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Hollander SA, Axelrod DM, Bernstein D, Cohen HJ, Sourkes B, Reddy S, Magnus D, Rosenthal DN, Kaufman BD. Compassionate deactivation of ventricular assist devices in pediatric patients. J Heart Lung Transplant 2016; 35:564-7. [PMID: 27197773 DOI: 10.1016/j.healun.2016.03.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/14/2016] [Accepted: 03/23/2016] [Indexed: 10/22/2022] Open
Abstract
Despite greatly improved survival in pediatric patients with end-stage heart failure through the use of ventricular assist devices (VADs), heart failure ultimately remains a life-threatening disease with a significant symptom burden. With increased demand for donor organs, liberalizing the boundaries of case complexity, and the introduction of destination therapy in children, more children can be expected to die while on mechanical support. Despite this trend, guidelines on the ethical and pragmatic issues of compassionate deactivation of VAD support in children are strikingly absent. As VAD support for pediatric patients increases in frequency, the pediatric heart failure and palliative care communities must work toward establishing guidelines to clarify the complex issues surrounding compassionate deactivation. Patient, family and clinician attitudes must be ascertained and education regarding the psychological, legal and ethical issues should be provided. Furthermore, pediatric-specific planning documents for use before VAD implantation as well as deactivation checklists should be developed to assist with decision-making at critical points during the illness trajectory. Herein we review the relevant literature regarding compassionate deactivation with a specific focus on issues related to children.
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Lee SSJ, Kelley M, Cho MK, Kraft SA, James C, Constantine M, Meyer AN, Diekema D, Capron AM, Wilfond BS, Magnus D. Adrift in the Gray Zone: IRB Perspectives on Research in the Learning Health System. AJOB Empir Bioeth 2016; 7:125-134. [PMID: 27917391 DOI: 10.1080/23294515.2016.1155674] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Human subjects protection in healthcare contexts rests on the premise that a principled boundary distinguishes clinical research and clinical practice. However, growing use of evidence-based clinical practices by health systems makes it increasingly difficult to disentangle research from a wide range of clinical activities that are sometimes called "research on medical practice" (ROMP), including quality improvement activities and comparative effectiveness research. The recent growth of ROMP activities has created an ethical and regulatory gray zone with significant implications for the oversight of human subjects research. METHODS We conducted six semi-structured, open-ended focus group discussions with IRB members to understand their experiences and perspectives on ethical oversight of ROMP, including randomization of patients to standard treatments. RESULTS Our study revealed that IRB members are unclear or divided on the central questions at stake in the current policy debate over ethical oversight of ROMP: IRB members struggle to make a clear distinction between clinical research and medical practice improvement, lack consensus on when ROMP requires IRB review and oversight, and are uncertain about what constitutes incremental risk when patients are randomized to different treatments, any of which may be offered in usual care. They characterized the central challenge as a balancing act, between, on the one hand, making information fully transparent to patients and providing adequate oversight, and on the other hand, avoiding a chilling effect on the research process or harming the physician-patient relationship. CONCLUSIONS Evidence-based guidance that supports IRB members in providing adequate and effective oversight of ROMP without impeding the research process or harming the physician-patient relationship is necessary to realize the full benefits of the learning health system.
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Magnus D, Rizk N. Professional Judgment and Justice: Equal Respect for the Professional Judgment of Critical-Care Physicians. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:1-2. [PMID: 26734733 DOI: 10.1080/15265161.2016.1128748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Magnus D. Finding the Right Tools for Assessing Quality of Clinical Ethics Consultation. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:1-2. [PMID: 26913650 DOI: 10.1080/15265161.2016.1150682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Sharma A, Sebastiano V, Scott CT, Magnus D, Koyano-Nakagawa N, Garry DJ, Witte ON, Nakauchi H, Wu JC, Weissman IL, Wu SM. Lift NIH restrictions on chimera research. Science 2015; 350:640. [DOI: 10.1126/science.350.6261.640-a] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Cho MK, Magnus D, Constantine M, Lee SSJ, Kelley M, Alessi S, Korngiebel D, James C, Kuwana E, Gallagher TH, Diekema D, Capron AM, Joffe S, Wilfond BS. Attitudes Toward Risk and Informed Consent for Research on Medical Practices: A Cross-sectional Survey. Ann Intern Med 2015; 162:690-6. [PMID: 25868119 PMCID: PMC4776759 DOI: 10.7326/m15-0166] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The U.S. Office for Human Research Protections has proposed that end points of randomized trials comparing the effectiveness of standard medical practices are risks of research that would require disclosure and written informed consent, but data are lacking on the views of potential participants. OBJECTIVE To assess attitudes of U.S. adults about risks and preferences for notification and consent for research on medical practices. DESIGN Cross-sectional survey conducted in August 2014. SETTING Web-based questionnaire. PATIENTS 1095 U.S. adults sampled from an online panel (n = 805) and an online convenience river sample (n = 290). MEASUREMENTS Attitudes toward risk, informed consent, and willingness to participate in 3 research scenarios involving medical record review and randomization of usual medical practices. RESULTS 97% of respondents agreed that health systems should evaluate standard treatments. Most wanted to be asked for permission to participate in each of 3 scenarios (range, 75.2% to 80.4%), even if it involved only medical record review, but most would accept nonwritten (oral) permission or general notification if obtaining written permission would make the research too difficult to conduct (range, 70.2% to 82.7%). Most perceived additional risk from each scenario (range, 64.0% to 81.6%). LIMITATION Use of hypothetical scenarios and a nonprobability sample that was not fully representative of the U.S. population. CONCLUSION Most respondents preferred to be asked for permission to participate in observational and randomized research evaluating usual medical practices, but they are willing to accept less elaborate approaches than written consent if research would otherwise be impracticable. These attitudes are not aligned with proposed regulatory guidance. PRIMARY FUNDING SOURCE National Center for Advancing Translational Sciences at the National Institutes of Health.
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Sharp RR, Taylor HA, Brinich MA, Boyle MM, Cho M, Coors M, Danis M, Havard M, Magnus D, Wilfond B. Research ethics consultation: ethical and professional practice challenges and recommendations. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2015; 90:615-20. [PMID: 25607942 PMCID: PMC4414686 DOI: 10.1097/acm.0000000000000640] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The complexity of biomedical research has increased considerably in the last decade, as has the pace of translational research. This complexity has generated a number of novel ethical issues for clinical investigators, institutional review boards (IRBs), and other oversight committees. In response, many academic medical centers have created formal research ethics consultation (REC) services to help clinical investigators and IRBs navigate ethical issues in biomedical research. Key functions of a REC service include assisting with research design and implementation, providing a forum for deliberative exploration of ethical issues, and supplementing regulatory oversight. As increasing numbers of academic research institutions establish REC services, there is a pressing need for consensus about the primary aims and policies that should guide these activities. Establishing clear expectations about the aims and policies of REC services is important if REC programs are to achieve their full potential. Drawing on the experiences of a Clinical and Translational Science Award Research Ethics Consultation Working Group, this article describes three major ethical and professional practice challenges associated with the provision of REC: (1) managing multiple institutional roles and responsibilities, (2) managing sensitive information, and (3) communicating with consultation requestors about how these issues are managed. The paper also presents several practical strategies for addressing these challenges and enhancing the quality of REC services.
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Char DS, Cho M, Magnus D. Whole genome sequencing in critically ill children. THE LANCET RESPIRATORY MEDICINE 2015; 3:264-6. [PMID: 25704991 DOI: 10.1016/s2213-2600(15)00006-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 01/16/2015] [Indexed: 11/18/2022]
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Harvey H, Havard M, Magnus D, Cho MK, Riedel-Kruse IH. Innocent fun or "microslavery"? An ethical analysis of biotic games. Hastings Cent Rep 2015; 44:38-46. [PMID: 25412975 DOI: 10.1002/hast.386] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Magnus D. Clinical ethics consultation: a need for evidence. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:1-2. [PMID: 25562213 DOI: 10.1080/15265161.2015.987577] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Magnus D, Fishbeyn B. The proper locus of professionalization: the individual or the institutions? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:1-2. [PMID: 25970381 DOI: 10.1080/15265161.2015.1038936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Abstract
Geron Corporation is a publically traded company that launched a phase I clinical trial of a human embryonic stem cell-based therapy for spinal cord injury. The company enrolled the first patient in October 2010 and stopped the trial 1 year later. The fifth patient had been enrolled but not transplanted when the company announced the trial's end. After discussions with clinical staff and family, an agreement was reached to add her to the cohort and proceed with the transplant. Two and half years later, the research is still waiting to restart. With this background in mind, we discuss the major ethical and social questions raised by the Geron case. We offer recommendations for institutional review boards and clinical sites as they deliberate approvals of early-phase trials in frontier medicine.
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Langford R, Bonell C, Jones H, Pouliou T, Murphy S, Waters E, Komro K, Gibbs L, Magnus D, Campbell R. The World Health Organization’s Health Promoting Schools Framework: A Cochrane Systematic Review and Meta Analysis. Eur J Public Health 2014. [DOI: 10.1093/eurpub/cku165.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Magnus D, Parsi K, Sharp R. AJOB 2.0: Taking bioethics to a new level. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2014; 14:1-2. [PMID: 25046284 DOI: 10.1080/15265161.2014.936788] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Magnus D. Compassion and research in compassionate use. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2014; 14:1-2. [PMID: 25325800 DOI: 10.1080/15265161.2014.969968] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Allyse MA, Sayres LC, Havard M, King JS, Greely HT, Hudgins L, Taylor J, Norton ME, Cho MK, Magnus D, Ormond KE. Best ethical practices for clinicians and laboratories in the provision of noninvasive prenatal testing. Prenat Diagn 2013; 33:656-61. [PMID: 23613322 PMCID: PMC4057377 DOI: 10.1002/pd.4144] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Revised: 04/18/2013] [Accepted: 04/18/2013] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The goal of this study is to provide an ethical framework for clinicians and companies providing noninvasive prenatal testing using cell-free fetal DNA or whole fetal cells. METHOD In collaboration with a National Institutes of Health-supported research ethics consultation committee together with feedback from an interdisciplinary group of clinicians, members of industry, legal experts, and genetic counselors, we developed a set of best practices for the provision of noninvasive prenatal genetic testing. RESULTS Principal recommendations include the amendment of current informed consent procedures to include attention to the noninvasive nature of new testing and the potential for a broader range of results earlier in the pregnancy. We strongly recommend that tests should only be provided through licensed medical providers and not directly to consumers. CONCLUSION Prenatal tests, including new methods using cell-free fetal DNA, are not currently regulated by government agencies, and limited professional guidance is available. In the absence of regulation, companies and clinicians should cooperate to adopt responsible best ethical practices in the provision of these tests.
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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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Ladd JM, Karkazis K, Magnus D. Parental refusal of vaccination and transplantation listing decisions: a nationwide survey. Pediatr Transplant 2013; 17:244-50. [PMID: 23347536 DOI: 10.1111/petr.12046] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2012] [Indexed: 12/01/2022]
Abstract
Many professional societies and research studies recommend complete vaccination before pediatric solid organ transplantation. Nevertheless, incompletely vaccinated children often receive transplants. As the number of parents refusing to vaccinate children for nonmedical reasons increases, pediatric transplantation programs face difficult listing decisions. Given the importance of psychosocial criteria in listing decisions, this study explores how parental refusal of vaccination affects those listing decisions. Surveys were emailed to individuals at 195 pediatric solid organ transplantation programs in the United States, with a 71% response rate. Forty-four respondents (39%) reported that their programs have had cases involving parental refusal of vaccination. In response to hypothetical scenarios, 93 respondents (82%) would list a child not vaccinated for medical reasons, whereas only 54 respondents (47%) would list a child whose parents refused vaccination. Only five respondents (4%) reported that their programs had written policies regarding parental refusal of vaccination. These data reveal inconsistencies across pediatric transplantation programs regarding how parental refusal of vaccination affects listing decisions and raise the issue of whether and how the reason for incomplete vaccination should be factored into listing decisions. We recommend further discussion and the development of written guidelines to unify programs' assessments of incompletely vaccinated pediatric transplantation candidates.
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Magnus D. The SUPPORT controversy and the debate over research within the standard of care. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2013; 13:1-2. [PMID: 24256521 DOI: 10.1080/15265161.2013.857257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Milner LC, Magnus D. Can informed consent go too far? Balancing consent and public benefit in research. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2013; 13:1-2. [PMID: 23514383 DOI: 10.1080/15265161.2013.778645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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