Are research ethics committees behaving unethically? Some suggestions for improving performance and accountability

Ethics on the floor

The work of the 'Human Research Ethics Committee' (HREC) is expanding as the dimensions of ethical practice and research grow in the clinical arena. Over the past five years, the demands on practitioners and ethics committee members have expanded, as the general public demands accountability on the part of clinical and other researchers. This paper presents a case study of an ethics committee in an Area Health Service in Sydney. It represents the views of the members as to why they see their job as important, what aspects are difficult, how they delineate between ethical/legal and scientific issues, and what are the major stumbling blocks for them in enacting their membership of a HREC. The data for the case study was collected using interviews with nine out of eleven members. The audio taped interviews were transcribed, the text thematically analysed for commonalities and contrasts, and a description of the members' perspective on various issues written. Issues emerging include: amount of material members read prior to the committee meeting, the difficulty in educating practitioners (all researchers) to write information sheets that are simple and comprehensible to laypersons, the payment of subjects for their time, the appropriate amount of monitoring to be applied on each project, the difficulty in letting researchers know that the ethics committee is committed to encouraging research and that its questions are intended to ensure the best possible project answering the researchers' questions/aims is conducted, and the slow or no response by researchers to ethics committee questions. The findings imply that reviewing research proposals for their ethical value is individual and members of human research ethics committees need to synthesise these in a committee context to make informed decisions.

Short-term low-dose corticosteroids vs placebo and nonsteroidal antiinflammatory drugs in rheumatoid arthritis

BACKGROUND

The effect of low dose corticosteroids, equivalent to 15 mg prednisolone daily or less, in patients with rheumatoid arthritis has been questioned. We performed a systematic review of trials which compared corticosteroids with placebo or non-steroidal, anti-inflammatory drugs.

OBJECTIVES

To determine whether short-term (i.e. as recorded within the first month of therapy), oral low-dose corticosteroids (corresponding to a maximum of 15 mg prednisolone daily) is superior to placebo and non-steroidal, anti-inflammatory drugs in patients with rheumatoid arthritis.

SEARCH STRATEGY

Medline Silverplatter, The Cochrane Controlled Trials Register, reference lists and a personal archive. Date of last search May 2002.

SELECTION CRITERIA

All randomised studies comparing an oral corticosteroid (not exceeding an equivalent of 15 mg prednisolone daily) with placebo or a non-steroidal, anti-inflammatory drug were eligible if they reported clinical outcomes within one month after start of therapy. For adverse effects, long-term trials and matched cohort studies were also selected.

DATA COLLECTION AND ANALYSIS

Decisions on which trials to include were made independently by two observers based on the methods sections of the trials. Standardised mean difference (random effects model) was used for the statistical analyses.

MAIN RESULTS

Ten studies, involving 320 patients, were included. Prednisolone had a marked effect over placebo on joint tenderness (standardised mean difference 1.31, 95% confidence interval 0.78 to 1.83), pain (1.75, 0.87 to 2.64) and grip strength (0.41, 0.13 to 0.69). Measured in the original units, the differences were 12 tender joints (6 to 18) and 22 mm Hg (5 to 40) for grip strength. Prednisolone also had a greater effect than non-steroidal, anti-inflammatory drugs on joint tenderness (0.63, 0.11 to 1.16) and pain (1.25, 0.26 to 2.24), whereas the difference in grip strength was not significant (0.31, -0.02 to 0.64). Measured in the original units, the differences were 9 tender joints (5 to 12) and 12 mm Hg (-6 to 31). The risk of adverse effects, also during moderate- and long-term use, seemed acceptable.

REVIEWER'S CONCLUSIONS

Prednisolone in low doses (not exceeding 15 mg daily) may be used intermittently in patients with rheumatoid arthritis, particularly if the disease cannot be controlled by other means. Since prednisolone is highly effective, short-term placebo controlled trials studying the clinical effect of low-dose prednisolone or other oral corticosteroids are no longer necessary.

Ethical review of health service research in the UK: implications for nursing

BACKGROUND

This paper examines the current systems and structures for ethical review of health services research in the United Kingdom (UK). Past criticisms and the adequacy of recent governance arrangements for Ethics Committees in addressing these are discussed. The implications for nurses are then considered.

RATIONALE

This examination of the situation is prompted by the demand for more innovative research designs in health care evaluation, new regulations and guidance, and a climate of public anxiety regarding research conduct in the UK.

FINDINGS

The evolution of Research Ethics Committees (RECs) has been slow and resulted in a lack in consistency. Criticisms made of RECs can be categorized into four main areas. New governance arrangements for RECs have emerged as potential solutions to these criticisms. This review identifies the limitations of the new governance arrangements in addressing past criticisms because of two factors. The first is insufficient funding. The second is confusion about the confidentiality and consent requirements of clinicians working in areas where research is conducted and on whom recruitment processes often rely. The current situation regarding health research ethical review has implications for nurses, whether they are working as researchers, members of Ethics Committees or clinicians where research is conducted.

CONCLUSION

The new governance arrangements may go some way to addressing past problems. However, investment in RECs is required. It is also important to realize that maintaining ethical probity in health service research is a tripartite concern. It is reliant as it is on the actions of Ethics Committees and clinical research partners as well as those of the researchers themselves.

New governance arrangements for research ethics committees: is facilitating research achieved at the cost of participants' interest

This paper examines the UK's response to a recent European Clinical Trials Directive, namely the Department of Health, Central Office for Research Ethics Committee guidance, Governance Arrangements for NHS Research Ethics Committees. The revisions have been long awaited by researchers and research ethics committee members alike. They substantially reform the ethical review system in the UK. We examine the new arrangements and argue that though they go a long way toward addressing the uncertainty surrounding ethics committee function, the system favours the facilitation of research over the protection of the dignity and welfare of research participants.

Research ethics committees and public dissemination of clinical trial results

Biomedical research involving human beings is subject to codes of ethical conduct that mandate review, approval, and monitoring of clinical trials by research ethics committees (RECs). The role of RECs in public dissemination of results of research is not addressed explicitly in international codes or national regulations governing human research. I contend that RECs should have a prominent role in ensuring that trial results are publicly disseminated. I also propose specific responsibilities and actions that should be assumed and implemented by RECs to promote this objective.

Conflict of interest and medical publication

One of the important causes of bias in the medical literature is failure to publish data because it is "negative". Usually, this is due to failure to write a manuscript and submit it for publication. Since publication is an essential part of research and patients have been recruited into a study in the belief that they are participating in medical research, there is an ethical commitment to publish the observations made on volunteer subjects. This can be enforced by ethical committees if they refuse to approve studies of investigators and sponsors who have failed to publish earlier studies.

Ethics in exercise science research

Ethical evaluation is a vital but sometimes neglected component of research policy in the exercise sciences. This article reviews some issues in human research, with particular reference to studies undertaken by the exercise scientist. The typical composition and functions of the research review committee are examined in the context of individual and institutional ethical norms. In multicentre trials, there are often problems in coordinating ethical approval between institutions. On-going monitoring of research may have value in the detection of fraud. A reduction in the secrecy of committee proceedings would allow a closer auditing of the research review process. Authors need to give more thought to developing appropriate research questions. Scarce resources may be wasted because of inappropriate study design or an inadequate statistical analysis of the results. The costs of any proposed investigation must be weighed carefully against possible benefits. Confidentiality is particularly important when collecting data at the worksite or over the internet. Informed consent should be based on a full disclosure of risks; the participant should be competent to understand the nature and magnitude of these risks, and undue pressure to participate in an experiment must be avoided. The opposition to placebo trials expressed in the Declaration of Helsinki requires careful consideration of the use of control groups, since regular exercise is known to benefit health. If research is conducted in under-developed societies, the standards of treatment of the participants should match those expected in developed societies. The publication of findings must be fair and well balanced; examples of fraud and misconduct continue to be reported. Some journals apparently still publish papers, even if they have not received an initial institutional review. Editors should restore meaning to the word 'author', avoid the bias to a publication of 'positive' results, limit the impact of commercial sponsorship on reporting and curtail the current trend to redundant presentations and publications. Development of academic courses in research ethics may help to avoid some of these abuses.

Judging the ethics of qualitative research: considering the "ethics as process" model

Decision-making about the ethics of qualitative research is problematic where the research design is emergent, and the balance between risks and benefits for research subjects are difficult to ascertain prior to study implementation. The discourses of health/medical research ethics and those of social research are shown to be divergent and, furthermore, where ethics committees tie themselves to the health/medical model of ethical decision-making, qualitative research approaches can be disadvantaged. Having demonstrated the dual discourses and their relevance to qualitative research ethics, a critical review of current approaches to maximising the success of qualitative research proposals being considered for approval by ethics committees is undertaken. This leads to a call for a system of monitoring qualitative research so that the "benefit to risk" ratio is always on the side of benefit. This has implications for the ways in which ethics committees are organised and the ways in which they function.

Truth in clinical research trials involving pharmaceutical sponsorship

Large clinical trials are expensive to mount. Funding comes mainly from pharmaceutical companies seeking information on drug efficacy and adverse events. Patients should be informed of the financial and publication agreements reached between those conducting the trials. This is unlikely to have a significant effect on trial participation and will provide patients with information relevant to informed consent. A small proportion of monies raised from drug trials could be set aside to fund both a trial register site and further studies on adverse drug reactions.

Ethics that exclude: the role of ethics committees in lesbian and gay health research in South Africa

Prevailing state and institutional ideologies regarding race/ethnicity, gender, and sexuality help to shape, and are influenced by, research priorities. Research ethics committees perform a gatekeeper role in this process. In this commentary, we describe efforts to obtain approval from the ethics committee of a large medical institution for research into the treatment of homosexual persons by health professionals in the South African military during the apartheid era. The committee questioned the "scientific validity" of the study, viewing it as having a "political" rather than a "scientific" purpose. They objected to the framing of the research topic within a human rights discourse and appeared to be concerned that the research might lead to action against health professionals who committed human rights abuses against lesbians and gay men during apartheid. The process illustrates the ways in which heterosexism, and concerns to protect the practice of health professionals from scrutiny, may influence the decisions of ethics committees. Ethics that exclude research on lesbian and gay health cannot be in the public interest. Ethics committees must be challenged to examine the ways in which institutionalized ideologies influence their decision making.

Variation in institutional review board responses to a standard protocol for a multicenter clinical trial

Multicenter clinical trials require approval by multiple local institutional review boards (IRBs). The Multicenter Airway Research Collaboration mailed a clinical trial protocol to its U.S. investigators and 44 IRBs ultimately reviewed it.

OBJECTIVE

To describe IRB responses to one standard protocol and thereby gain insight into the advantages and disadvantages of local IRB review.

METHODS

Two surveys were mailed to participants, with telephone follow-up of nonrespondents. Survey 1 was mailed to 82 investigators across North AMERICA: Survey 2 was mailed to investigators from 44 medical centers in 17 U.S. states. Survey 1 asked about each investigator's local IRB (e.g., frequency of meetings, membership), whereas survey 2 asked about IRB queries and concerns related to the submitted clinical trial.

RESULTS

Both surveys had 100% response rate. Investigators submitted applications a median of 58 days (interquartile range [IQR], 40--83) after receipt of the protocol, and IRB approval took an additional 38 days (IQR, 26--62). Although eight applications were approved with little or no changes, IRBs requested an average of 3.5 changes per site. Changes involved study logistics and supervision for 45%, the research process for 43%, and the consent form for 91%. Despite these numerous requests, all eventually approved the basic protocol, including inclusion criteria, intervention, and data collection.

CONCLUSIONS

The IRBs showed extreme variability in their initial responses to a standard protocol, but ultimately all gave approval. Almost all IRBs changed the consent form. A national, multicenter IRB process might streamline ethical review and warrants further consideration.

Meta-analysis of short-term low dose prednisolone versus placebo and non-steroidal anti-inflammatory drugs in rheumatoid arthritis

OBJECTIVE

To determine whether short-term, oral low dose prednisolone (< or = 15 mg daily) is superior to placebo and non-steroidal anti-inflammatory drugs in patients with rheumatoid arthritis.

DESIGN

Meta-analysis of randomised trials of oral corticosteroids compared with placebo or a non-steroidal anti-inflammatory drug.

SETTING

Trials conducted anywhere in the world.

SUBJECTS

Patients with rheumatoid arthritis.

MAIN OUTCOME MEASURES

Joint tenderness, pain, and grip strength. Outcomes measured on different scales were combined by using the standardised effect size (difference in effect divided by SD of the measurements).

RESULTS

Ten studies were included in the meta-analysis. Prednisolone had a marked effect over placebo on joint tenderness (standardised effect size 1.31; 95% confidence interval 0.78 to 1.83), pain (1.75; 0.87 to 2.64), and grip strength (0.41; 0.13 to 0.69). Measured in the original units the differences were 12 (6 to 18) tender joints and 22 mm Hg (5 mm Hg to 40 mm Hg) for grip strength. Prednisolone also had a greater effect than non-steroidal anti-inflammatory drugs on joint tenderness (0.63; 0.11 to 1.16) and pain (1.25; 0.26 to 2.24), whereas the difference in grip strength was not significant (0.31; -0.02 to 0.64). Measured in the original units the differences were 9 (5 to 12) tender joints and 12 mm Hg (-6 mm Hg to 31 mm Hg). The risk of adverse effects during moderate and long term use seemed acceptable.

CONCLUSION

Prednisolone in low doses (< or = 15 mg daily) may be used intermittently in patients with rheumatoid arthritis, particularly if the disease cannot be controlled by other means.

Evidence-based pediatric pulmonary medicine: how can it help?

Evidence-based medicine aims to identify, critically appraise, and apply the best available evidence in making decisions about the care of patients. These aims are similar to those conscientious clinicians have always sought to achieve, but an evidence-based approach applies a systematic and rigorous methodology to this process to ensure that the evidence applied is relevant and of high quality. Because of the volume of potentially relevant information that needs to be accessed from the medical literature, many clinicians rely on reviews of the evidence. Systematic reviews provide summaries of the results of evidence-based healthcare, which can be made available to clinicians, healthcare administrators, and patients. The use of explicit, systematic methods in reviews limits bias (systematic errors) and reduces random errors (simple mistakes), thus providing reliable results on which to draw conclusions and make decisions. Meta-analysis is the use of statistical methods to summarize the results of independent studies. When used appropriately, meta-analysis can provide more precise estimates of the effects of healthcare than those derived from the individual studies included in a review. Childhood respiratory diseases can be a challenging area in which to undertake clinical research. These challenges include diagnostic uncertainty, lack of objective endpoints, and aspects of generalizability of randomized controlled trials. Despite these difficulties, there are now many examples of systematic reviews and evidence-based approaches in pediatric pulmonology. If applied appropriately, they can ensure that management of patients is based on clinically useful diagnostic tests and treatments that have been shown to be effective and not harmful.