Principles and process in the development of the Mayo Clinic's individual and institutional conflict of interest policy

In 1995, federal regulations required all academic medical centers to implement policies to manage individual financial conflict of interest. At the Mayo Clinic, all staff are salaried, and all medically related intellectual property from the staff belongs to the clinic. Hence, it was necessary to develop a policy for institutional conflict of interest to complement the policy for individual conflicts of interest. This article addresses the principles and process that led to the development of the Mayo Clinic's policies that guide the management of conflict of interest of individuals and of the institution. Empowered by the Bayh-Dole Act, the Mayo Clinic participates in technology transfer through its entity Mayo Medical Ventures. Individual conflicts of interest arising from such technology transfer are associated with Institutional conflicts because all individual intellectual property belongs to the institution, per clinic policy. This policy addresses conflicts of interest that arise in research, leadership, clinical practice, investments, and purchasing. Associated with the statutory annual disclosure on personal consulting and other relationships with Industry, which are guided by federal regulations, all research protocols or grant applications require financial disclosure on initial submission and in annual progress reports. The clinic's Conflict of Interest Review Board was established to review each disclosure and recommend management of individual and institutional conflicts of interest according to policy.

Attitudes of academic and clinical researchers toward financial ties in research: a systematic review

Involvement of industry in academic research is widespread and associated with favorable outcomes for industry. The objective of this study was to review empirical data on the attitudes of researchers toward industry involvement and financial ties in research. A review of the literature for quantitative data from surveys on the attitudes of researchers to financial ties in research, reported in English, resulted in the 17 studies included. Review of these studies revealed that investigators are concerned about the impact of financial ties on choice of research topic, research conduct and publication, but this concern is less among investigators already involved with industry. Researchers approve of industry collaboration and financial ties when the ties are indirectly related to the research, disclosure is upfront, and results and ideas are freely publicized. However, their trust in disclosure as a way to manage conflicts may reveal a lack of awareness of the actual impact of financial incentives on themselves and other researchers.

Institutional review board guidance on pediatric research: missed opportunities

OBJECTIVE

To examine whether and how institutional review boards (IRBs) are using their web-sites to provide guidance to investigators conducting pediatric research.

STUDY DESIGN

We studied guidance on pediatric research from IRB web-sites at the 25 US medical schools, plus affiliated hospitals, research centers, and public health schools, and the top National Institutes of Health-funded (>5 million dollars) children's hospitals with separate IRBs. We also included 1 IRB that was not otherwise eligible because other IRBs use its web-based research ethics training program. Our final study population was 39 IRB web-sites.

RESULTS

IRB web-sites generally provide basic information about pediatric research. However, few IRBs discuss important ethical issues on which the regulations are silent. Moreover, some IRBs provide incorrect advice about the regulations. More detailed IRB guidance may help pediatric investigators think through ethical issues and protect children in clinical research. Helpful approaches we identified include checklists and "points to consider," concrete examples to illustrate regulatory requirements, and discussion of areas of controversy.

CONCLUSION

Few IRBs present the kind of detailed guidance that investigators might need to ensure ethically designed protocols. IRBs should revise their web-sites to ensure that they provide accurate, comprehensive, and sufficiently detailed guidance.

Ethical goals of community consultation in research

In response to the traditional emphasis on the rights, interests, and well-being of individual research subjects, there has been growing attention focused on the importance of involving communities in research development and approval. Community consultation is a particularly common method of involving communities. However, the fundamental ethical goals of community consultation have not been delineated, which makes it difficult for investigators, sponsors, and institutional review boards to design and evaluate consultation efforts. Community consultation must be tailored to the communities in which it is conducted, but the purposes of consultation-the ethical goals it is designed to achieve-should be universal. We propose 4 ethical goals that give investigators, sponsors, institutional review boards, and communities a framework for evaluating community consultation processes.

An analysis of U.S. practices of paying research participants

BACKGROUND

Despite controversy about paying research subjects, little is known about actual practices in the U.S., including what type of studies offer payment, to what type of subjects, and how amounts are determined.

OBJECTIVE

To document current U.S. practices regarding payment to research subjects.

METHODS

The protocols and consent forms of 467 studies offering payment to research subjects approved by 11 IRBs across the U.S. were reviewed to analyze how they describe and justify payment to subjects.

RESULTS

Money was offered in a wide variety of study types, from short term physiologic studies to large clinical trials of therapeutic interventions, to both patient (61%) and healthy (24.4%) subjects or both (14.6%). Dollar amounts varied widely and were infrequently explicitly described as based on time (19%) or procedures (12%). Unexplained variation in dollar amounts occurred in similar studies or in the same (multi-site) study at different sites, and for similar procedures across studies sometimes even within one site. Although the range was wide ($5-$2000), total amounts were usually modest (overall median $155), and almost always described in the consent form (94.4%) and usually as pro-rated (73%).

CONCLUSIONS

Both patient and healthy subjects are offered payment in a wide variety of types of research in the U.S. Variation in the dollar amounts offered is largely unexplained.

Global approach to perinatal medicine: functional genomics and proteomics

Functional genomics (transcriptomics and proteomics) is a global, systematic and comprehensive approach to the identification and description of the processes and pathways involved in normal and abnormal physiological states. The functional genomics methods most applied today are DNA microarrays and proteomics methods, primarily two-dimensional gel electrophoresis coupled with mass spectrometry. To date, interesting research has been carried out, representing milestones for future implementation of functional genomics/proteomics in perinatal medicine. For instance, possible biomarkers of pre-eclampsia, preterm labor and gestational trophoblastic diseases have been discovered. Further systematic examination of differentially regulated genes and proteins in maternal and fetal tissues and fluids will be required. However, high-throughput technologies reflect biological fluctuations and methodological errors. Large amounts of such different data challenge the performance and capacity of the statistical tools and software available at present. Further major developments in this field are pending and the intellectual investment will certainly result in clinical advances.

Ethics and research assessing the relative roles of genes and the environment

Research on the interaction of genes and the environment is revealing that many human diseases have both genetic and environmental components. Even traditional "environmental" diseases, such as infections, appear to interact with genetic components in the human host. Environmental genetics research will inevitably increase understanding of individual susceptibilities to toxic exposures in the environment and harmful side effects of medications; therefore, it has great promise for improving the prevention and treatment of human diseases. However, realizing the benefits of this research requires careful attention to ethical issues that are particularly relevant in this context. This article reviews some of the most pressing issues related to research design and methods, as well as from the application of research results (e.g., workplace genetic screening and legal toxic torts, personal medical responsibility, and the relationship between genetics and public health measures).

Looking into the institutional review board: observations from both sides of the table

Institutional review board (IRB) reviews offer the benefit of perspective afforded by the board's distance from the research and the research subjects. At the same time, distance from research subjects that is geographic, socioeconomic, cognitive, linguistic, and cultural can undermine the positive role of perspective. In addition, distance between IRB and investigators, largely a result of attitudes and communication, can prolong the review process and can obscure its message. The tension that often characterizes IRB-investigator relationships is due, in part, to variability in the application of federal regulations by IRBs across institutions and, on the part of investigators, inexperience, communication problems, and difficulties in anticipating the needs of their subjects. Contributing to the variability are the demographics and the culture of the IRB, attitudes that influence IRB-investigator relationships, and the adequacy of support from the institution. The effects of these factors on review decisions and on the performance of the human subjects protection system are largely unstudied. The movement for IRB accreditation is causing institutions to examine their overall research protection system and promises a more collaborative approach, where IRB and investigators accept their common charge to meet the needs of subjects and to improve the quality of research.

Research on environmental health interventions: ethical problems and solutions

This article reviews a variety of ethical issues one must consider when conducting research on environmental health interventions on human subjects. The paper uses the Kennedy Krieger Institute lead abatement study as well as a hypothetical asthma study to discuss questions concerning benefits and risks, risk minimization, safety monitoring, the duty to warn, the duty to report, the use of control groups, informed consent, equitable subject selection, privacy, conflicts of interest, and community consultation. Research on environmental health interventions can make an important contribution to our understanding of human health and disease prevention, provided it is conducted in a manner that meets prevailing scientific, ethical, and legal standards for research on human subjects.

A model designed to enhance informed consent: experiences from the HIV prevention trials network

HIV prevention research in developing countries has resulted in increased attention to and discussion of ethical issues, particularly the issue of the quality of informed consent. We present a conceptual framework for an enhanced informed consent process, drawing on experiences garnered from domestic and international studies conducted by the HIV Prevention Trials Network, funded by the National Institutes of Health. This framework guides the development of an informed consent process designed to help ensure initial and continued comprehension of research participation, with an emphasis on HIV prevention research. Attention is focused at the individual and community levels and on 3 study phases: preenrollment, enrollment, and postenrollment.

Nurses' views of longitudinal genetic screening of and research on children

There is a lack of empirical data exploring ethical issues of genetic screening and longitudinal research involving children. Therefore, this pilot interview study explored the perceptions of nurses and midwives in relation to their involvement in an ongoing genetic preventive screening process involving children - the All Babies in South-east Sweden (ABIS) study (n=17,005). Data were collected through semistructured interviews with 10 nurses involved in all information and sampling procedures. While providing the preliminary nature of this study, it supports the idea of the importance of further research, both from a nursing professional perspective and from other parties involved in clinical research. The findings made in this study suggest that for such studies it is vital that nurses and midwives are fully informed about aims, methods, and potential intervention/prevention since in many cases they have a central role in several areas of screening and clinical longitudinal research involving children, e.g. information to potential research participants, obtaining informed consent, and data collection. With a thorough understanding of the research, including both basic aims and methods as well as potential future prevention aims, the nursing staff involved will be better placed to help participants make an informed choice and to provide additional information to the participants. Further research may be needed that aims to develop effective methods in preparing data collectors. It is also suggested that the design of the information process, and especially in longitudinal research involving young children, is of utmost importance before such studies are commenced.

Searching for an efficient institutional review board review model: Interrelationship of trainee-investigators, funding, and initial approval

In this study we sought to identify variables associated with institutional review board (IRB) decisions to develop an efficient "pre-IRB" review model. We explored several variables, including relationships among the identification of trainees as investigators, external sources of funding, and initial approval. The sample consisted of all new submissions reviewed by the 2 medical IRBs at the University of Miami (UM) during a 1-year period. Trainees included students, residents, and fellows. At least 1 trainee had to be identified for a proposal to be considered a trainee submission. The medical-science committees (MSCs) were similar with regard to the numbers of new submissions they reviewed during convened meetings (MSC-A 242, MSC-B 241) and the percentages of proposals that were initially approved (MSC-A 52.9%, MSC-B 53.1%). Approved submissions were defined as those initially approved or conditionally approved pending minor modifications. We noted a robust statistical difference between the percentages of trainee submissions initially approved (39.9%) and submissions that did not identify a trainee (59.4%) ( P <.0001). Of the proposals that were initially not approved (tabled [deferred] or rejected [not approved]), 28.9% of those including a trainee were rejected, compared with 11.0% without a trainee ( P <.001). Proposals in which the source of funding was identified were more likely to be approved (64.2%) than were those in which it was not (30.8%) ( P <.0001). Funding also seemed to influence the trainee and initial-approval interaction. Our results show that new submissions that identified trainee investigators were more likely to be deferred or not approved than those that did not. Nonapproved proposals that identified a trainee were 3.8 times more likely to be initially rejected than those that did not. A prereview model could target those submissions that list a trainee, lack funding, or both.

Emerging findings in ethics of schizophrenia research

PURPOSE OF REVIEW

We review recent publications pertaining to six topics: investigators, professional integrity, and sources of potential bias; scientific designs; protocol safeguards; influences on research participation decisions and perceptions of risk; informed consent--decision-making capacity, appreciation and the therapeutic misconception, and voluntarism; and informed consent--intervention studies.

RECENT FINDINGS

Little empirical work has been conducted on investigator training and potential conflicts of interest. Numerous conceptual pieces have tackled controversial issues related to study designs, with the initial focal point being the ethics of placebo-controlled studies; only a handful of reports, however, have empirically addressed these topics. Emerging findings pertinent to protocol safeguards in schizophrenia research suggest general support by individuals with schizophrenia for a variety of safeguards. Recent work on influences on participation decisions suggests that people with schizophrenia use fundamentally similar considerations as medically ill people and healthy comparison participants--a combination of personal and altruistic motives. Much of the data-based literature has focused on informed consent. We highlight studies indicating that patients living with schizophrenia show heterogeneity in consent-related abilities but may possess key strengths in the research situation, not simply greater vulnerability as suggested in the historical literature. Furthermore, consent-related abilities appear to be enhanced with educational interventions.

SUMMARY

Empirical studies focusing on a variety of ethically relevant domains in schizophrenia research are needed. Future studies should incorporate quantitative and qualitative methods, integrate perspectives of stakeholders, and investigate the effects and appropriateness of current protocol safeguards.

Evaluation of new treatments in radiation oncology: are they better than standard treatments?

CONTEXT

The superiority of innovative over standard treatments is not known. To describe accurately the outcomes of innovations that are tested in randomized controlled trials (RCTs) 3 factors have to be considered: publication rate, quality of trials, and the choice of the adequate comparator intervention.

OBJECTIVE

To determine the success rate of innovative treatments by assessing preferences between experimental and standard treatments according to original investigators' conclusions, determining the proportion of RCTs that achieved primary outcomes' statistical significance, and performing meta-analysis to examine if the summary point estimate favored innovative vs standard treatments.

DATA SOURCES

Randomized controlled trials conducted by the Radiation Therapy Oncology Group (RTOG).

STUDY SELECTION

All completed phase 3 trials conducted by the RTOG since its creation in 1968 until 2002. For multiple publications of the same study, we used the one with the most complete primary outcomes and with the longest follow-up information.

DATA EXTRACTION

We used the US National Cancer Institute definition of completed studies to determine the publication rate. We extracted data related to publication status, methodological quality, and treatment comparisons. One investigator extracted the data from all studies and 2 independent investigators extracted randomly about 50% of the data. Disagreements were resolved by consensus during a meeting.

DATA SYNTHESIS

Data on 12,734 patients from 57 trials were evaluated. The publication rate was 95%. The quality of trials was high. We found no evidence of inappropriateness of the choice of comparator. Although the investigators judged that standard treatments were preferred in 71% of the comparisons, when data were meta-analyzed innovations were as likely as standard treatments to be successful (odds ratio for survival, 1.01; 99% confidence interval, 0.96-1.07; P = .5). In contrast, treatment-related mortality was worse with innovations (odds ratio, 1.76; 99% confidence interval, 1.01-3.07; P = .008). We found no predictable pattern of treatment successes in oncology: sometimes innovative treatments are better than the standard ones and vice versa; in most cases there were no substantive differences between experimental and conventional treatments.

CONCLUSION

The finding that the results in individual trials cannot be predicted in advance indicates that the system and rationale for RCTs is well preserved and that successful interventions can only be identified after an RCT is completed.

Informed consent in pediatric clinical trials

PURPOSE OF REVIEW

Clinical research in children is increasing. Concerns have been raised about both the inclusion and the exclusion of children in such research. Corresponding to these concerns, issues in informed consent for pediatric trials have become more pressing. This review discusses informed consent in pediatric trials and characterizes the latest literature.

RECENT FINDINGS

Research into the consent process has shown that central concepts in pediatric research such as randomization and the distinctions between phases of clinical trials are not uniformly understood by parents or older pediatric patients. Newer approaches that are being developed to help remedy these deficits include the use of staged informed consent, the incorporation of interactive computer technologies to convey complex ideas, and variations in approaches to assent of the child based on multifactorial assessments of competence. Other variables in the consent process that are being studied for their impact on the process include individual life experiences and cultural background. Gaps in federal regulation and oversight of "informed consent" are emerging as new cases test established assumptions.

SUMMARY

Lessons learned from recent studies regarding oversight of the consent process in pediatric clinical trials, the complex nature of assent, the impact of cultural variables, and more effective means of communicating what is involved in a clinical trial will shape future studies in consent and help to improve the process.

Who Enrolls in Observational End of Life Research? Report from the Cultural Variations in Approaches to End of Life Study

BACKGROUND

Response bias in end of life research is important though not well understood.

OBJECTIVES

To compare consenting advanced cancer patient participants and refusers in observational end of life research. We hypothesized that, compared with refusers, consenters would: 1) have a stronger belief in personal gain from research participation, 2) be more satisfied with their medical care, 3) be more satisfied with support from family and friends, and 4) be in less physical discomfort compared with refusers.

METHODS

Sixty eight patients consented to enroll in the 'parent' observational study. Thirty six patients refused to participate. Reasons for refusal were recorded verbatim and coded using qualitative techniques. Both patient consenters and patient refusers were asked the same questions regarding personal gain, satisfaction with medical care, family and social support, and physical discomfort.

RESULTS

Consenters believed that they had more to gain from participation in research compared with refusers (p = 0.04). Consenters felt that aches or pain were more of a problem for them compared with refusers (p < 0.001). Both satisfaction with medical care and with support from family and friends were similar between consenters and refusers.

CONCLUSIONS

Consenting study participants in observational research at end of life believe they have more to gain from study participation than do refusers. Contrary to our hypothesis, consenting participants were those who were experiencing greater physical discomfort compared to refusers.

Child and parent reactions to participation in clinical research

BACKGROUND

Psychological and psychiatric research studies in medical settings often enroll children who are ill, injured, coping with pain or undergoing stressful medical procedures. Yet empirical evidence to date regarding the effects of research on these participants is scarce. This study assessed reactions of injured children and their parents to research participation and examined associations with demographic, injury and acute stress variables.

METHODS

Administered standard research reactions questionnaires to 203 injured children (5-17) and 200 parents participating in a study of acute posttraumatic stress.

RESULTS

Fifty-two percent of children and 74% of parents were glad they had participated; 77% of children and 90% of parents felt good about helping others. Self-reported distress from study participation was uncommon (5% of children and parents). Child age was associated with more positive appraisals of the research process and with greater trust in and information about elements of informed consent.

CONCLUSIONS

Participation in a research interview following traumatic injury had little risk of generating distress for children or parents. The most commonly reported positive aspect of research participation was feeling good about helping others. This study supports the feasibility of incorporating standardized assessment of participant reactions in clinical research protocols.

Informed consent and biobanks

Biomedical research has always relied on access to human biological materials and clinical information, resources that when combined form biobanks. In the past, it appears that investigators sometimes used these resources with relatively little oversight, and without the consent of the individuals from whom these materials and information were obtained. Several developments in the last ten to fifteen years have converged to place greater emphasis on the role of individual consent in the creation and use of biobanks. The most important by far is the power of information technology, which has transformed our lives in almost every domain. In the research setting, it is now easy to abstract information from electronic medical records. Computers make it possible to analyze enormous datasets and have contributed in essential ways to the dramatic increases in our understanding of genomics and other areas of biomedical science.

Public health and terrorism preparedness: cross-border issues

On December 15, 2003, the Centers for Public Health Preparedness at the University of Minnesota and the University of Iowa convened the "Public Health and Terrorism Preparedness: Cross-Border Issues Roundtable." The purpose of the roundtable was to gather public health professionals and government agency representatives at the state, provincial, and local levels to identify unmet cross-border emergency preparedness and response needs and develop strategies for addressing these needs. Representatives from six state and local public health departments and three provincial governments were invited to identify cross-border needs and issues using a nominal group process. The result of the roundtable was identification of the needs considered most important and most doable across all the focus groups. The need to collaborate on and exchange plans and protocols among agencies was identified as most important and most doable across all groups. Development of contact protocols and creation and maintenance of a contact database was also considered important and doable for a majority of groups. Other needs ranked important across the majority of groups included specific isolation and quarantine protocols for multi-state responses; a system for rapid and secure exchange of information; specific protocols for sharing human resources across borders, including emergency credentials for physicians and health care workers; and a specific protocol to coordinate Strategic National Stockpile mechanisms across border communities.

The physician/investigator's obligation to patients participating in research: the case of placebo controlled trials

Some authors argue that the ethics of medical care and the ethics of research differ, and that it is a mistake to conflate the two. They propose “that medical research and medical treatment are two distinct forms of activities, governed by different ethical principles.” This raises the question of whether physicians who are also clinical investigators may separate their role as physician from that of researcher when they are involved in clinical trials, thereby avoiding the obligations required in the physician-patient relationship. Miller and Brody suggest that medical training is to blame for what they believe is the physicians’ tendency to confound the obligations of research and practice. “Physician-investigators, after all, went to medical school” they explain. They believe that considering research with patients outside the ethical framework of the physician-patient relationship may be “difficult and threatening” to physicians who have “psychological needs” to consider the ethical obligations flowing from their relationship with their patients.

Rethinking research ethics

Contemporary research ethics policies started with reflection on the atrocities perpetrated upon concentration camp inmates by Nazi doctors. Apparently, as a consequence of that experience, the policies that now guide human subject research focus on the protection of human subjects by making informed consent the centerpiece of regulatory attention. I take the choice of context for policy design, the initial prioritization of informed consent, and several associated conceptual missteps, to have set research ethics off in the wrong direction. The aim of this paper is to sort out these confusions and their implications and to offer instead a straightforward framework for considering the ethical conduct of human subject research. In the course of this discussion I clarify different senses of autonomy that have been confounded and present more intelligible justifications for informed consent. I also take issue with several of the now accepted dogmas that govern research ethics. These include: the primacy of informed consent, the protection of the vulnerable, the substitution of beneficence for research's social purpose, and the introduction of an untenable distinction between innovation and research.

Efficacy and safety of single- and multiple-dose ketotifen fumarate 0.025% ophthalmic solution in a pediatric population

Allergic conjunctivitis can seriously disrupt children's daily activities. This study assessed the efficacy (onset and duration of action) and safety of ketotifen fumarate 0.025% ophthalmic solution compared with vehicle placebo in pediatric subjects after single and multiple dosing. This was a double-masked, multicenter, fellow-eye, placebo-controlled, conjunctival allergen challenge trial. Eligible subjects (8-16-yr-olds) who produced a qualifying reaction to allergen were randomized to a single dose (one drop) of ketotifen fumarate in one eye and vehicle placebo in the fellow eye, followed by an allergen challenge at 15 min and 8 h post-dose. Subjects who had a qualifying reaction to allergen in the placebo-treated eye and a qualifying response to ketotifen in the active-treated eye following the single dose were re-randomized to a multiple-dose treatment period. They were instructed to instill one drop of ketotifen fumarate in one eye and placebo in the other eye twice daily for 4 wk. An allergen challenge was conducted 8 h after the last dose. The primary efficacy assessment was ocular itching, judged by the subject at 3, 7, and 10 min post-allergen challenge after single- and multiple-dose treatments. Other ocular signs and symptoms were assessed at 7, 10, and 15 min post-dose. A total of 133 subjects were randomized to single-dose treatment; 105 were evaluable for efficacy. Of these, 60 were re-randomized to multiple-dose treatment, and 55 were evaluable for efficacy. After single and multiple doses, ketotifen fumarate significantly inhibited ocular itching compared with placebo at all post-challenge timepoints (p < 0.001) and also significantly reduced hyperemia, chemosis, and lid swelling (p = 0.031). No drug-related systemic adverse events were reported, and ocular adverse events were comparable to placebo. No subject discontinued prematurely due to an adverse event. These results indicate that ketotifen fumarate 0.025% ophthalmic solution is an effective and safe treatment option for children with allergic conjunctivitis.

Investigation of Ethnic Differences in Willingness to Enroll in a Rehabilitation Research Registry

OBJECTIVE

To investigate differences between African American and white respondents in willingness to enroll in a rehabilitation research registry for future research and to determine if reasons for consenting and refusing to enroll differ by ethnicity.

DESIGN

Inpatient recruitment results from 739 African American and white respondents in which patients were admitted to a rehabilitation hospital with a diagnosis of stroke or traumatic brain injury.

RESULTS

A similar proportion of African American and white respondents (both patients and surrogates) consented to enroll in the registry (72% of all African American respondents vs. 68% of all white respondents). African Americans and whites provided similar reasons for consenting and refusing to enroll. Demographic variables associated with consent were: higher education, younger age, and facility. The odds of consenting to enroll in the registry were 5 times as high for those who thought they had a great deal to gain from enrollment compared with those who thought they had less to gain and were nearly 2 times as high for those who reported little concern about privacy compared with those who were more concerned about privacy.

CONCLUSIONS

Ethnicity was not found to be a predictor of willingness to enroll in a study registry. A greater belief of gain and less concern over privacy were associated with willingness to enroll, even after controlling for age, education, facility, and ethnic group.

Gene therapy in the clinic: whose risks?

Current experience with gene therapy for X-linked severe combined immunodeficiency disorder (X-SCID) suggests that we might now be at the point where it can be considered the 'standard of care'. This therapy carries an unquantified risk of leukaemia, raising important questions for regulators. How dangerous does a potentially curative therapy for a fatal illness need to be before we call it unsafe. How uncertain does a risk need to be for us to regard a therapy as still 'experimental'? Whose interests should prevail? Here I argue that in X-SCID it is the parents and children whom we should listen to first and foremost. How far does this patient-centred approach to licensing therapies extend? Can it be given a rational basis?

Ethical issues in the collection, storage, and research use of human biological materials

Human biological materials (HBMs) are samples of blood, DNA, organs and tissues commonly obtained during routine surgical procedures or through direct donation by an individual. This article reviews four of the most pressing issues arising from the collection, storage, and use of HBMs in research: current regulations governing research with human subjects, misuse of genetic information, economic factors, and public knowledge.

The social and ethical issues of post-genomic human biobanks

Biobanking - the organized collection of biological samples and associated data - ranges in scope from small collections of samples in academic or hospital settings to large-scale national repositories. Biobanks raise many ethical concerns, to which authorities are responding by introducing specific regulations. Genomics research, which thrives on the sharing of samples and information, is affected by two prominent ethical questions: do ethical principles prevent or promote the sharing of stored biological resources? How does the advent of large-scale biobanking alter the way in which ethical issues are addressed?

The distribution of biomedical research resources and international justice

According to some estimates, less than 10% of the world's biomedical research funds are dedicated to addressing problems that are responsible for 90% of the world's burden of disease. This paper explains why this disparity exists and what should be done about it. It argues that the disparity exists because: 1) multinational pharmaceutical and biotechnology companies do not regard research and development investments on the health problems of developing nations to be economically lucrative; and 2) governmental agencies that sponsor biomedical research face little political pressure to allocate funds for the problems of developing nations. This paper argues that developed nations have an obligation to address disparities related to biomedical research funding. To facilitate this effort, developed countries should establish a trust fund dedicated to research on the health problems of developing nations similar to the Global AIDS Fund.

Neonatal research and the validity of informed consent obtained in the perinatal period

BACKGROUND

Consent for participation in clinical research is considered valid if it is informed, understood, and voluntary. In the case of minors, parents give permission for their child to participate in research studies after being presented with all information needed to make an informed decision. Although informed consent is a vital component of clinical research, there is little information evaluating its validity in neonatal intensive-care populations. The objective of this project was to determine the validity of informed consent obtained from parents of infants enrolled in the multicenter randomized research study, neurologic outcomes and pre-emptive analgesia in the neonate (NEOPAIN).

DESIGN/METHODS

Parents of infants who survived to discharge and had signed consent for their newborn to participate in the NEOPAIN study at the University of Kentucky were asked 20 open-ended questions to determine their level of understanding about the NEOPAIN study. The NEOPAIN consent form, which had been approved by the University of Kentucky Medical Institutional Review Board (IRB), was used to formulate these questions. Questions addressed the timing of consent, parental understanding of the purpose, benefits, and risks of the study, the voluntary nature of the project, and their willingness to enroll in future studies if the opportunity presented. Answers were scored on a Likert scale, with 1 for no understanding and 5 for complete understanding.

RESULTS

Five of 64 parents (7.8%) had no recollection of the NEOPAIN study or of signing consent. Of those who remembered the study, only 67.8% understood the purpose of the study, with a higher proportion of the mothers than fathers knowing the purpose of the study (73.3% vs 57.1%), (p=0.029). Of those who understood the purpose of the study 95% were able to verbalize the benefits, but only 5% understood any potential risks. No parents reported feeling pressured or coerced to sign consent for the project and all parents reported they would enroll their child in additional studies if asked.

CONCLUSIONS

Valid consent in the antenatal/perinatal population is difficult, if not impossible, to obtain. To maximize validity of consent in the antenatal/perinatal population every effort should be made to include mothers in the consent process. Additional attention during the consent process should be given to possible risks of the study.

Music and learning-induced cortical plasticity

Auditory stimuli are encoded by frequency-tuned neurons in the auditory cortex. There are a number of tonotopic maps, indicating that there are multiple representations, as in a mosaic. However, the cortical organization is not fixed due to the brain's capacity to adapt to current requirements of the environment. Several experiments on cerebral cortical organization in musicians demonstrate an astonishing plasticity. We used the MEG technique in a number of studies to investigate the changes that occur in the human auditory cortex when a skill is acquired, such as when learning to play a musical instrument. We found enlarged cortical representation of tones of the musical scale as compared to pure tones in skilled musicians. Enlargement was correlated with the age at which musicians began to practice. We also investigated cortical representations for notes of different timbre (violin and trumpet) and found that they are enhanced in violinists and trumpeters, preferentially for the timbre of the instrument on which the musician was trained. In recent studies we extended these findings in three ways. First, we show that we can use MEG to measure the effects of relatively short-term laboratory training involving learning to perceive virtual instead of spectral pitch and that the switch to perceiving virtual pitch is manifested in the gamma band frequency. Second, we show that there is cross-modal plasticity in that when the lips of trumpet players are stimulated (trumpet players assess their auditory performance by monitoring the position and pressure of their lips touching the mouthpiece of their instrument) at the same time as a trumpet tone, activation in the somatosensory cortex is increased more than it is during the sum of the separate lip and trumpet tone stimulation. Third, we show that musicians' automatic encoding and discrimination of pitch contour and interval information in melodies are specifically enhanced compared to those in nonmusicians in that musicians show larger functional mismatch negativity (MMNm) responses to occasional changes in melodic contour or interval, but that the two groups show similar MMNm responses to changes in the frequency of a pure tone.

Ethics in psychiatric research: study design issues

OBJECTIVE

To identify and discuss ethical aspects of study design issues in psychiatric research.

METHOD

We conducted a literature review and conceptual analysis of study design in psychiatric research focusing on placebo, medication tapering and withdrawal (washout), and symptom provocation (challenge) designs.

RESULTS

While advances in the care and treatment of persons with psychiatric disorders are crucial to the improved well-being of this stigmatized and often forgotten population, past abuses demonstrate the importance of the thoughtful application of ethical principles in the conduct of research. Some ethical issues have particular relevance to psychiatric research arising primarily from the specific vulnerabilities of those with mental illness and the risks posed by some research methodologies. Accordingly, sensitivity is required in the design of psychiatric research.

CONCLUSION

Placebo, challenge, and washout study designs can present particular risks in the population of persons with mental illness. These issues are described and suggestions offered to promote the ethical design of psychiatric research.

Regulatory and ethical principles in research involving children and individuals with developmental disabilities

Children and individuals with developmental disabilities (DD) compared to typical participants are disadvantaged not only by virtue of being vulnerable to risks inherent in research participation but also by the higher likelihood of exclusion from research altogether. Current regulatory and ethical guidelines although necessary for their protection do not sufficiently ensure fair distributive justice. Yet, in view of disproportionately higher burdens of co-occurring physical and mental disorders in individuals with DD, they are better positioned to benefit from research by equitable participation. Greater elucidation of this ethical dilemma is called for by researchers, institutional review boards, and funding agencies to urgently redress the imbalance. This article discusses many of the regulatory principles to ensure better research participation of children and individuals with DD: human rights, validity, distributive justice, beneficence/nonmaleficence, and autonomy.

How can we help? From "sociology in" to "sociology of" bioethics

Sociology and bioethics have an uneasy relationship. Bioethicists find sociology helpful for describing and analyzing ethical issues, but they are less enthusiastic when bioethics becomes the subject of sociological scrutiny. After review of different sociological approaches to bioethical topics -- descriptive, evaluative, and analytical -- I explain how bioethics will benefit by using the tools of sociology to answer its questions ("sociology in bioethics") and by allowing sociology to use bioethics to answer sociological questions ("sociology of bioethics").

Leopards in the temple: restoring scientific integrity to the commercialized research scene

For more than two decades, significant controversies have been brewing over the efficacy and safety of Selective Serotonin Reuptake Inhibitors (or SSRIs) and other treatments for depression, and also over the expansion of their use for the treatment of a variety of other conditions. These controversies culminated, in June 2004, with alawsuit intended by Eliot Spitzer, Attorney General of the State of New York. The lawsuit accused pharmaceutical giant GlaxoSmith-Kline of “repeated and persistent fraud by misrepresentation, concealing and otherwise failing to disclose to physicians information in its control concerning the safety and effectiveness of its antidepressant medication paroxetine” (better known as “Paxil”) in treating children and adolescents suffering from depression.

Suppression of environmental science

There is a long history of attacks on scientists. During the Inquisition, the Roman Catholic Church charged Galileo with heresy and, after imprisonment and threats of torture, forced him to renounce his theory that the sun, not the earth, was the center of the universe. In the 1950s, politicians sought to silence scientists that allegedly held political views sympathetic to Communists.

In recent years, research results, rather than the scientist's religion or politics, have motivated attacks on scientists. As environmental issues grow in economic significance and as science takes on increasing importance in influencing public opinion and resolving environmental policy debates, suppression of environmental science has become increasingly common. As one author observed, the power of science to legitimate environmental positions by claiming exclusive truth makes ownership of science one of the most contested issues in modern environmentalism.

Regulating Research and experimentation: a view from the U.K

A medical profession which did not seek improved means to conquer disease would be condemned for dereliction of its duty, Members of the public will not accept the current state of the medical arts as finite but feel justified in expecting the development of more effective therapies for illness, and the promotion of improved means of preventive care.

With this assertion, the distinguished academic, Bernard Dickens, places research firmly in the domain of the public interest. Foster agrees, saying that, “[t]o improve medical care as much as we can, if not to perfect it, means that we have to accept the need for research.” Giesen adds a further emphasis to the search for medical advancements, saying that “freedom of research and scientific inquiry is, in itself, an important aspect of open societies.“

Exposing the "myth" of ABC, "anything but chrysotile": a critique of the Canadian asbestos mining industry and McGill University chrysotile studies

BACKGROUND

Beginning in the 1930s, the Canadian asbestos industry created and advanced the idea that chrysotile asbestos is safer than asbestos of other fiber types.

METHODS

We critically evaluate published and unpublished studies funded by the Quebec Asbestos Mining Association (QAMA) and performed by researchers at McGill University.

RESULTS

QAMA-funded researchers put forth several myths purporting that Quebec-mined chrysotile was harmless, and contended that the contamination of chrysotile with oils, tremolite, or crocidolite was the source of occupational health risk. In addition, QAMA-funded researchers manipulated data and used unsound sampling and analysis techniques to back up their contention that chrysotile was "essentially innocuous."

CONCLUSIONS

These studies were used to promote the marketing and sales of asbestos, and have had a substantial effect on policy and occupational health litigation. Asbestos manufacturing companies and the Canadian government continue to use them to promote the use of asbestos in Europe and in developing countries. Am. J. Ind. Med. 44:540-557, 2003.