2.1 Cultural Safety

The concept of cultural safety arose in New Zealand in 1988 from nursing education leadership as a response to the recruitment and retention issues facing Māori nurses (Nursing Council of New Zealand 2011). Ramsden (2002) proposed three steps in the development of culturally safe practices. This included (i) cultural awareness, defined as the understanding that differences exist, (ii) cultural sensitivity, defined as accepting the legitimacy of these differences and reflecting on the impact providers life experience may have and their positioning on others, (iii) cultural safety, which is an outcome that provides safe service and is defined by those that receive the service (Ramsden 2002). Curtis et al. (2019) state cultural safety requires healthcare professionals and organisations to reflect on how their own culture, biases, and assumptions impact care delivery. It involves ongoing self-awareness, accountability, and a commitment to reducing bias and achieving health equity. Culturally safe care is defined by individuals and their communities and measured by progress towards health equity (Curtis et al. 2019).

Since Ramsden, cultural safety has been applied to healthcare contexts on a global scale. For example, the Canadian Indigenous Nurses Association (CINA) and the First Nations Health Authority (FNHA) in British Columbia both work to promote cultural safety in nursing practice for First Nations peoples (Aboriginal Nurses Association of Canada [ANAC] 2009; FNHA 2024). In Australia, organisations such as the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM) and National Aboriginal Community Controlled Health Organisation (NACCHO) have been instrumental in promoting cultural safety as a core competency for healthcare professionals working with First Nations communities (Australian Institute of health and Welfare [AIHW] 2023). Incorporation of cultural safety in health research involving First Nations populations ensures that cultural, spiritual, and historical contexts are respected and incorporated throughout the research. By understanding and acknowledging cultural safety principles researchers can approach research with sensitivity and cultural humility to ensure that their work respects and aligns with the values, traditions, and ways of knowing of the communities the research aims to serve.

2.2 Historical Context of Research

Literature highlights the significance of conducting health research with First Nations peoples in a respectful manner, raising crucial ethical considerations regarding the involvement of First Nations peoples in research and the incorporation of First Nations belief systems, spiritual frameworks, and worldviews (Smith 2012; Gilbert 2021). However, this has not always been the case when conducting research involving First Nations peoples. Throughout the history of colonisation, research has been used as a tool of power and control, utilised to validate and perpetuate injustices against First Nations peoples (Kennedy et al. 2022). For example, medical research was used to justify the assimilation of “Mixed Blood” children into Western society during the Australian Stolen Generation. Similarly, racial classification and skull measurements were employed to support the notion that Western colonists were superior to First Nations populations (Australian Human Rights Commission 1997; Buchan and Andersson Burnett 2019). Examples like this highlight how historical research involving First Nations peoples has been grossly misused with a violation of research ethics principles as they are known in the present day. While this exploitation of the research ethics process may have originated from a position of ignorance or arrogance, through selective interpretation, Western research continues to perpetuate the dispossession of land, cultural identity, and systemic oppression for many First Nations peoples.

Unfortunately, even in post-colonialism times, research ethics processes have not advocated for the needs of First Nations peoples. Some research involving First Nations peoples has not been conducted in an ethically sensitive manner. It has remained exploitative, where First Nations peoples and their knowledge have been portrayed as instruments of interest and utility which serve the purpose of generating knowledge and empowerment often solely for the advantage of non-First Nations researchers (Morris et al. 2023; Bainbridge et al. 2015). These research approaches have treated First Nations communities, individuals, and knowledge they possess as subjects of curiosity, to be discovered and exploited, rather than recognising and respecting First Nations peoples as holders of this valuable knowledge deserving of acknowledge and respect (Kwaymullina 2016). The concept of epistemic injustice, particularly testimonial and hermeneutical injustices discussed by Fricker (2007) offers a valuable framework for understanding this exploitation of First Nations knowledge. Testimonial injustice involves prejudice that devalues First Nations narratives in academic settings while hermeneutical injustice occurs when there are gaps in collective interpretive resources, leading to the marginalisation of First Nations knowledge systems and holistic worldviews. This specific injustice means First Nations ways of knowing are often misunderstood or ignored because they do not fit Western frameworks, resulting in their exploitation without proper recognition or benefit-sharing, thus reinforcing colonial power dynamics (Fricker 2007).

2.3 Exploitive Research on a Global Scale

Unfortunately, exploitative research practices persist globally, often disregarding established ethical principles. According to the World Health Organisation (WHO), core research ethics principles encompass respect for persons, beneficence, and justice, necessitating informed consent, maximising benefits, minimising harm, and ensuring equitable distribution of research benefits and burdens (WHO 2011). The European Union Horizon 2020 framework recently coined the term ‘ethic dumping’ which refers to the practice of conducting unethical research that would be considered unethical in one country or context and transferring it to another country or context with less stringent ethical regulations. Ethics dumping takes advantage of marginalised populations in research activities that would be prohibited or highly regulated, for example, from higher-income to lower-income settings (Schroeder et al. 2019). Examples of ethics dumping may include conducting clinical trials without informed consent, using human subjects for dangerous or risky experiments without appropriate safeguards, or exploiting lax regulations to carry out unethical research practices. Ethics dumping undermines the principles of research ethics and the protection of human rights and can lead to harm and exploitation of individuals and communities. This notion highlights the power structures systemically in place that are still being used to exploit populations and their knowledge (Schroeder et al. 2019).

In Western countries, such as Australia, ethical regulations on research have improved the approach of working with First Nations people. However, many ethical applications or research involving First Nations peoples often still fail to approach research from a First Nations standpoint as opposed to a Western structure of how ethics and the attainment of knowledge may be conducted. First Nations Australians are often regarded as some of the most researched people in the world; however, this extensive research has not consistently translated into proportional improvements in health, well-being, or social standing for First Nations Australians (Bainbridge et al. 2015). This introduces the question of whether current research approaches in Australia are necessary or beneficial for First Nations peoples and whether there are still systemic barriers in place that support the exploitation of First Nations peoples and knowledges.

Exploitive research supported by systemic and structural racial ideology has been conducted on a global scale. While First Nations people globally have faced similar exploitation, these ideologies also create power structures that affect other colonised groups. The thalidomide trials in West Africa saw colonised pregnant women subjected to trials that led to birth defects, while the Nigerian Trovan trials resulted in the deaths of several children, with many of their parents unaware that their children were even part of an experimental drug study (Lenzer 2006). These are clear unethical and exploitive research studies; however, exploitative research can also take a more hidden form in the extraction of genetic data from populations without consent, or the exploitive nature of traditional knowledges without recognition of the sources of this knowledge (Australian Humans Rights Commission 2002; Janke 2018). Lessons need to be learned to prioritise informed consent, respect for cultural knowledge, and equitable treatment in research to prevent further exploitation and harm.

2.4 Data Sovereignty

Data sovereignty emphasises the inherent right of First Nations peoples and communities to govern and control their own data, ensuring that it aligns with their cultural values, priorities, and self-determination aspirations (Bodkin-Andrews et al. 2019). In health research, the exploitation of First Nations knowledges is evident in the appropriation of this knowledge without proper acknowledgment of ownership, effectively depriving First Nations individuals and communities of their rightful recognition (Hummel et al. 2021). First Nations healing practices and medicinal knowledge have often been appropriated by external researchers without proper acknowledgment or consultation with First Nations communities (Ruckstuhl et al. 2023). Furthermore, research conducted on First Nations health issues has often been conducted without the meaningful involvement or consent of First Nations peoples and communities, resulting in studies that may not accurately reflect their needs, priorities, or produce improvements in health (O'Brien et al. 2022). The concept of data sovereignty is crucial in this context, as it asserts First Nations peoples' rights to control the collection, use, and dissemination of health-related data and knowledge (Hummel et al. 2021). Biopiracy is another concept to be aware of when discussing data sovereignty in research. Biopiracy is when First Nations knowledges are extracted for research, development, and profit without reciprocal authorisation or compensation to First Nations communities to recognise their knowledges (Lochner and Robinson 2021). The following examples demonstrate biopiracy and lack of recognition of First Nations knowledges in health research.

2.5 The Story of the Four Corners Outbreak

In the Spring of 1993, a health outbreak unfolded in the Four Corners region of the Navajo Nation. After 12 deaths and a 50% mortality rate, multiple laboratory examinations proved unsuccessful in recognising the pathogen responsible (Centre of Disease Control and Prevention, [CDC] 2020). However, Navajo Elders in the region had oral traditions that told of a similar illness that had happened in the past. These stories talked about how sickness struck after excessive rainfall leading to an increased crop in piñon pine nuts, which then led to an increase in local rodent populations (MacDonald 2018). These stories told of bad luck and illness associated with the increase in rodents (Fimrite 2012). With this information, Western researchers were able to link increased rainfalls in the region to El Niño. This increase in rainfall led to an increase of rodent populations which inevitably spread Hantavirus throughout the region. Traditional oral legend told by Navajo Elders was the key to treating this outbreak and saving lives. To this day, the CDC pays little recognition to the Navajo Elders as the traditional knowledge keepers of this discovery (CDC 2020; MacDonald 2018).

2.6 Pacific Yew Cures Cancer

In the 1960s, the National Cancer Institute (NCI) initiated a screening program to identify potential anti-cancer agents from natural sources. Researchers isolated a compound from the bark of the Pacific yew tree (Taxus brevifolia) during this screening process. This compound, later named Taxol, demonstrated promising anti-cancer properties in laboratory tests (Cech and Oberlies 2023). However, this discovery was not new. First Nations groups in the region such as the Swinomish, Sts'ailes, Tsimshian, and Cowlitz people have been using Pacific yew to treat physical ailments including cancer for generations prior to Western discovery and trademark (Reynolds 2022). After billions of dollars in profit from the sales of Taxol, traditional owners of this knowledge have not been acknowledged (Chacko and Sambuc 2003).

2.7 Exploitation of the Kakadu Plum

The Kakadu plum has been utilised by First Nations communities such as the Bardi, Nyul Nyul, Goolarabalooi, and Yawuru of North-Western Australia for its medicinal and nutritional benefits (Botsman 2018). It has gained widespread and international recognition for its high vitamin C content and antioxidant properties. Mary Kay, a cosmetic company from the United States (US), attempted to patent the ingredients from the Kakadu plum, stating it had never been used for cosmetic formulations before. After challenges from Professor Robinson and the Gundjeihmi Aboriginal corporation, a representative of the Mirrar people of West Arnhem Land, Mary Kay's patent application was withdrawn (Janke 2018). However, Mary Kay filed and successfully obtained US patents for properties taken directly from the Kakadu plum without involvement or recognition of any First Nations community supplying the Kakadu plum (Janke 2018).

These examples are just a few in the many instances where traditional First Nations knowledge has been taken without acknowledgement of the original source of knowledge. Examples such as these lead to exploitation that can affect First Nations access to employment and economic development (Carroll 2017). This emphasises the urgent need to reform research ethics practices when working with First Nations peoples. Researchers must learn from instances of epistemic injustice and ensure that their practices prioritise the acknowledgment and protection of First Nations knowledge. By doing so, researchers can contribute to more equitable and respectful research relationships with First Nations communities.

2.8 Ethical Review Processes and Barriers

2.9 Moving Forward

Barriers continue to exist when applying First Nations methodologies in a Western research setting. The idea of integrating Indigenous methodologies and ways of knowing, doing, and being into Western research and ethical framework approaches positions First Nations knowledges and methodologies as complementary to Western research as opposed to a standalone approach. This viewpoint creates an environment whereby First Nations researchers must adapt their methodologies and knowledges to succeed within a Western model of research. It is often the responsibility of First Nations researchers, or researchers who chose to use Indigenous methodology to educate Western researchers or ethical panels about the legitimacy of Indigenous research methodologies. Often, this integration involves aligning these methodologies with Western frameworks of research or ethics.

In order to address these barriers within research, First Nations knowledges and Indigenous methodologies need to be viewed as standalone approaches to research with the same credibility as Western counterparts. This approach helps decolonise current research by challenging dominant Western paradigms to foster a more culturally safe and equitable approach to research. Factors incorporated into Indigenous methodologies are not only beneficial in research with First Nations peoples. Concepts such as respect, reciprocity, and responsibility which are essential components of First Nations research have applications in Western models of ethics and research (Williams and Shipley 2023).

2.10 Tool to Guide Researchers to Conduct Ethically Sensitive and Culturally Safe Research

The following section of this paper provides a tool kit to audit and check inherent biases that might exist when undertaking research with First Nations communities. The tool shown in Table 1 aims to promote a First Nations standpoint as a philosophical position to aid in the evaluation of ethics that underpin research design and implementation. The goal of this tool is to help researchers identify where research design may be biased towards Western ideologies and help to promote reflective research practices that help to strengthen the trustworthiness of the research outcomes while ensuring the research is beneficial to the target population without being exploitative. The tool has been adapted from concepts established from various sources (Bessarab and Ng'andu 2010; Brunger et al. 2021; Gilbert 2021; NHRMC 2023; Smith 2012).