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Sisk BA, DuBois J, Kodish E, Wolfe J, Feudtner C. Navigating Decisional Discord: The Pediatrician's Role When Child and Parents Disagree. Pediatrics 2017; 139:peds.2017-0234. [PMID: 28562285 PMCID: PMC5470498 DOI: 10.1542/peds.2017-0234] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2017] [Indexed: 11/24/2022] Open
Abstract
From the time when children enter the preteen years onward, pediatric medical decision-making can entail a complex interaction between child, parents, and pediatrician. When the child and parents disagree regarding medical decisions, the pediatrician has the challenging task of guiding the family to a final decision. Unresolved discord can affect family cohesiveness, patient adherence, and patient self-management. In this article, we outline 3 models for the pediatrician's role in the setting of decisional discord: deference, advocative, and arbitrative. In the deference model, the pediatrician prioritizes parental decision-making authority. In the advocative model, the pediatrician advocates for the child's preference in decision-making so long as the child's decision is medically reasonable. In the arbitrative model, the pediatrician works to resolve the conflict in a balanced fashion. Although each model has advantages and disadvantages, the arbitrative model should serve as the initial model in nearly all settings. The arbitrative model is likely to reach the most beneficial decision in a manner that maintains family cohesiveness by respecting the authority of parents and the developing autonomy of children. We also highlight, however, occasions when the deference or advocative models may be more appropriate. Physicians should keep all 3 models available in their professional toolkit and develop the wisdom to deploy the right model for each particular clinical situation.
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Statler A, Radivoyevitch T, Siebenaller C, Gerds AT, Kalaycio M, Kodish E, Mukherjee S, Cheng C, Sekeres MA. The relationship between eligibility criteria and adverse events in randomized controlled trials of hematologic malignancies. Leukemia 2016; 31:1808-1815. [DOI: 10.1038/leu.2016.374] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 10/20/2016] [Accepted: 11/02/2016] [Indexed: 12/21/2022]
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Bester J, Cole CM, Kodish E. The Limits of Informed Consent for an Overwhelmed Patient: Clinicians' Role in Protecting Patients and Preventing Overwhelm. AMA J Ethics 2016; 18:869-86. [PMID: 27669132 DOI: 10.1001/journalofethics.2016.18.9.peer2-1609] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
In this paper, we examine the limits of informed consent with particular focus on ways in which various factors can overwhelm decision-making capacity. We introduce overwhelm as a phenomenon commonly experienced by patients in clinical settings and distinguish between emotional overwhelm and informational overload. We argue that in these situations, a clinician's primary duty is prevention of harm and suggest ways in which clinicians can discharge this obligation. To illustrate our argument, we consider the clinical application of genetic sequencing testing, which involves scientific and technical information that can compromise the understanding and decisional capacity of most patients. Finally, we consider and rebut objections that this could lead to paternalism.
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Hazen R, Greenley RN, Drotar D, Kodish E. Recommending Randomized Trials for Pediatric Leukemia: Observer and Physician Report of Recommendations. J Empir Res Hum Res Ethics 2016; 2:49-56. [DOI: 10.1525/jer.2007.2.2.49] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Physicians' presentation of treatment options in a non-coercive manner is critical for informed consent for participation in randomized clinical trials (RCTs). This study examined discrepancies between observer and physician report of treatment recommendations for pediatric leukemia RCTs. This study also assessed relationships between recommendations and decisions to participate in RCTs. Participants were 104 parents of children with leukemia and the treating physicians. Measures included observations of informed consent conferences (ICCs), physician report of treatment recommendations, and parent report of trial participation. Observation revealed that physicians recommended RCTs in 38% of ICCs, while physicians reported recommending RCTs in 73% of ICCs. Treatment recommendations were unrelated to decisions to participate in RCTs. Results highlight the importance of enhancing parent-physician communication regarding RCT participation.
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Malbasa T, Kodish E, Santacroce SJ. Adolescent Adherence to Oral Therapy for Leukemia: A Focus Group Study. J Pediatr Oncol Nurs 2016; 24:139-51. [PMID: 17475980 DOI: 10.1177/1043454206298695] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This secondary qualitative analysis of extant focus group data was performed to develop an understanding of suboptimal adherence to 6-mercaptopurine therapy in adolescents with acute lymphoblastic leukemia. Six participants, aged 16 to 23 years at the time of data collection, were interviewed about their adherence to oral maintenance chemotherapy during their treatment for acute lymphoblastic leukemia. The primary aim of the study was to understand the role of adolescent development in adolescents' perception of adherence to therapy. The secondary aim was to understand how factors other than development, including the features of the disease such as its chronic nature and family involvement, can affect treatment adherence to 6-mercaptopurine. Four broad themes emerged as critical elements in adolescent adherence to oral maintenance therapy: a desire for normalcy, egocentrism, concrete thinking, and parental involvement. Incorporation of these themes into clinical practice with adolescents may help increase adherence and improve clinical outcomes.
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Sisk B, Frankel R, Kodish E, Harry Isaacson J. The Truth about Truth-Telling in American Medicine: A Brief History. Perm J 2016; 20:15-219. [PMID: 27352417 PMCID: PMC4991917 DOI: 10.7812/tpp/15-219] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Transparency has become an ethical cornerstone of American medicine. Today, patients have the right to know their health information, and physicians are obliged to provide it. It is expected that patients will be informed of their medical condition regardless of the severity or prognosis. This ethos of transparency is ingrained in modern trainees from the first day of medical school onward. However, for most of American history, the intentional withholding of information was the accepted norm in medical practice. It was not until 1979 that a majority of physicians reported disclosing cancer diagnoses to their patients. To appreciate the current state of the physician-patient relationship, it is important to understand how physician-patient communication has developed over time and the forces that led to these changes. In this article, we trace the ethics and associated practices of truth-telling during the past two centuries, and outline the many pressures that influenced physician behavior during that time period. We conclude that the history of disclosure is not yet finished, as physicians still struggle to find the best way to share difficult information without causing undue harm to their patients.
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Opel DJ, Kronman MP, Diekema DS, Marcuse EK, Duchin JS, Kodish E. Childhood Vaccine Exemption Policy: The Case for a Less Restrictive Alternative. Pediatrics 2016; 137:peds.2015-4230. [PMID: 26993127 PMCID: PMC4811320 DOI: 10.1542/peds.2015-4230] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/25/2016] [Indexed: 11/24/2022] Open
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Smith ML, Kodish E. The ethics of ICDs: History and future directions. Cleve Clin J Med 2016; 83:99-100. [DOI: 10.3949/ccjm.83a.15122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Fins JJ, Kodish E, Cohn F, Danis M, Derse AR, Dubler NN, Goulden B, Kuczewski M, Mercer MB, Pearlman RA, Smith ML, Tarzian A, Youngner SJ. A Pilot Evaluation of Portfolios for Quality Attestation of Clinical Ethics Consultants. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:15-24. [PMID: 26913652 DOI: 10.1080/15265161.2015.1134705] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Although clinical ethics consultation is a high-stakes endeavor with an increasing prominence in health care systems, progress in developing standards for quality is challenging. In this article, we describe the results of a pilot project utilizing portfolios as an evaluation tool. We found that this approach is feasible and resulted in a reasonably wide distribution of scores among the 23 submitted portfolios that we evaluated. We discuss limitations and implications of these results, and suggest that this is a significant step on the pathway to an eventual certification process for clinical ethics consultants.
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Dekking SAS, van der Graaf R, de Vries MC, Bierings MB, van Delden JJM, Kodish E, Lantos JD. Is a New Protocol for Acute Lymphoblastic Leukemia Research or Standard Therapy? Pediatrics 2015; 136:566-70. [PMID: 26283776 PMCID: PMC4893943 DOI: 10.1542/peds.2014-2327] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2014] [Indexed: 11/24/2022] Open
Abstract
In the United States, doctors generally develop new cancer chemotherapy for children by testing innovative chemotherapy protocols against existing protocols in prospective randomized trials. In the Netherlands, children with leukemia are treated by protocols that are agreed upon by the Dutch Childhood Oncology Group. Periodically, the Dutch Childhood Oncology Group revises its protocols. Sometimes, these revisions are categorized as research, sometimes as treatment. In this Ethics Rounds, we analyze whether enrollment in a new protocol ought to be considered research and, if so, we discuss the implications of that designation. Our discussion highlights the different ways different countries approach complex issues of research ethics.
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Rose SL, Sanghani RM, Schmidt C, Karafa MT, Kodish E, Chisolm GM. Gender Differences in Physicians' Financial Ties to Industry: A Study of National Disclosure Data. PLoS One 2015; 10:e0129197. [PMID: 26067810 PMCID: PMC4466034 DOI: 10.1371/journal.pone.0129197] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 05/07/2015] [Indexed: 11/18/2022] Open
Abstract
Background Academic literature extensively documents gender disparities in the medical profession with regard to salary, promotion, and government funded research. However, gender differences in the value of financial ties to industry have not been adequately studied despite industry’s increasing contribution to income and research funding to physicians in the U.S. Methods & Findings We analyzed publicly reported financial relationships among 747,603 physicians and 432 pharmaceutical, device and biomaterials companies. Demographic and payment information were analyzed using hierarchical regression models to determine if statistically significant gender differences exist in physician-industry interactions regarding financial ties, controlling for key covariates. In 2011, 432 biomedical companies made an excess of $17,991,000 in payments to 220,908 physicians. Of these physicians, 75.1% were male. Female physicians, on average, received fewer total dollars (-$3,598.63, p<0.001) per person than men. Additionally, female physicians received significantly lower amounts for meals (-$41.80, p<0.001), education (-$1,893.14, p<0.001), speaker fees (-$2,898.44, p<0.001), and sponsored research (-$15,049.62, p=0.05). For total dollars, an interaction between gender and institutional reputation was statistically significant, implying that the differences between women and men differed based on industry’s preference for an institution, with larger differences at higher reputation institutions. Conclusions Female physicians receive significantly lower compensation for similarly described activities than their male counterparts after controlling for key covariates. As regulations lead to increased transparency regarding these relationships, efforts to standardize compensation should be considered to promote equitable opportunities for all physicians.
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Thomas SM, Ford PJ, Weise KL, Worley S, Kodish E. Not just little adults: a review of 102 paediatric ethics consultations. Acta Paediatr 2015; 104:529-34. [PMID: 25611088 DOI: 10.1111/apa.12940] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 12/30/2014] [Accepted: 01/19/2015] [Indexed: 11/27/2022]
Abstract
AIM The American Academy of Pediatrics statement on institutional ethics committees highlights the importance of paediatric ethics consultation. However, little has been published on actual experience with ethics consultation in paediatrics. The objective of this study was to review and describe topics covered by a large retrospective sample of clinical ethics consultations in paediatric medicine. METHODS We reviewed ethics consultations involving patients of <18 years of age from January 2005 to July 2013 at one institution. Descriptive statistics of the patient population, the reason for the ethics consultation and the consultant's perceived contribution to the case were generated. Subgroups of patients were compared based on demographic and clinical characteristics using Wilcoxon's rank sum tests, chi-square tests and logistic regression models. RESULTS Most of the 102 eligible consultations originated from intensive care units and were requested by attending physicians. The most frequent topic leading to consultation was end-of-life issues. Both younger age and male sex were associated with consults for end-of-life issues (p < 0.001 and p = 0.010). CONCLUSION This analysis provides important information describing the type of consults requested in paediatric medicine, which is necessary given the movement towards professionalising clinical ethics consultation. Further empirical research is needed on ethics consultation in paediatrics.
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Hazen RA, Zyzanski S, Baker JN, Drotar D, Kodish E. Communication about the risks and benefits of phase I pediatric oncology trials. Contemp Clin Trials 2015; 41:139-45. [PMID: 25638751 PMCID: PMC4404031 DOI: 10.1016/j.cct.2015.01.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 01/22/2015] [Accepted: 01/23/2015] [Indexed: 11/16/2022]
Abstract
Introduction Phase 1 pediatric oncology trials offer only a small chance of direct benefit and may have significant risks and an impact on quality of life. To date, research has not examined discussions of risks and benefits during informed consent conferences for phase 1 pediatric oncology trials. The objective of the current study was to examine clinician and family communication about risks, benefits, and quality of life during informed consent conferences for phase 1 pediatric oncology trials. Methods Participants included clinician investigators, parents, and children recruited from 6 sites conducting phase 1 pediatric oncology trials. Eighty-five informed consent conferences were observed and audiotaped. Trained coders assessed discussions of risks, benefits, and quality of life. Types of risks discussed were coded (e.g., unanticipated risks, digestive system risks, death). Types of benefits were categorized as therapeutic (e.g. discussion of how participation may or may not directly benefit child), psychological, bridge to future trial, and altruism. Results Risks and benefits were discussed in 95% and 88% of informed consent conferences, respectively. Therapeutic benefit was the most frequently discussed benefit. The impact of trial participation on quality of life was discussed in the majority (88%) of informed consent conferences. Conclusion Therapeutic benefit, risks, and quality of life were frequently discussed. The range of information discussed during informed consent conferences suggests the need for considering a staged process of informed consent for phase 1 pediatric oncology trials.
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Davis DS, Kodish E. Laws that conflict with the ethics of medicine: What Should Doctors Do? Hastings Cent Rep 2014; 44:11-4. [PMID: 25412971 DOI: 10.1002/hast.382] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Flamm AL, Kodish E. Empirical Bioethics Research Is a Winner, But Bioethics Mission Creep Is a False Alarm. THE JOURNAL OF CLINICAL ETHICS 2014. [DOI: 10.1086/jce201425302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Koyfman SA, Reddy CA, Hizlan S, Leek AC, Kodish E. Text, talk, and informed consent: A component analysis. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.e20558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Shafran D, Kodish E, Tzakis A. Organ Shortage: The Greatest Challenge Facing Transplant Medicine. World J Surg 2014; 38:1650-7. [DOI: 10.1007/s00268-014-2639-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Flamm AL, Kodish E. Empirical bioethics research is a winner, but bioethics mission creep is a false alarm. THE JOURNAL OF CLINICAL ETHICS 2014; 25:189-193. [PMID: 25192342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
While we do not share Evans's view that social science research is needed to shield bioethics from competitive threat, we incorporate and engage in social science research to inform our knowledge base, our clinical practice, and our contributions to the ongoing development of the field.
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Kodish E, Fins JJ, Braddock C, Cohn F, Dubler NN, Danis M, Derse AR, Pearlman RA, Smith M, Tarzian A, Youngner S, Kuczewski MG. Quality attestation for clinical ethics consultants: a two-step model from the American Society for Bioethics and Humanities. Hastings Cent Rep 2013; 43:26-36. [PMID: 24092588 DOI: 10.1002/hast.198] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Koyfman SA, Agre P, Carlisle R, Classen L, Cheatham C, Finley JP, Kuhrik N, Kuhrik M, Mangskau TK, O'Neill J, Reddy CP, Kodish E, McCabe MS. Consent form heterogeneity in cancer trials: the cooperative group and institutional review board gap. J Natl Cancer Inst 2013; 105:947-53. [PMID: 23821757 DOI: 10.1093/jnci/djt143] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Cooperative group (CG) provided consent forms (CGP-CFs) undergo re-review and revision by local institutional review boards (IRB) before institutional approval. We compared the relative readability and length of IRB-approved consent forms (IRB-CFs) used at seven academic institutions with their corresponding CGP-CFs. We also assessed the variability of these metrics across our institutions. METHODS This study included 197 consent forms (CFs) from 56 CG trials that were open in at least two of the participating institutions. The Flesch Reading Ease Score (FRES), the Flesch-Kincaid Grade Level (FKGL), and document length were collected on all CFs. Unpaired t test was used to compare length and readability of CGP-CF with the IRB-CF. Analysis of variance and Bonferroni-Dunn tests were used to assess interinstitutional variability in readability for all IRB-CFs. All statistical tests were two-sided. RESULTS IRB-CFs were statistically significantly longer than CGP-CFs (mean number of pages = 17 vs 13; P < .001). Mean FKGLs were higher (10.3 vs 9.4; P < .0001) and the mean FRESs were lower (53.1 vs 57.1; P < .0001) for IRB-CFs compared with CGP-CFs. Readability varied statistically significantly between institutions for all sections of the IRB-CF (P < .0001). Finalized IRB-CFs for identical clinical trials at different institutions demonstrated substantial heterogeneity of readability and length. CONCLUSIONS As CFs progress from National Cancer Institute (NCI)-sponsored CGs to local IRBs, they seem to become longer and less readable. Interinstitutional heterogeneity in CF readability is substantial and widespread. More consistent adherence to CGP-CFs based on the newly revised NCI CF template with minimal modification by local IRBs should help simplify and standardize CFs used in cancer clinical trials.
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Wilfond BS, Magnus D, Antommaria AH, Appelbaum P, Aschner J, Barrington KJ, Beauchamp T, Boss RD, Burke W, Caplan AL, Capron AM, Cho M, Clayton EW, Cole FS, Darlow BA, Diekema D, Faden RR, Feudtner C, Fins JJ, Fost NC, Frader J, Hester DM, Janvier A, Joffe S, Kahn J, Kass NE, Kodish E, Lantos JD, McCullough L, McKinney R, Meadow W, O'Rourke PP, Powderly KE, Pursley DM, Ross LF, Sayeed S, Sharp RR, Sugarman J, Tarnow-Mordi WO, Taylor H, Tomlinson T, Truog RD, Unguru YT, Weise KL, Woodrum D, Youngner S. The OHRP and SUPPORT. N Engl J Med 2013; 368:e36. [PMID: 23738513 DOI: 10.1056/nejmc1307008] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Crites J, Kodish E. Unrealistic optimism and the ethics of phase I cancer research. JOURNAL OF MEDICAL ETHICS 2013; 39:403-406. [PMID: 23118468 PMCID: PMC3697015 DOI: 10.1136/medethics-2012-100752] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
One of the most pressing ethical challenges facing phase I cancer research centres is the process of informed consent. Historically, most scholarship has been devoted to redressing therapeutic misconception, that is, the conflation of the nature and goals of research with those of therapy. While therapeutic misconception continues to be a major ethical concern, recent scholarship has begun to recognise that the informed consent process is more complex than merely a transfer of information and therefore cannot be evaluated only according to how well an individual understands such information. Other components of decision-making operate independently of understanding and yet still may compromise the quality of informed consent. Notable among these components is unrealistic optimism, an event-specific belief that one has a better chance of receiving benefit than others similarly situated. In this article, we consider responses to interviews with parents who had recently completed an informed consent conference for enrolling their child in a phase I cancer clinical trial to examine how this influence manifests and how investigators might address it during informed consent.
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Miller VA, Baker JN, Leek AC, Hizlan S, Rheingold SR, Yamokoski AD, Drotar D, Kodish E. Adolescent perspectives on phase I cancer research. Pediatr Blood Cancer 2013; 60:873-8. [PMID: 23034985 PMCID: PMC3538102 DOI: 10.1002/pbc.24326] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Accepted: 08/21/2012] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to examine adolescent patients' perspectives on their understanding and decision making about a pediatric phase I cancer study. PROCEDURE Participants included adolescents ages 14-21 years with cancer (N = 20), all of whom attended a phase I study consent conference. Participants responded to closed- and open-ended questions on a verbally administered structured interview, which assessed aspects of understanding and decision making about the phase I study. RESULTS All participants decided to enroll in the phase I study. The majority of participants understood that participation was voluntary, entailed risks, and that they could withdraw. Most also believed that participation in the phase I study would increase the length of their lives. The most frequent reasons for enrolling were positive clinical benefit, needing an option, impact on quality of life, and few side effects or fewer than those of current or past treatments. Eighty-five percent of participants reported that they themselves made the final decision about enrollment in the phase I study. CONCLUSIONS Most participants hoped or expected that the phase I study would provide a direct benefit (increased survival time or cure) and reported that they themselves were the final decision-maker about enrollment. Clinicians may underestimate the role of adolescents, especially if they believe that parents typically make such decisions. Future research should assess the actual participation of children and adolescents during the informed consent process and explore the role of hope in their decision making about phase I studies.
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