What makes clinical research ethical?

Many believe that informed consent makes clinical research ethical. However, informed consent is neither necessary nor sufficient for ethical clinical research. Drawing on the basic philosophies underlying major codes, declarations, and other documents relevant to research with human subjects, we propose 7 requirements that systematically elucidate a coherent framework for evaluating the ethics of clinical research studies: (1) value-enhancements of health or knowledge must be derived from the research; (2) scientific validity-the research must be methodologically rigorous; (3) fair subject selection-scientific objectives, not vulnerability or privilege, and the potential for and distribution of risks and benefits, should determine communities selected as study sites and the inclusion criteria for individual subjects; (4) favorable risk-benefit ratio-within the context of standard clinical practice and the research protocol, risks must be minimized, potential benefits enhanced, and the potential benefits to individuals and knowledge gained for society must outweigh the risks; (5) independent review-unaffiliated individuals must review the research and approve, amend, or terminate it; (6) informed consent-individuals should be informed about the research and provide their voluntary consent; and (7) respect for enrolled subjects-subjects should have their privacy protected, the opportunity to withdraw, and their well-being monitored. Fulfilling all 7 requirements is necessary and sufficient to make clinical research ethical. These requirements are universal, although they must be adapted to the health, economic, cultural, and technological conditions in which clinical research is conducted. JAMA. 2000;283:2701-2711.

Medical ethics: four principles plus attention to scope

The "four principles plus scope" approach provides a simple, accessible, and culturally neutral approach to thinking about ethical issues in health care. The approach, developed in the United States, is based on four common, basic prima facie moral commitments--respect for autonomy, beneficence, nonmaleficence, and justice--plus concern for their scope of application. It offers a common, basic moral analytical framework and a common, basic moral language. Although they do not provide ordered rules, these principles can help doctors and other health care workers to make decisions when reflecting on moral issues that arise at work.

Career Benefits Associated With Mentoring for Proteges: A Meta-Analysis

Meta-analysis was used to review and synthesize existing empirical research concerning the career benefits associated with mentoring for the protégé. Both objective (e.g., compensation) and subjective (e.g., career satisfaction) career outcomes were examined. Comparisons of mentored versus nonmemored groups were included, along with relationships between mentoring provided and outcomes. The findings were generally supportive of the benefits associated with mentoring, but effect sizes associated with objective outcomes were small. There was also some indication that the outcomes studied differed in the magnitude of their relationship with the type of mentoring provided (i.e. career or psychosocial).

Cues of being watched enhance cooperation in a real-world setting

We examined the effect of an image of a pair of eyes on contributions to an honesty box used to collect money for drinks in a university coffee room. People paid nearly three times as much for their drinks when eyes were displayed rather than a control image. This finding provides the first evidence from a naturalistic setting of the importance of cues of being watched, and hence reputational concerns, on human cooperative behaviour.

Physician recommendations and patient autonomy: finding a balance between physician power and patient choice

Medical care in the United States has rapidly moved away from a paternalistic approach to patients and toward an emphasis on patient autonomy. At one extreme end of this spectrum is the "independent choice" model of decision making, in which physicians objectively present patients with options and odds but withhold their own experience and recommendations to avoid overly influencing patients. This model confuses the concepts of independence and autonomy and assumes that the physician's exercise of power and influence inevitably diminishes the patient's ability to choose freely. It sacrifices competence for control, and it discourages active persuasion when differences of opinion exist between physician and patient. This paper proposes an "enhanced autonomy" model, which encourages patients and physicians to actively exchange ideas, explicitly negotiate differences, and share power and influence to serve the patient's best interests. Recommendations are offered that promote an intense collaboration between patient and physician so that patients can autonomously make choices that are informed by both the medical facts and the physician's experience.

Principles of Clinical Ethics and Their Application to Practice

An overview of ethics and clinical ethics is presented in this review. The 4 main ethical principles, that is beneficence, nonmaleficence, autonomy, and justice, are defined and explained. Informed consent, truth-telling, and confidentiality spring from the principle of autonomy, and each of them is discussed. In patient care situations, not infrequently, there are conflicts between ethical principles (especially between beneficence and autonomy). A four-pronged systematic approach to ethical problem-solving and several illustrative cases of conflicts are presented. Comments following the cases highlight the ethical principles involved and clarify the resolution of these conflicts. A model for patient care, with caring as its central element, that integrates ethical aspects (intertwined with professionalism) with clinical and technical expertise desired of a physician is illustrated.

Clinical trials and medical care: defining the therapeutic misconception

A key component of informed consent to participate in medical research includes understanding that research is not the same as treatment.

Procreative beneficence: why we should select the best children

Eugenic selection of embryos is now possible by employing in vitro fertilization (IVF) and preimplantation genetic diagnosis (PGD). While PGD is currently being employed for the purposes of detecting chromosomal abnormalities or inherited genetic abnormalities, it could in principle be used to test any genetic trait such as hair colour or eye colour. Genetic research is rapidly progressing into the genetic basis of complex traits like intelligence and a gene has been identified for criminal behaviour in one family. Once the decision to have IVF is made, PGD has few 'costs' to couples, and people would be more inclined to use it to select less serious medical traits, such as a lower risk of developing Alzheimer Disease, or even for non-medical traits. PGD has already been used to select embryos of a desired gender in the absence of any history of sex-linked genetic disease. I will argue that: (1) some non-disease genes affect the likelihood of us leading the best life; (2) we have a reason to use information which is available about such genes in our reproductive decision-making; (3) couples should select embryos or fetuses which are most likely to have the best life, based on available genetic information, including information about non-disease genes. I will also argue that we should allow selection for non-disease genes even if this maintains or increases social inequality. I will focus on genes for intelligence and sex selection. I will defend a principle which I call Procreative Beneficence: couples (or single reproducers) should select the child, of the possible children they could have, who is expected to have the best life, or at least as good a life as the others, based on the relevant, available information.

Disclosing individual genetic results to research participants

Investigators and institutional review boards should integrate plans about the appropriate disclosure of individual genetic results when designing research studies. The ethical principles of beneficence, respect, reciprocity, and justice provide justification for routinely offering certain results to research participants. We propose a result-evaluation approach that assesses the expected information and the context of the study in order to decide whether results should be offered. According to this approach, the analytic validity and the clinical utility of a specific result determine whether it should be offered routinely. Different results may therefore require different decisions even within the same study. We argue that the threshold of clinical utility for disclosing a result in a research study should be lower than the threshold used for clinical use of the same result. The personal meaning of a result provides additional criteria for evaluation. Finally, the context of the study allows for a more nuanced analysis by addressing the investigators' capabilities for appropriate disclosure, participants' alternative access to the result, and their relationship with the investigators. This analysis shows that the same result may require different decisions in different contexts.

Bad but Bold: Ambivalent Attitudes Toward Men Predict Gender Inequality in 16 Nations

A 16-nation study involving 8,360 participants revealed that hostile and benevolent attitudes toward men, assessed by the Ambivalence Toward Men Inventory (P. Click & S.T. Fiske, 1999), were (a) reliably measured across cultures, (b) positively correlated (for men and women, within samples and across nations) with each other and with hostile and benevolent sexism toward women (Ambivalent Sexism Inventory, P. Click & S.T. Fiske, 1996), and (c) negatively correlated with gender equality in cross-national comparisons. Stereotype measures indicated that men were viewed as having less positively valenced but more powerful traits than women. The authors argue that hostile as well as benevolent attitudes toward men reflect and support gender inequality by characterizing men as being designed for dominance.

Forgiveness, forbearance, and time: the temporal unfolding of transgression-related interpersonal motivations

The investigators proposed that transgression-related interpersonal motivations result from 3 psychological parameters: forbearance (abstinence from avoidance and revenge motivations, and maintenance of benevolence), trend forgiveness (reductions in avoidance and revenge, and increases in benevolence), and temporary forgiveness (transient reductions in avoidance and revenge, and transient increases in benevolence). In 2 studies, the investigators examined this 3-parameter model. Initial ratings of transgression severity and empathy were directly related to forbearance but not trend forgiveness. Initial responsibility attributions were inversely related to forbearance but directly related to trend forgiveness. When people experienced high empathy and low responsibility attributions, they also tended to experience temporary forgiveness. The distinctiveness of each of these 3 parameters underscores the importance of studying forgiveness temporally.

Blatant benevolence and conspicuous consumption: when romantic motives elicit strategic costly signals

Conspicuous displays of consumption and benevolence might serve as "costly signals" of desirable mate qualities. If so, they should vary strategically with manipulations of mating-related motives. The authors examined this possibility in 4 experiments. Inducing mating goals in men increased their willingness to spend on conspicuous luxuries but not on basic necessities. In women, mating goals boosted public--but not private--helping. Although mating motivation did not generally inspire helping in men, it did induce more helpfulness in contexts in which they could display heroism or dominance. Conversely, although mating motivation did not lead women to conspicuously consume, it did lead women to spend more publicly on helpful causes. Overall, romantic motives seem to produce highly strategic and sex-specific self-presentations best understood within a costly signaling framework.

To tell the truth, the whole truth, may do patients harm: the problem of the nocebo effect for informed consent

The principle of informed consent obligates physicians to explain possible side effects when prescribing medications. This disclosure may itself induce adverse effects through expectancy mechanisms known as nocebo effects, contradicting the principle of nonmaleficence. Rigorous research suggests that providing patients with a detailed enumeration of every possible adverse event-especially subjective self-appraised symptoms-can actually increase side effects. Describing one version of what might happen (clinical "facts") may actually create outcomes that are different from what would have happened without this information (another version of "facts"). This essay argues that the perceived tension between balancing informed consent with nonmaleficence might be resolved by recognizing that adverse effects have no clear black or white "truth." This essay suggests a pragmatic approach for providers to minimize nocebo responses while still maintaining patient autonomy through "contextualized informed consent," which takes into account possible side effects, the patient being treated, and the particular diagnosis involved.

A critique of principlism

The authors use the term "principlism" to refer to the practice of using "principles" to replace both moral theory and particular moral rules and ideals in dealing with the moral problems that arise in medical practice. The authors argue that these "principles" do not function as claimed, and that their use is misleading both practically and theoretically. The "principles" are in fact not guides to action, but rather they are merely names for a collection of sometimes superficially related matters for consideration when dealing with a moral problem. The "principles" lack any systematic relationship to each other, and they often conflict with each other. These conflicts are unresolvable, since there is no unified moral theory from which they are all derived. For comparison the authors sketch the advantages of using a unified moral theory.

On the Benefits of Giving as Well as Receiving Autonomy Support: Mutuality in Close Friendships

Two studies examined autonomy support within close friendships. The first showed that receiving autonomy support from a friend predicted the recipient’s need satisfaction within the relationship and relationship quality as indexed by emotional reliance, security of attachment, dyadic adjustment, and inclusion of friend in self and that there was significant mutuality of receiving autonomy support and of each other variable. The relations of perceived autonomy support to need satisfaction and relationship quality held for both female-female and male-male pairs across the two studies. The second study replicated and extended the first, showing that receiving autonomy support also predicted psychological health. Furthermore, giving autonomy support to a friend predicted the givers’ experience of relationship quality over and above the effects of receiving autonomy support from the friend. When both receiving and giving autonomy support competed for variance in predicting well-being, giving, rather than receiving, autonomy support was the stronger predictor.

Ethnic minority older adults participating in clinical research: developing trust

OBJECTIVE

African American, Latino, and American Indian older adults are underrepresented in clinical research studies. A significant barrier to participation in research is mistrust of the scientific community and institutions. The aims of this article are to discuss the lack of representation of ethnic minorities in clinical research.

METHODS

This article presents a review of the literature regarding medical research mistrust. Also described are the trust-building activities of the Resource Centers on Minority Aging Research (RCMAR), federally funded centers focused on research and aging in communities of color.

DISCUSSION

The RCMAR centers are building trust with the communities they serve, resulting in the recruitment and retention of ethnic minority older adults in clinical research studies and health promotion projects. Implications are discussed for other researchers toward building trust with ethnic minority elders to increase their participation in research.

Nonabandonment: a central obligation for physicians

Nonabandonment is one of a physician's central ethical obligations; it reflects a longitudinal commitment both to care about patients and to jointly seek solutions to problems with patients throughout their illnesses. The depth of this commitment may vary depending on the physician's and the patient's values and personalities, their shared experiences, and the patient's clinical circumstances. Traditional principled ethical analyses must balance the personal histories, values, motivations, and intentions of the participants with more general considerations. Such analyses often focus on a particular act, isolated in time, and yet the consequences of one decision immediately lead to a new set of choices. Nonabandonment places the physician's open-ended, long-term, caring commitment to joint problem solving at the core of medical ethics and clinical medicine. There is a world of difference between facing an uncertain future alone and facing it with a committed, caring, knowledgeable partner who will not shy away from difficult decisions when the path is unclear.

Competency to consent to research: a psychiatric overview

The requirement that a subject be competent as a condition of valid consent to participate in research has been accepted by most students of legal and ethical problems of human experimentation. "Competency," however, has lacked a clear and generally agreed on standard. There are four commonly used standards for competency: evidencing a choice in regard to research participation, factual understanding of the issues, rational manipulation of information, and appreciation of the nature of the situation. These standards can be arranged hierarchically such that each represents a stricter test of competency. The decision as to how rigorous a standard for competency is desirable cannot be made on psychiatric grounds. It requires consideration of the policy goals on hopes to attain. Empirical research helps demonstrate the consequences of choosing a particular standard but cannot replace the need for achieving consensus on policy goals.

Physicians do not have a responsibility to provide futile or unreasonable care if a patient or family insists

OBJECTIVE

This article was written to argue that physicians are not ethically obligated to provide care which they consider futile, unreasonable, or both, either voluntarily or in response to patient or surrogate demands.

DATA SOURCES

Data used to prepare this article were drawn from published articles, including original investigations, position papers and editorials in the author's personal files.

STUDY SELECTION

Articles were selected for their relevance to the subjects of medical ethics, the concepts of futility and medical reasonableness, case law, and healthcare reform.

DATA EXTRACTION

The author extracted all applicable data.

DATA SYNTHESIS

Physicians may feel obligated to provide care in all clinical circumstances due to the single master view of medicine and the ethical principle of autonomy. However, care may be considered futile according to several definitions of that word, including that which describes futile treatment as something that does not benefit the patient as a whole. Furthermore, care may be considered unreasonable if it is excessive and not generally agreed upon. Physician refusal to provide futile or unreasonable care is supported by the ethical principles of nonmaleficence, beneficence, and distributive justice. The last principle is particularly relevant in the current climate of healthcare reform.

CONCLUSIONS

Although the issue of physician refusal of requested care has not been resolved by case law or legal statute, it is supported by compelling ethical principles. Physicians are not ethically required to provide futile or unreasonable care, especially to patients who are brain dead, vegetative, critically or terminally ill with little chance of recovery, and unlikely to benefit from cardiopulmonary resuscitation.