is negatively correlated with the legal cultures of the former colonial heritage.
International quantitative trade constraints shift the economy from directly productive activities to unproductive rent seeking activities.
Corrupt behaviors grow and flourish in closed economies, while countries involved in international economy expose themselves to all types of controls that minimize corruption.
In many cases, globalization has increased corruption as it involves a low level of risk discovery and penalty which encourages a high benefit of bribery and profit.
Occupation of Palestinian state by Israel represents the worst from of international corruption that violates the international law and the international humanitarian laws.
Defending the Israeli occupation for Palestinian state by USA and some powerful European states works against the aims of all international agencies that fight corruption including World Bank and IMF.
Any effort from USA and some powerful European states to hinder the revolutions of developing countries is an effort to perpetuate corruption and increase the likelihood of migration and terrorism that they are currently suffering from.
“The hierarchical universal theory of journalism/corruption determinants” intends to accommodate the various variables and underlying relations affecting corruption organized in a continuum from macro-international to micro-journalistic or individual level. In our effort to build the theory, we went—right now—through three steps: (1) The first step identifies the five interactive hierarchical levels of influences. (2) The second step reviews the most relevant empirical studies carried out in each level. (3) The third step introduces the generalizations/the results obtained from the empirical studies/existing literature. (4) The remaining step (the fourth) intends to synthesize the main cross-border hypotheses that create linkages capable to explain corruption, predict it, direct the future studies, and finally contribute to reducing it.
The challenging question is how to study variables pertaining to several levels interacting together to restrain or spread corruption. This question suggests a conceptual universal cross-cultural, multidisciplinary perspective beyond the traditionally single studies dedicated to examining a direct liner relationship within a specific level or sublevel. A levels-of-analysis perspective, as suggested by Thomas Hanitzsch, has been promising in sketching a universal framework for large-scale comparative analysis [139]. In this respect, Stephen Reese argues-in his conceptualization of the hierarchical influences approach—that is dedicated only to global journalism studies—that most research is not planned to examine variables attached to all levels of influence once. However, scholars can consider a multilevel interpretation of their results or actually take a further step to account for interaction among hierarchical levels [140]. The hierarchal theory shows to what extent there is a need to redirect corruption research to understand how it works to help them contribute to policies and initiatives of corruption fighting.
Before stating such hypotheses and closing this chapter, it is important to emphasize some cautions. (1) As is obvious, it is beyond my capacity, time and space limit to review all relevant theoretical and empirical works that fit into each level of analysis. Given the richness and unlimited scholarship produced on the subject, it would be impossible to cover all at once. The aim of my attempt is to redesign a new theory that aims at drawing a universal map for what has been carried out and what is still missing. What is important is the conceptual framework and methodological underpinnings that future research can consider. (2) Despite the fact that multidisciplinary international comparative studies are the recommended type of research to test the cross-border hypotheses, other types of research studies and methods, quantitative and qualitative, single cases using different indexes measuring corruption through one point of time or longitudinal studies are of added value for understanding corruption. (3) The approach we adopt in building this theory is based on the concept of science as a dynamic process of critical thinking, raising questions, and formulating hypotheses and not a body of knowledge. It is a matter of identifying the possible relationships between variables we can empirically observe and test [141]. (4) The following list of hypotheses is just initial step in the ongoing research and conceptual work that helps understand journalism-corruption determinants in their comprehensive framework. They are not by any definition a comprehensive view.
As journalism institutions become more restricted in nondemocratic countries that exhibit the least competitive markets, along with the least international economic integration and the lowest level of education, corruption will expand and flourish in all spheres of life.
The more democratic institutions are, and the more rule of law and accountability mechanisms exist, the more free and independent journalism institutions become and the less corruption levels prevail.
Journalism conditions and specifically its freedom, diversity, and independence are closely related to higher levels of economic and political competitions and higher levels of social capital and international integration and lower levels of corruption.
The watchdog role of journalism enhances good governance, rule of law, accountability, less levels of income inequality and hence lower levels of corruption.
Alliances between USA, powerful European nations, and dictators in developing countries are related to diffusion of state-owned and captured journalism, centralized governments, lower levels of transparency, and, hence, higher levels of corruption.
As totalitarian and authoritarian systems prevail, monopoly and centralization dominate, bureaucracy and public sector increase, the closed economies exist, and corruption diffuses in all domains of life.
As double standards in international politics dominate, sources of corruption develop, and alliances between ruling elites in developed and developing countries strengthen, journalism institutions are more likely to serve the interests of the elites at the expense of the general public, and the divide between the rich and the poor widens, leading to higher levels of corruption.
As educational and cultural levels of the general public increase, journalism ethical performance prevails, its watchdog role intensifies, democratic and accountability institutions and practices are more likely to exist, and corruption levels decrease.
As social networks penetration increase, vertical accountability dominates, rule of law enhances, the cost of corrupt behavior grows, and incidence of corruption reduces.
Watchdog journalism is more likely to have a preventive effect of corruption in a context where vertical and horizontal accountability exist, anti-corruption norms prevail, discretionary power of the elites is at its minimum, and finally where the judicial system offers higher level of corruption penalty.
Journalists’ autonomy and safety are prerequisites in the fight against corruption as independent investigative reports threaten and damage the horizontal and vertical cooperation between the corrupt agencies in the corrupt states. However, without independent judiciary system, and strong civil society, the corrupt authority will suppress the independent and free voices of journalism.
Perception of corruption as a proxy for actual corruption should not be taken for granted. In corrupt regimes where journalism is owned, controlled, and operated by corrupt ruling elites, corruption crimes and accusations are used as conspiracy tool in the hands of dictators to manipulate the public mind and distract the attention from focusing on efforts of regime change.
Though systemic corruption is rooted in the historical, cultural, and political structure, policy changes and definitely mass education and press freedom can help in reducing corruption.
Press freedom, democracy, rule of law, horizontal and vertical accountability, women empowerment, global openness, and education are complements rather than substitutes in their fight against corruption.
Press freedom causes less corruption; however, lower corruption level is an indicator of a healthy social, cultural, political, and economic environment that serves as a real cause for enhancing press freedom. As such, the direction of causation runs from lower corruption to higher press freedom as well.
According to the World Health Organization (WHO), TM consists of knowledge, skills, and practices used for protection from physical and mental illnesses, diagnosis, improvement, and treatment of these diseases, as well as maintaining the health well, which is based on theories, beliefs, and experiences indigenous to different cultures, whether explicable or not. TM practices have a long history [1]. In general terms, the use of supplementary methods in addition to modern medicine in the patient treatment process is called “complementary medicine,” while the use of other methods instead of modern medicine is called “alternative medicine.” Similar terms had also been used in Turkey for a long time. However, as a result of the evaluations done based on the definition of WHO, it has been concluded that medicine cannot have an alternative, only the treatment can have one. Accordingly, the definition, “traditional and complementary medicine,” has come to the fore [2].
People resort more to TM and CAM applications because these applications have low cost, are easy to access, are often free of invasive procedures, are considered promising in some chronic and terminal stage diseases, and some side effects of new treatment options can cause distrust. Also, in countries where TM and CAM applications are covered by public insurance, the inclination toward these applications will inevitably increase [3]. Friends talk about the solution to certain problems and articles about TM and CAM are frequently seen in the printed media. Many hospitals include these treatment methods in their care plans. Courses on TM and CAM are placed in the curriculum of medicine, pharmacy, and nursing faculties [4].
When the literature is evaluated, TM and CAM applications are observed to become widespread all over the world, and especially the increase in the use of TM and CAM in the western world in the last decade has increased the need for field-specific evidence-based research [5]. Although CAM has an effect, there are many unknown points about these treatments regarding scientific research that will convincingly reveal the value of individual treatments.
Scientific knowledge reveals the cause and effect relationship logically based on experiments. It aims to clarify the cause and effect link between events investigated as a result of accepted, proven, and reproducible experiments. Scientific research should be planned in a way to show useful results and healing in patient care. Clinical research consists of scientific studies that are carried out with the participation of volunteer people and aim to obtain medical information. For new drugs, medical devices, and other treatment methods to be beneficial to humans, scientific information should be provided on topics such as showing their safety and effectiveness, developing new treatment methods, and determining the side effects of medications and medical devices employed in treatment before they are used widely. After all treatments have been shown to be successful in the laboratory and on laboratory animals, the effects/side effects on human volunteers are investigated. Answers to questions such as the effectiveness of treatment, suitable doses for treatment, and the possible side effects can be found with clinical research results.
Medical research is carried out systematically using scientific methods based on a plan to obtain scientific information. Medical research that is conducted on humans is carried out systematically with scientific methods based on a protocol by staff (physicians) who are authorized to perform their profession in the field of medicine on patients or healthy volunteers by doing physical, chemical, or psychological medical interventions, or using biological samples taken from these people, or utilizing other personal data of these people. Medical research on humans primarily aims to obtain new and generalizable scientific data. On the other hand, its effects on the human body may not be foreseen precisely [6].
Researchers should know and apply common methods, measures, and standards so that necessary evidence can be produced and interpreted to make their decision on the use of TM and CAM treatments. Scientific thinking must remain within the ethical framework while focusing on the solution of problems. Scientific research that can be carried on human volunteers should be designed with great scientific and ethical sensitivity. Each stage of the research should be applied in a way that will protect human rights and dignity and will not cause permanent harm for future generations.
Research carried out in the field of TM and CAM can be handled under two headings.
These are studies carried out on human beings to reveal or verify the clinical or pharmacological effects of one or more products and/or methods falling within the field of traditional and complementary medicine applications, to identify their adverse events or reactions, and to investigate their safety and effectiveness.
These can be defined as traditional and complementary medicine applications that will be carried out using methods that will not require direct attention or intervention of a physician or dentist provided that observational studies, survey studies, retrospective studies, and traditional and complementary medicine applications are administered under conditions that are specified within the legal regulations of countries.
In studies to be conducted in the field of TM and CAM, natural, synthetic, or biotechnology-rooted active substance or combination of substances administered to human beings to prevent, diagnose, or treat diseases, correct, regulate, or change a physiological function can be defined as a drug or human medicinal product.
To ensure that studies are conducted in international scientific and ethical standards, good clinical practice titles consist of rules that should be obeyed by parties participating in the research and cover regulations about topics such as designing, conducting, following, budgeting, evaluating and reporting the research, protecting all rights of the volunteer and body integrity, providing the reliability of research data, and maintaining their confidentiality.
Randomized clinical trials, which are shown as a source of evidence for the applicability of a particular intervention, provide important data for making practical decisions. They were accepted as the gold standard by A. Hill. Although the level of evidence is evaluated according to the type of the research, each study should also be evaluated in terms of strengths and weaknesses [7].
While randomized controlled studies are considered as the gold standard of evidence for treatment effectiveness, other research models will be needed about the activity field of CAM when randomized controlled trials cannot be conducted. These models may include studies meeting randomized and nonrandomized conditions, observational cohort studies, case-control studies, studies evaluating the effectiveness of certain treatment packages as a whole, and studies measuring placebo or add-on effects [4].
Evidence-based medicine (EBM) can be defined as the systematic approach where physicians make their decisions by combining their experiences, preferences, and patient characteristics in light of the best available evidence. Today, opinion-based decision-making approach referring to individual clinical experience has been replaced by evidence-based decision-making practice because the former causes variations and inconsistencies among clinical practices, it leads to disconnections between clinical practice and medical research, and it has become difficult to follow all the sources in the rapidly growing medical literature as a result of the ever-increasing number of studies in the field of medicine [8]. EBM practices, which have replaced TM practices, necessitate that decisions should be supported with qualified and current researches with a systematic approach to make the right decisions in the diagnosis and treatment processes. It is very important to reach information about evidence by following a conscious approach in the process of EBM applications. Evidence is determined by carefully selecting from the findings of clinical trials carried out by using real patients as subjects and applying original, powerful research methods [9].
Value is defined as an evaluation done in a socially accepted manner, showing the positive or negative meanings of objects in the outside world for people and society (e.g., good and bad, beautiful and ugly, underlying in nature and society phenomena) [10]. Value, as a criterion, includes the distinction between what is and what should be, and always appears as something positive or negative. The value that something has in terms of producing the desired results or the value displayed by something that acts as a tool in reaching the desired result is called instrumental or pragmatic value [11]. It can be said that the results of studies, too, have instrumental value. It should be borne in mind that research has a social value through knowledge production.
When the value of a research project is analyzed for social and scientific reasons, it increases as much as it has the promise of improving health or increasing knowledge that is important for health.
Studies that have no social value can be seen as a waste of resources and may pose participants some risks. It is an ethical imperative that in clinical trials, volunteer participants are not at risk other than investigating socially and scientifically important results. For this reason, only therapies with the greatest scientific and social importance should be selected for research purposes. Ensuring that social and scientific value prevails over commercial value is an ongoing ethical responsibility. Preliminary studies on research are absolutely valuable. The information they provide can cumulatively improve healthcare. From time to time, additions to clinical applications can be made in this way [12].
Determining who will benefit from the research result is important in determining possible benefits. The potential value of each research should be outlined at the outset. The results of the research should not only be subject of scientific meetings and publications but should be disclosed to all stakeholders in an appropriate language and expression. The reason why a patient or a relative of a patient seeks remedy other than evidence-based medicine is that there is no treatment of the disease in question or probabilities are very low. We should also understand people who seek health alternatives. For TM and CAM, the social value of the research has a special importance in this sense. On the other hand, research should not be allowed to weaken the existing health system of the society. In TM and CAM research, researchers should carefully monitor the socio-cultural dimensions of disease experiences, practitioner-patient interactions, and mutual compliance with treatment instructions during the research process. Research in this field can be categorized as empirical, semi-empirical, descriptive, case presentation, and historical interviews. Regional differences, being patient-centered, using several approaches together, differences of research participant inclusion/exclusion criteria, and approaches of appropriate placebo selection can affect research outcomes. According to WHO, data supporting the global use of TM and CAM practices are insufficient. More researches are needed to integrate CAM and TM practices in healthcare systems and understand their efficiency, safety, and mechanisms [13].
To give a definition, the source is the sum of all inputs such as money, manpower, and equipment, which are essential for any production or utilized during production. The sources to be allocated for transplantation, dialysis, or cancer treatment and the share allocated to other services such as vaccination, infection treatment, and treatment of acute diseases should be balanced. The search for balance leads to discussions on how far scientific and technical possibilities should be used to support patients. However, the limited resources make this issue controversial, imposing the necessity to make a choice [14].
When the limitations of the sources are in question, it is of significance which CAM treatments to evaluate. Research into this area may aim at understanding the biological mechanism of disease or treatment, as well as primarily addressing common disease issues. Acupuncture is used in the case of back pain, headache, migraine, knee pain, facial pain, inducing labor, nausea, vomiting, post-operative pain, essential hypertension, depression, stroke, and so forth. Analgesic effects of acupuncture practices are outcomes of patients’ expectations and interaction of neurochemical, physiological, and psychological factors. One of the weakest parts of acupuncture evaluation researches may be the lack of adequate control of placebo [15]. The potential benefit may be another important topic to focus on. It is also possible to center on existing evidence that interventions are effective. Besides the pre-research geographic records, existing records can be evaluated. Regardless of what subject to be addressed, evidence to justify funding for research should be disclosed. Having evidence at hand is crucial to reveal the reliability and effects of TM and CAM treatments. There are few studies comparing treatments specific to these areas [4].
In the process of scientific research, the researcher is basically seeking an explanation and answer to a question. There are two important concepts in this regard. These are validity and reliability. Validity is a concept that determines whether the answer, which is the subject of the research, can be answered with the applied research method.
Predictive validity about how predictive the research tool is in real-life situations and the construct validity regarding how much the tool correlates with the theoretical psychosocial structure of the sample that is being measured should be carefully reviewed in studies to be validated. A valid sample for the research must be calculated correctly. Neutral data collection is necessary for unbiased measurement and evaluation of the result. Science means measurement. Doing wrong measurements will lead to unreliable evidence and treatments. For this reason, utmost attention should be paid to ensure that measurement tools give valid and reliable results [16].
Scientific principles and methods are needed to produce reliable results. Scientific validity should be in accordance with the research methodology [12]. The scientific validity range and what the conditions are for the current treatment must be clarified in CAM studies. This situation is important for the social value of the research, as well as epistemologically. According to the research results in relation to CAM treatments, labels of therapies such as approved/unapproved or overridden require an epistemological and ethical evaluation.
It is claimed that cupping has a therapeutic effect on many diseases that could not be conventionally treated. It is used in conditions such as enhancing immune system, fibromyalgia, chronic pain caused by rheumatic diseases, digestive system diseases, nausea, and vomiting. It was also mentioned that cupping could also reduce side effects of some medications [17]. Evidence-based research data are needed in treatment of diseases.
The right to health is about health. The term health in national and international sources of law does not only refer to not being ill but also expresses “a complete state of physical, mental and social well-being.” The WHO Constitution and the 1978 Alma-Ata Declaration define health as “not only being not ill or disabled; instead, a complete state of well-being in physical, mental, and social terms.” The committee, which is the authorized interpretation body of the United Nations Convention on Economic Social and Cultural Rights, can be seen to base its interpretations of the right to health on the definitions of WHO [18].
Health, which is the value protected by the right to health, is not only a value that requires service for improvement when it deteriorates but also a value that must be respected and maintained, just like body integrity. The example that people should be protected against activities harmful to their health can be considered in this context [19].
According to the United Nations Convention on Economic Social and Cultural Rights, the right to health should not be understood as just the right to be healthy. The freedom dimension of the right to health includes a person’s control over their health and body and not being a subject of medical and experimental interventions that are not based on the person’s consent or end up with torture, as well as gender and reproduction freedom of the person [20].
From this point of view, topic selection is important for all clinical trials. Equal sharing of benefits and burdens in research is an important requirement. Various headings such as the vulnerability of volunteers, risks, socioeconomic status, and gender inequality in high-risk research are important in determining the subject of the research. In the selection of the subject of the research, vulnerable groups should be carefully monitored. The use of CAM is believed to be closely related to sociodemographic variables such as gender, age, education, income, and health complaints. TM and CAM applications are often preferred by women [21]. This general information suggests that field-specific CAM and TM studies are expected to be carried out mostly on women, as opposed to conventional medicine. EBM information shows that there are important differences between men and women in terms of diagnosis, treatment, and disease prognosis of arthritis, heart diseases, and infectious diseases. These differences exist due to the biological (sex) and social (gender) differences between men and women. For example, according to research, the side effects of antihistamines, antibiotics, antiarrhythmics, and antipsychotics are more severe and/or more common in women than in men. The effectiveness of aspirin in the primary prevention of cardiovascular disease is another example of the existence of a significant gender difference. Therefore, both sexes must be included in studies.
Although there are many definitions for vulnerable and easily affected groups, they are known as disadvantaged groups of society. People with vulnerable and easily affected status had been one of the basic concepts studied in bioethics and health policies from the 1970s to 1990s. Over the years, so many groups, from old people who can be easily hurt to those with low levels of education, from individuals with insufficient resources to citizens without rights and a whole country open to exploitation, have been declared vulnerable that the scope of the term has expanded excessively [22]. There are three types of security vulnerabilities for this group. The first is vulnerability to physical harm, the second is vulnerability to damage to social stance or reputation, and the third is vulnerability to psychological and emotional distress. Vulnerable and easily affected groups include children suspected of the informed consent they deliver; individuals with inadequate mental capacity to give consent; individuals with learning difficulties, dementia, or similar ailments; individuals with cognitive impairments due to stroke; individuals with psychiatric or personality disorders; individuals who cannot socially give consent freely; students; individuals under care; members of the armed forces; juvenile criminals; prisoners and asylum-seekers; pregnant women; unconscious patients; and family members of researchers. The Belmont Report, the first document to identify vulnerable and easily affected groups, identifies individuals who cannot make decisions, are exposed to disproportionate incentives, and are involved in research due to administrative convenience as abusable [23].
The nineteenth article of the Declaration of Helsinki, titled Vulnerable Groups and Individuals, states that some groups and individuals are particularly vulnerable, and they may be more likely to be abused or damaged. Specially considered protective measures should be taken for all vulnerable groups and individuals. According to Article 20, medical research on vulnerable groups can be accepted provided that the research addresses the health needs and priorities of the group in question and it is not possible to conduct the research in a nonvulnerable group. Also, it involves the provision that the information, practices, and interventions obtained from the research should benefit the group in question. The eighth article of the UNESCO Universal Declaration on Bioethics and Human Rights (2005), which centers on the need to show respect to personal integrity and protect vulnerable and easily affected individuals and groups, emphasizes that human vulnerability should be taken into consideration in the application and development of scientific knowledge accumulation, medicine, and related technologies [24].
In research to be conducted on vulnerable and easily affected groups, risk/benefit measures, security, vulnerability, and assurances attached to privacy should be determined. It should be remembered that unethical use of personal data and privacy violations will affect the social texture of disadvantaged groups. Situations that involve sensitive issues related to stigmatization can also discredit individuals [25].
As for evidence of the effectiveness of TM and CAM approaches, the results of these studies have been found sufficient to construct a hypothesis to be tested by sound clinical trials. In many countries, TM and CAM applications are provided outside the national health system. Since the philosophy of CAM therapies is often seen as the mobilization of self-healing, there is a perception that they are safe. Due to this perception, volunteers can easily be found. These people do not think that they may be exposed to serious side effects during the research process. Side effects seen in CAM studies should be reported to the relevant authorities. As pointed out in many international documents (e.g., Helsinki Declaration, Article 12), medical research on volunteers should only be carried out by individuals with adequate ethical and scientific education, training, and qualifications. Research on patients or healthy volunteers should be conducted under the supervision of a competent and qualified physician or other healthcare professional.
In any biomedical research on humans, the risks and burdens that participants may be exposed to and the possible benefits from the research must be balanced. Possible risks and burdens should always be minimal. This important rule stems from the principle of ethics that requires not to harm but to be useful. In studies involving interventions that may directly benefit the participant, higher risk and burden is acceptable. The potential risks that participants face can be not only physical but also psychological or social. Likewise, the possible benefits of the research to the participant may be of palliative as well as having a therapeutic nature [26].
According to the Nuremberg codes announced in 1947, the level of the risk to be taken in an experiment should never be more than the level to be determined according to the importance of solving the problem under the experiment for humanity. Appropriate measures should be taken to protect the subjects against low injury, disability, and possible death, and necessary environment and equipment should be provided. According to Articles 16, 17, and 18 under the Risk, Disadvantages, and Benefits heading of the Helsinki Declaration, before each medical research on humans, the estimated dangers and disadvantages that the research may cause compared to the benefits to be gained by the individuals or groups participating in the study of other individuals or groups who are affected by the disease that is the subject of the research should be carefully evaluated. Unless physicians make sure that risks are adequately assessed and they are satisfactorily addressed, they cannot participate in studies on human volunteers. According to the Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine, the dangers that the subjects of the research may be exposed to should not be disproportionate to the expected benefits of the research. Products such as plant extracts used in CAM research are likely to be pharmacologically complex. This may increase potential harm in research that tests to combine many compounds into a single product.
Use of Hirudo medicinalis has been a commonly used treatment method since sixth century BC. Some of the enzymes present in Hirudo medicinalis’ saliva (e.g., calin, eglin, acetylcholine, and hyaluronidase) show anticoagulant, vasodilator, and anti-inflammatory effects. In many countries, Hirudo medicinalis is used in plastic surgery, traumatology, neurology, and ophthalmology fields. Point of application of Hirudo medicinalis can be chosen in different ways (for example, around the wound site, above the painful area). Researchers also try to make stimulating effects from on top of the acupuncture points [27]. Lack of a specific standard for TM and CAM research makes it difficult to address and assess the differences between practitioners and the risk-benefit ratio [28].
Without the involvement of researchers and host communities, a study is unlikely to have a lasting effect in developing countries. Without the investment of health policymakers, research results are unlikely to affect policymaking and scarce resource allocation. In almost all of the research, there is a collaborative communication between sponsors, policymakers, and research groups. In TM and CAM research, it is not always possible to predict the permanent effects of the research in question at the outset. It is difficult to be a stakeholder in the use of scarce resources without the investments of health policymakers. Emphasizing the importance of the health problem, evaluating the contribution of the research to the society, and planning, carrying out, and publishing the research all require cooperation. Controlled clinical trials, one of the ways to access scientifically proven information, always need a competent and adequate research team with professional experience for the research. These studies are always carried out with a multidisciplinary approach. In this process, the follow-up of the volunteer participants can be maintained healthily with the work share plan within the research team. Records of the research can be taken and maintained following a protocol. Different situations arising during the research can be evaluated on time. In research based on compliance with patient rights, the safety of the patient and volunteer participants is ensured. The security profile of the applications can be followed. Patient and voluntary participant training can be maintained.
In addition to the abovementioned benefits of collaboration concerning clinical trials, there is also the opportunity that research results can be reviewed and they can be returned to the health sector as an investment. Cooperation is also inevitable for the population, in which the research has been conducted, to be able to obtain the expected benefit from the results, and to carefully follow the intellectual property rights and copyrights in the publication of the research report [29].
Human dignity is still an up to date topic as it has been in every period. As Baranzke [30] puts it, “biomedical ethics debates have raised a growing awareness that medicine may have a side that can violate human rights.” Meeting people’s health needs is a prerequisite for a dignified life. The existence of human dignity and what it means cannot be clearly understood anywhere other than extraordinary situations where it is seriously damaged [30]. Alan Gewirt bases human dignity on the person’s opportunity to make a choice and take action based on these choices. Actions have two founding conditions and specific characteristics. Freedom is based on the control of the action performed by the person with all the information they need without any coercion. Happiness, on the other hand, can be described as the knowledge of having the skills and conditions necessary to fulfill various goals [31].
The right of the person, which is in parallel with the development of basic human rights, to make decisions about themselves, the right to determine their own destiny, has made up the rationale for a new ethical assignment to the physician in terms of giving the necessary information to the person to make an informed choice.
Informed consent can be considered as a concrete indicator of trust-based communication between physician/researcher and patient/volunteer participants. The informed consent is also an official document on the right of the patients/volunteer participants to determine their own future. It helps the communication between physician/researcher and patient/volunteer participants to conform to the law. Current literature focuses on research in which volunteering cannot be achieved in providing informed consent [32]. After the Second World War, Nuremberg Codes were developed to fill the legal and ethical gaps regarding the experiments, due to Nazi experiments carried out on humans. According to these codes, human subjects should definitely give their consent with their free will. In other words, the person participating in the experiment must have the quality to grant consent legally, must not be exposed to any sanction, deception, lie, threat or any other restriction or pressure, must be in a state to make decisions by making free choices, must be informed about the research and have enough information to make informed decision, and must understand everything.
According to the Helsinki Declaration (Article 25), the participation of individuals who can deliver informed consent in a study should be on a voluntary basis. Although it is deemed appropriate to consult family members or community leaders, no individual with the capacity to give informed consent can be included in any research study unless they agree with their free will. This statement has special importance in TM and CAM research in terms of not harming the participants. For instance, in countries like India, clinical research is based on the perception of the disease perceived through social values and power hierarchies in the village family based on regional values and practices and cultural values. Obtaining informed consent in these settings becomes difficult due to differences in local traditions in developing countries, including India [33].
According to the United Nations Convention on Civil and Political Rights, adopted by the United Nations on 16 December 1966, which aims to protect human rights and freedoms, no one can be subjected to torture or cruel, inhuman or degrading treatment or punishment. In particular, no one can undergo medical or scientific experiments without their free consent.
Article 16 of the Convention of Human Rights and Biomedicine on the Protection of Human Rights and Human Dignity in terms of the Application of Biology and Medicine, individuals who are the subjects of research must be informed about their rights and guarantees prescribed by law for their protection, the informed consent must be given clearly and in a specific manner, and this must be documented. According to Article 3 of the European Convention on Patient Rights (Rome 2002) titled “the right to information,” each individual has the right to receive information about their health status, current health services and how they can benefit from them, and all scientific research and technological innovations.
Components of informed consent can be listed as voluntariness, autonomy, competence, clarity, and comprehensibility of the information supplied. Voluntariness is the situation where the person decides to do something with their free will for a purpose without expecting anything in return and realizes it. Respecting individual autonomy lies at the heart of volunteering. The concept of volunteering also includes the autonomy of a person and being free from compelling effects. For some people, volunteering can be defined as the presence of adequate information and the absence of psychological pressure and external restrictions.
The most important issue to consider regarding informed consent is whether the patient/volunteer has the capacity of giving consent. The orientation of capacity, informing, and consent to the authorized person is the first condition for a free and healthy will to form. In terms of medical intervention law, responsibilities such as respect for patient privacy, informing, and consent, which are accepted on the side of physicians, can be said to serve the patient to create an autonomous will.
The third article of the Categorical Imperative (act according to the principle of autonomy) refers to the self-governing of the will, which is ruled by the mind. It is not enough just to know what autonomy is. Active use of autonomy and the formation of personality will not be possible without moving to the autonomy stage. The basic condition of moral action is to be competent beyond being responsible. In any case, CAM studies are based on applications. Volunteer participants should always be at the center when investigating treatments. Additional efforts are necessary to inform these people if they have received multiple treatments and to ensure that the information provided is understood. In TM and CAM studies, therapeutic misunderstandings should be corrected and the components of belief and expectation should be taken into account in the informed consent process.
The aim of giving information is to ensure that participants are in a position to decide on their own future and to increase the cooperation ability of the patient/volunteer participant.
The Belmont Report, which defines the ethical principles of human research, emphasizes that the form and context in which information is transferred is as important as the information itself. Information about the research should be clear, understandable, and accurate. It should be given to the person in a clear and comprehensible language. A person from the research team who is responsible for obtaining informed consent should provide the information. The information to be given about the research should first clearly reveal the purpose and duration of the research. Research procedures should be explained in detail. The risks and ailments related to the research, the possible duration of these conditions, and how they will be eliminated should be explained. The benefits expected from the research, alternative approaches, records regarding the research, who will reach the records and how, and the extent of confidentiality of the records should be explained. Research involving more than minimum risk should include available medical treatments for volunteers when needed; information about where to get more information, who to consult to in case of a research-related injury, and the amount of payment/compensation to be given to volunteers; explanation of who can be contacted for answers to questions about research and rights about the research (includes the patient representative and phone number of the research center); and information that participation is voluntary, the volunteer may quit the research at any time, and that there will be no loss of rights.
The information provided to volunteer participants regarding the research to obtain informed consent should be completely understood by the patients, but it has quite a complex content. This complexity poses a major barrier for nearly a quarter of adults with low literacy skills to grasping the information supplied. Research communities are responsible for developing innovative forms of consent, which increase patients’ willingness to read and skills to understand. To speak of fully informed consent, it is important that the information provided is well understood and that the person can fully grasp what is to be done to their body and participate in the process. Readability is a language-specific concept developed in the United States (USA) in the early nineteenth century. Among the factors affecting the readability are average word length, word frequency, number of words with multiple syllables, average sentence length, number of words with multiple meanings, and average number of syllables. As the number of words in the sentence increases, the readability of a sentence decreases. Readability means full understanding of the text. Readability is highly impacted by issues such as the level of reading, the format of writing, the shortness of sentences and paragraphs, and the technical language. Therefore, to increase the readability, short sentences and paragraphs should be selected and text appropriate for the reading level should be created [34].
As a rule, the person to provide information is the person from the research team who undertakes the task of obtaining informed consent. The person to be provided with information is the person who is competent and adequate to give consent, who is invited to the research, and who meets the criteria for participation in the research. In the case of giving information and obtaining consent for the research, separate procedures are followed for children and vulnerable groups. As stated in the Helsinki Declaration, for a volunteer candidate who is deemed not having the capacity to grant an informed consent can give consent to participate in the research, an additional approval of a physician and the legal representative is necessary. If the person does not give consent, this should be respected. According to the World Medical Association, children, the family, and the legal representative have the right to actively participate in the medical practice decisions [35].
Pediatricians must take medical responsibility as a responsible researcher or assistant researcher in any research on children. One of the main points of Helsinki Criteria is that physicians who are specialists in the research topic take part in scientific research on people. Pediatricians should be included in the team in all studies on children. Responsibilities awaiting pediatricians who will take part in this matter are discussed in other approaches.
The provision of information about the research should be done during the process of the invitation of the volunteers to the research without time pressure, and the volunteer should be given some time to decide.
In Turkey, the frequency of use of TM and CAM applications in the general population and the distribution rate by methods are not known. Also, a few available studies include specific patient groups.
The first regulation governing traditional and complementary medicine practices in Turkey was the “Regulation of Acupuncture Treatment,” which was published in 1991. The Department of Traditional, Complementary and Alternative Medicine Practices was established in 2012 under the Ministry of Health. It was renamed as the Department of Traditional and Complementary Medicine Practices in 2014, and the Regulation on Traditional and Complementary Medicine was published in the Official Gazette with the date October 27, 2014, and issue 29158. The regulation involves the definition of 15 traditional and complementary medicine applications (acupuncture, apitherapy, phytotherapy, hypnosis, leech applications, homeopathy, chiropractic, cup application, larva application, mesotherapy, osteopathy, prolotherapy, ozone application, reflexology, and music therapy). It also includes the personnel who can perform these applications, indication/contraindication, and materials to be found at the application center [36].
Regulation on Traditional and Complementary Medicine Practices Clinical Research was published in the Official Gazette with the date March 9, 2019 and issue 30709. The purpose of this Regulation is to regulate the principles and procedures for conducting scientific research on people and protecting the rights of volunteers in the fields of traditional and complementary medicine within the framework of international agreements and good clinical practices. This regulation covers clinical studies on medicine, medicinal and biological products on humans, and clinical studies with cosmetic products and raw materials; observational drug studies; clinical studies of medical devices; stem cell clinical studies; noninterventional clinical studies; and traditional and complementary medicine applications. In cases where the research topic directly concerns children or is a clinical condition that can only be examined in children, or data obtained as a result of research on adult individuals have to be validated in children, the research is delivered to the assessment of the ethics committee after a child psychiatry specialist and/or child health and diseases specialist at the university or training and research hospital gives a positive opinion of the research on children if the research does not pose a predictable risk for the health of volunteers and there is a general medical opinion that the research will provide direct benefit to volunteers. Apart from children, another group of vulnerable—easily affected—subjects is pregnant, postpartum, or lactating women. In cases where the topic of the research is directly related to pregnant, postpartum, or lactating women or is a clinical condition that can only be examined in these women, and the research does not pose a predictable risk for the volunteer and the fetus or the infant, and there is a general medical opinion that the research will directly benefit the volunteers, then research on pregnant, postpartum, and lactating women may be allowed provided that the general research principles are followed. In cases where the subject of the research is directly related to the persons with limitations or is a condition that can only be examined in people with limitations, or where the current treatment options related to the disease of the person with limitations have completely been exhausted, the research does not pose a predictable risk for the health of the person with limitation, and there is a general medical opinion that research will provide a direct benefit to the people with limitations, then people with limitations can be the participants of TM and CAM research. The aforementioned regulation covers the provisions for starting, executing, stopping, and terminating the research, the responsibilities of the responsible researchers and supporters, and the details of the research product. Where and how the adverse events or serious adverse reactions will be reported detail the confidentiality of research records.
Good clinical practice, which is based on the principles of the current Helsinki Declaration, is an ethical and scientific quality standard for the design, execution, recording, and reporting of clinical trials on humans.
Good clinical practice assures the society that the rights, health, and privacy of the volunteers participating in the research are protected and that the data obtained from the research are reliable. The purpose of the Good Clinical Practices Guide is to provide a single standard to facilitate the international mutual acceptance of clinical data. Traditional and Complementary Medicine Practice Good Clinical Practice Manual (May 14, 2019) guides the collection of clinical data to be presented to the Health Services General Directorate and of their respective ethics committees and explains the details and principles of the traditional and complementary medicine practices clinical research that is carried out or scheduled to be conducted in Turkey [37].
Whether volunteer’s participation will is accepted or not, these subjects are individuals whose free decision-making willpower can be affected due to the expectation of benefit of participation or the expectation of retaliation by individuals in a hierarchical structure if they refuse to participate. The examples of these individuals include people who are in a certain hierarchical structure such as medical, pharmacy, dentistry, and nursing students; hospital or laboratory staff working in the research setting; those working in the pharmaceutical industry; members of the armed forces; and soldiers and detainees. Also, the group involves patients with an incurable disease; those who live in nursing homes; unemployed or poor people; people who need urgent medical attention; and children or people who cannot give consent. Clinical research is defined as studies conducted on humans to reveal or confirm the clinical or pharmacological effects of one or more research products or traditional and complementary medicine methods, to identify adverse events or reactions, and to investigate their safety and efficacy. In scientific, medical, and ethical terms, TM and CAM research is evaluated in ethics committees assembled according to the Regulation on Traditional and Complementary Medicine Practices Clinical Research. According to the current legislation in Turkey, ethics committee members are required to receive basic training on good clinical practices and clinical research before starting to work in these boards. If possible, an equal gender distribution among members should be provided in ethics committees.
Development of good empirical practices have been guiding ethical discussions and specifying a normative approach and framework for human research at the same time. CAM field necessitates evidence-based results on clinical research. Due to their approaches of preventing illnesses and providing treatment that have been preferred by many individuals, TM and CAM practices and research are expected to progress. Clinical research is essential in ensuring medical advances, and it establishes the bond between theory and practice in the field of medicine. In addition to determining effectiveness of a treatment, strength of the evidences on the medical application should be evaluated. The right path with CAM and TM clinical research and practices would include not to disacknowledge them, but to pave the way for the scientific research on the ones that have the potential to be beneficial and to bring the proven benefits to modern medicine. One challenge with these practices would be the fact that a considerable amount of CAM and TM data are not systematic and standardized, which have made them difficult to scientifically accept. In order to assist the international acceptance of CAM and TM data to pave the way for CAM and TM databases, meta-analyses and so on, good clinical practice guides being made specific to these areas is essential. For all human research, informed consent must be obtained from the voluntary participants. Throughout this process, it is imperative to show respect to participants’ dignity, to omit forcing potential voluntary participants in any pecuniary and nonpecuniary way, to care on their confidentiality, and to pay utmost attention on privacy of their data. New treatment procedures and medications as results of clinical research are for public welfare, but the benefit of the voluntary participant must be prioritized.
When it comes to CAM and TM clinical research, a framework to their ethical evaluation is suggested herein. For clinical research on CAM and TM, legal arrangements are necessary regardless of geographical region, belief and cultural differences. Ethical committees for clinical practices and researches should be established specifically for CAM and TM research. In these committees, physicians from different fields of specialization who participated in clinical research conducted according to good clinical practices, physicians having expertise on CAM and TM, legal experts with specialization on medical law and patients’ rights, pharmacology and pharmacognosy specialists, along with medical ethics and public health experts. Instructions should be prepared to cover how these committees to work and make decisions; number of members and their employment periods, duties and authorities in these committees; how the applications to these committees are to be done, and how the decisions are to be delivered to the researcher(s); within the legal framework of the countries that the ethical committees belong to.
The author declares that there is no conflict of interest.
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