Full-spectrum proxy consent for research participation when persons with Alzheimer disease lose decisional capacities: research ethics and the common good

This article focuses on riskier forms of research in Alzheimer disease (AD). It asks two fundamental questions. First, what is the upper threshold of potential risk that should be allowable in AD Research ("maximal potential risk")? Second, should proxy consent be permitted in higher-risk research even when there is no clear potential therapeutic value to the subject? There has been little discussion of maximal potential risk at a time when studies may be becoming increasingly invasive and risky. Proxy consent under such circumstances merits more thorough defense. This article discusses these questions on the basis of a "common good" ethic and calls for more input from researchers and the AD-affected constituency in resolving them.

Implementing ethics in the professions: examples from environmental epidemiology

The need to integrate ethics into professional life, from the grassroots up, has been recognized, and a comprehensive ethics program has been proposed as a model. The model includes the four dimensions of: consensus building, ethics guidelines development and review, education, and implementation. The activities of the International Society for Environmental Epidemiology (ISEE) are presented as examples and compared with the proposed model. Several innovative activities are described and incentives for ethical professional conduct are highlighted. The examples are provided for emulation by other professional organizations in the hope that, thereby, greater protection of the public interest will be achieved.

Educating researchers: ethics and the protection of human research participants

To improve the protection of human participants in research, the federal government has mandated education and training in bioethics and issues relevant to human research. Despite the large time and financial commitments involved with such education, little is known about whether these efforts will actually improve the protection of human subjects. In this article, I review the history of ethics education in research leading up to the 2000 mandate. I then explore ethics education and its evaluation in the biological sciences and medicine and describe the previous successes and failures of these efforts. Many objectives can be the focus of educational interventions and evaluation. Some interventions in these fields had small, though statistically significant, effects on moral reasoning skills, knowledge, and confidence. Interventions are more likely to have lasting impact on moral reasoning if they were of moderate duration and involved small group discussion of dilemmas. Whether these measurable differences lead to changes in behavior or real-time application of moral reasoning skills remains to be determined. By having a clear understanding of the specific objectives, strengths, and limitations of an educational intervention, educators can design programs that may have an increased likelihood of improving protection of human research participants.

Statistical issues on objective, design, and analysis of noninferiority active-controlled clinical trial

In practice, "noninferiority" active-controlled trials have been designed for three different objectives: establishing evidence of efficacy over placebo, preserving a specific percentage of the effect size of the active control, or demonstrating the test treatment is "not much inferior" to the active control. All three objectives can be represented by the same set of statistical hypotheses with the parameters defined differently. The various designs and statistical analysis procedures for active-controlled trials proposed in the literature can be group into two basic types: the historical-controlled trial approach and the cross-study comparison approach. These approaches require some unverifiable constancy assumptions. Under the constancy assumptions, the cross-study comparison uses the estimate effect of active-control treatment as the unbiased estimate of the active/placebo difference in the current noninferiority trial. A normalized Z-statistic is used to test the hypotheses. On the other hand, the historical controlled trial approach uses a conservative confidence limit as if it were a constant to replace the active/placebo difference in the current trial. The two approaches may lead to consistent conclusions only when the constancy assumptions can be supported by a large number of historical studies giving a consistent active-control treatment effect over placebo and that the active-control effect does not change over time.

TACT method for non-inferiority testing in active controlled trials

In active controlled trials without a placebo arm, non-inferiority testing is often considered but has different objectives. For the objective of demonstrating the efficacy of an experimental treatment or retention of a fraction of the control effect by the treatment, there are two types of statistical methods for testing - the synthesis method and the confidence interval method. According to the study of Wang, Hung and Tsong, the former is efficient under the so-called constancy condition but may have the alpha error rate inflate rapidly if the condition does not hold. In contrast, the latter method with careful selection of the non-inferiority margin tends to be conservative if the condition holds and may still have a valid alpha error otherwise unless the effect of the active control is less to a large extent in the active controlled trial than in the historical trials. We developed the TACT method, Two-stage Active Control Testing, as a viable compromise between the two methods. Through the TACT method, the uninterpretable non-inferiority testing may be avoided prior to the end of the trial. The TACT method carefully constructed can have a valid alpha error rate and the power close to the synthesis method if the constancy condition holds. In addition, the TACT method is more powerful than the confidence interval method for testing for the efficacy of the new treatment relative to the putative placebo and for showing that the new treatment is not inferior to the active control comparator.

Some fundamental issues with non-inferiority testing in active controlled trials

In an active controlled non-inferiority trial without a placebo arm, it is often not entirely clear what the primary objective is. In many cases the considered goal is to demonstrate that the experimental treatment preserves at least some fraction of the effect of the active control. The active control effect is a parameter, the value of which is unknown. To test the hypothesis of effect preservation, the classical confidence interval approach requires specification of a non-inferiority margin which is a function of the unknown active control effect. When the margin is estimated, it is also not clear what is the relevant type I error of making a false assertion about preservation of the active control effect. The statistical uncertainty of the estimated margin arguably needs to be incorporated in evaluation of the type I error. In this paper we discuss these fundamental issues. We show that the classical confidence interval approach cannot attain the target type I error exactly since this error varies as the sample size or as the values of the nuisance parameters in the active controlled trial change. In contrast, the preservation tests, as proposed in literature, can attain the target type I error rate exactly, regardless of the sample size and the values of the nuisance parameters, but can do so only at the price of several strong assumptions holding that may not be directly verifiable. One assumption is the constancy condition holding whereby the effect of the active control in the historical trial populations is assumed to carry to the population of the active control trial. When this condition is violated, both the confidence interval approach and the preservation test method may be problematic.

Non-inferiority trials: design concepts and issues - the encounters of academic consultants in statistics

Placebo-controlled trials are the ideal for evaluating medical treatment efficacy. They allow for control of the placebo effect and are most efficient, requiring the smallest numbers of patients to detect a treatment effect. A placebo control is ethically justified if no standard treatment exists, if the standard treatment has not been proven efficacious, there are no risks associated with delaying treatment or escape clauses are included in the protocol. Where possible and justified, they should be the first choice for medical treatment evaluation. Given the large number of proven effective treatments, placebo-controlled trials are often unethical. In these situations active-controlled trials are generally appropriate. The non-inferiority trial is appropriate for evaluation of the efficacy of an experimental treatment versus an active control when it is hypothesized that the experimental treatment may not be superior to a proven effective treatment, but is clinically and statistically not inferior in effectiveness. These trials are not easy to design. An active control must be selected. Good historical placebo-controlled trials documenting the efficacy of the active control must exist. From these historical trials statistical analysis must be performed and clinical judgement applied in order to determine the non-inferiority margin M and to assess assay sensitivity. The latter refers to establishing that the active drug would be superior to the placebo in the setting of the present non-inferiority trial (that is, the constancy assumption). Further, a putative placebo analysis of the new treatment versus the placebo using data from the non-inferiority trial and the historical active versus placebo-controlled trials is needed. Useable placebo-controlled historical trials for the active control are often not available, and determination of assay sensitivity and an appropriate M is difficult and debatable. Serious consideration to expansions of and alternatives to non-inferiority trials are needed.

The human subjects trade: ethical and legal issues surrounding recruitment incentives

Over the past 5 years, a series of articles in leading American newspapers has revealed the extent to which the conduct of clinical trials may be affected by inducements offered by corporate research sponsors and accepted by some unscrupulous physicians. The cases described were disturbing. They involved physicians engaged in excessive “enrollment activities” in exchange for money. Some of these physicians perpetrated fraud, falsifying their recruitment records in order to increase their profits. Others ignored exclusion criteria designed to ensure the safety of subjects and the validity of research results, referring their patients to research investigating treatments for conditions from which they did not suffer. One of the articles reports that physicians focusing exclusively on commercial research regularly divulge annual incomes upwards of $1,000,000 with profits in excess of $300,000. Two physicians accumulated well over $10,000,000 through clinical trials activities in less than a decade.

Proving non-inferiority or equivalence of two treatments with dichotomous endpoints using exact methods

Since the early work of RA Fisher, exact methods have been recognized as important tools in data analysis because they provide valid statistical inference even with small sample sizes, or with sparse or skewed data. With the recent advance of computational power and the availability of commercial software packages, exact methods have gained substantial popularity over the past two decades. However, most of these exact methods have been devoted to testing classical null hypotheses of no differences, and until recently little was known about exact methods dealing with non-inferiority or equivalence hypotheses. The presence of nuisance parameters in testing non-inferiority/equivalence hypotheses presents a special challenge for exact methods because of the intense computational requirement. In this paper, we review exact methods available for proving non-inferiority or equivalence of two treatments with a dichotomous endpoint. First, we present the general methodology for conducting exact tests for non-inferiority or equivalence; we then discuss several unconditional and conditional methods available for constructing hypothesis tests and confidence intervals based on three commonly used measures, namely, the difference, relative risk, and odds ratio of two independent proportions or rates. Finally, we illustrate with several examples the application of these exact methods in analysing and planning non-inferiority or equivalence trials.

Adverse events reporting--the tip of an iceberg

NIH data indicate that annually seven million human subjects are enrolled in research sponsored by NIH alone. In addition, there are sixteen federal agencies and numerous departments outside NIH conducting experiments with human subjects. Moreover, the pharmaceutical industry spends $26 billion on research (compared to $16 billion for NIH), thus, the total number of human subjects enrolled in research for both the public and private sectors can be estimated as high as nineteen million. I present data on the potential magnitude of adverse events in the United States among human subjects enrolled in research that appear to be unreported and unaccounted for. We obtained data from the Office for Human Research Protections (OHRP) through the Freedom of Information Act for the years 1990 to August 2000 regarding all Institutional Incident Reports (IRPTs) and a list of Compliance Oversight Branch Investigations (COBIs) involving Multiple Project Assurances (MPAs). In the ten years of reporting for nearly seventy million human subjects, there were only 878 IRPTs and 41 investigations. From the incident reports to OHRP, 44% involved adverse events. Those projects investigated for Multiple Project Assurances violations (41 such investigations) showed that 51% were suspended or terminated. The number of deaths reported to OHRP in ten years for the seventy million human subjects is merely eight. The anticipated number of deaths among the general population in seventy million (assuming subject's duration in trials is one month) is 51,000. The number of suicides and attempted suicides alone among the seventy million expected research subjects can be anticipated to be about 5,000. Therefore, the number of expected deaths should have been between 5,000 and 51,000. These numbers and percentages represent minimal numbers since they are not a result of random audits or investigations, but a result of self-reporting or an exogenous complaint. Despite the fact that these are conservative estimates, they represent a significant problem. The purpose of this paper is to present the potential boundaries and magnitude of the problem in the current use of human subjects in research. This is a call for responsible institutions to undertake a thorough evaluation of the problem in order to obtain accurate information. For the immediate future, strong actions need to be taken to increase the protection of human subjects enrolled in research. This precautionary policy is prudent in light of recent revelations and data from this investigation.

Power and sample size determination for noninferiority trials using an exact method

Noninferiority studies are frequently conducted to justify the development of new drugs and vaccines that have been shown to offer better safety profiles, easier administration, or lower cost while maintaining similar efficacy as compared to the standard treatment. Recently, exact methods have been developed to address the concern that existing asymptotic methods for analyzing and planning noninferiority may fail because of small sample size or because of skewed or sparse data structure. In this paper, we explore the use of exact methods in determining sample size and power for noninferiority studies that focus on the difference of two proportions. The methodology for sample size and power calculations is developed based on an exact unconditional test of noninferiority. We illustrate this exact method using a clinical trial example in childhood nephroblastoma and briefly discuss the optimal sample-size allocation strategy. This exact unconditional method performs very well in various scenarios and compares favorably to its asymptotic counterpart in terms of sensitivity. Therefore, it is a very desirable tool for planning noninferiority trials, especially in situations where asymptotic methods are likely to fail.

Policy developments in regulatory approval

Although radical changes in drug regulation are rare (e.g., the Federal Food, Drug and Cosmetic Act of 1938 and the 1962 amendment to the Act creating an effectiveness requirement), regulations and guidance do evolve significantly in the face of new problems and accumulating experience. Recent changes have been driven by the Food and Drug Administration Modernization Act (FDAMA), user fee legislation, the International Conference on Harmonization, recent safety related drug withdrawals, and concerns about trial ethics and investigator conflict of interest. FDAMA and guidance developed in response to it has helped circumstances in which FDA would rely on a single study to support effectiveness and the circumstances in which surrogate endpoints could support approval. An ICH Document 'Choice of control group and related design issues in clinical trials' focussed attention on the ethics of placebo controls (acceptable, even if there is existing therapy, when the placebo-treated patient will suffer no irreversible injury) and the design of 'equivalence' or 'non-inferiority' trials. There has been greatly increased attention to obtaining good dose-response information and to assessing need for modifying treatment in demographic (age, gender, race) and concomitant disease (renal or hepatic function abnormalities) subgroups, and in assessing drug-drug interactions. Other important trends are increasing reliance on non-U.S. data, increasing numbers of FDA-industry meetings during drug development, and new focus on risk assessment and risk management.

What's end of life got to do with it? Research ethics with populations at life's end

PURPOSE

This study addressed key concerns that gave rise to the question of whether special guidelines were needed to monitor research at the end of life.

DESIGN AND METHODS

Summary of established ethical and legal guidelines that govern the conduct of research with human subjects, with discussion of issues relevant to populations at life's end. Discussion of whether special guidelines are indicated focuses on four questions concerning: (a). time periods; (b). methods and approaches; (c). informed consent; and (d). obligations of researchers.

RESULTS

Although research involving patients at end of life does present important ethical and moral challenges to researchers and should be scrutinized carefully by institutional review boards (IRBs), special guidelines are not required.

IMPLICATIONS

Closer examination of the dimensions discussed will enhance the research endeavor and model the qualities for which end-of-life research should become known.

Design and reporting modifications in industry-sponsored comparative psychopharmacology trials

This review of recently published pharmaceutical industry-sponsored comparative psychotropic drug trials aims to classify apparent design and reporting modifications that favor the sponsor's product. The modifications have been grouped into 13 discrete categories, and representative examples of each are presented. Strong circumstantial evidence suggests that marketing goals led to these adjustments. The consequences of marketing influences on comparative psychopharmacology trials are discussed in terms of conflicts of interest, the integrity of the scientific literature, and costs to consumers, as well as their impact on physician practice.

The reactions to research participation questionnaires for children and for parents (RRPQ-C and RRPQ-P)

Systematic assessment of the effect of clinical research studies on child and parent participants has been limited. Such assessment could provide an empirical basis for the ethical conduct of research, assisting investigators and institutional review boards in balancing the need for sound research with the need to protect study participants. The Reactions to Research Participation Questionnaire for Children (RRPQ-C) and the RRPQ for Parents (RRPQ-P) are brief measures designed to assess child or parent views of clinical research studies. Both measures were piloted and then administered as part of an interview-based study of traumatically injured children and their parents, to assess their psychometric properties and potential usefulness as addenda to future study protocols. The RRPQ-C and RRPQ-P each demonstrated acceptable internal consistency. Exploratory factor analyses provided general support for their conceptual basis. Both were easily administered and well-accepted by respondents. There is evidence that children and adults were willing to answer honestly, even about negative responses. Brief measures such as the RRPQ-C and RRPQ-P may provide a practical and empirically informed method for assessing children's and parents' responses to research participation. Investigators should consider including systematic standardized assessment of participant reactions in child clinical research studies.

Lessons from everyday lives: a moral justification for acute care research

Progress in emergency and critical care requires that clinical research be performed on patients who are incapable of granting consent for research participation. Analyses of the ethics of such research have left some questions incompletely answered. Why should we be permitted to expose vulnerable patients to research risks without their consent? In particular, how do we justify research interventions that have no potential benefit for participants (nontherapeutic interventions)? This article presents a moral justification for nontherapeutic interventions in emergency research. By relying on a framework for assessing research risks, and by drawing on the example of pediatric research, this justification is founded in how institutional review boards, and society in general, analyze risk. Our justification for emergency research also suggests additional protections for emergency research participants, including a stringent threshold for research risk, that still permit important research to proceed.

The misuse of statistics: concepts, tools, and a research agenda

This paper presents concerns regarding misuse of statistics in scientific work, especially in biomedical research. The paper discusses what is meant by "misuse." It appears that misuse arises from various sources: degrees of competence in statistical theory and methods, honest error in the application of methods, egregious negligence, and deliberate deception (misconduct.) The incidence of error is partly due to a perceived need to meet artificial statistical criteria for acceptance of research reports for publication by journals. There has been no systematic research into the prevalence of misuse or its breakdown by type. Nonetheless, there are ways to encourage, or even to enforce, good statistical practice. These can be greatly supported by use of available statistical ethics documents. This article suggests lines of further research that could define the problem more explicitly and that might lead to additional corrective measures.

Is the randomized, controlled trial in children an endangered species?

OBJECTIVE: To discuss the potential effects of current Food and Drug Administration (FDA) policy in the United States facilitating the approval of novel therapies for use in children (based on safety trials) on pediatric randomized, controlled trials in the pediatric intensive care unit setting. Method: The history of randomized, controlled trials, the FDA, and the events that led to this ruling are discussed. RESULTS: A recent FDA ruling ensures increased drug testing in children; however, it also opens the possibility for drug approval for use in children without any requirement for randomized, controlled trial testing of the efficacy of the drug on disease-specific outcomes. CONCLUSIONS: In light of the high degree of instability of pediatric intensive care unit patients, the frequent use of multiple drugs in a given patient with resultant drug-drug interactions, the risk of toxicity in critically ill infants and children with impaired drug metabolism, and age-dependent differences in physiology, clinicians must strive to be informed of the meaning of FDA approval or disapproval of the drugs they use for children.

Choosing an equivalence limit for noninferiority or equivalence studies

Studies that compare treatments with the purpose of demonstrating that the treatments are similar require an a priori definition of an equivalence limit, how different the treatments can be before the difference is of concern. Defining such an equivalence limit is one of the most difficult aspects of planning the study. Three principles are proposed for setting such limits, depending on the objective of the study: a putative placebo calculation, an approach based on clinically important differences, and methods based on statistical properties. All methods will be useful for many studies, but the study objective should determine the final choice of an equivalence limit. The statistician must play an integral role in determining the final equivalence limit. Advice is offered for helping the statistician participate in the decision on the equivalence limits.

Utility and pitfalls of some statistical methods in active controlled clinical trials

Increasingly often, the study objective in an active controlled clinical trial without a placebo arm is to show that a new treatment is no less effective than the active control treatment within some noninferiority range. Two issues behind this objective are that of whether the new treatment is efficacious relative to a putative placebo and that of whether the new treatment preserves a certain fraction of effect of the active control. To address these issues, two types of statistical analysis methods are employed in recent pharmaceutical applications. In one type of method, a noninferiority margin is determined, and then the relative effect of the new treatment versus the control is compared against the margin to test noninferiority and the efficacy of the new treatment. In the other type of method, a synthetic statistic is constructed to directly estimate or test the effect of the new treatment relative to the putative placebo without resorting to noninferiority argument. Preservation of control effect can also be estimated and tested. These methods carry some crucial assumptions. The effect of active control is often estimated from a collection of historical placebo controlled trials using the random effects modeling of DerSimonian and Laird. In this work we find that statistical validity of the latter method rests highly on the assumptions that control effect is not reduced in the current active controlled trial population compared to the historical trials and that a normal approximation is appropriate in the random effects modeling. This type of method is very sensitive to departure from these assumptions. In contrast, the former method is ultraconservative in terms of type I error when the assumptions are met and can be anticonservative when control effect is substantially less in the active controlled trial than estimated from the historical placebo controlled trials.

I need a placebo like I need a hole in the head

In this issue of the Journal of Law, Medicine & Ethics Peter Clark provides a comprehensive and sound ethical analysis of clinical trials examining the treatment of advanced Parkinson's disease with fetal tissue transplantation. These studies raise profound questions about how clinical trials of surgical interventions ought to be conducted. At stake is not only the ethical basis of such trials, but differing views as to the proper role of science in medicine and its limitations.

Experience with the broader debate on the ethical permissibility of placebo controls has taught us that the choice of control treatment is an aspect of trial design in which ethical and scientific issues overlap. Accordingly, I will highlight, and perhaps expand upon, three issues raised by Clark: What scientific questions ought clinical trials of surgical interventions ask? How should the ethical analysis of risk for such trials be conceived? And, are surgical patients a vulnerable population?

The ethics of drug research in children

The obligation of society to improve the welfare of its members requires the conduct of paediatric drug trials. Nevertheless, research activities must satisfy obligations to individual participants. The obligation to protect the welfare of children requires that nontherapeutic research procedures generally involve no more than minimal risk. It also requires that randomisation occurs only when the relative merits of therapeutic procedures remain unsettled among the relevant community of experts. The duty to respect the developing autonomy of children requires that they be included in decision-making about research participation in a manner consistent with the level of their decision-making capacity. However, when children lack mature decision-making capacities, the duty of parents to protect their welfare may properly constrain their choices. Justice requires that the benefits and burdens of research be distributed in a manner that assures equal opportunity for all children. Vulnerable children should receive special protection against the burdens of nontherapeutic research procedures. The benefits of participating in clinical trials should be available to all children with serious illnesses for which current treatment is unsatisfactory. Justice also requires that initiatives be undertaken to rectify current shortcomings in the scope of paediatric drug research. Striking an appropriate balance between obligations to conduct research and to protect the interests of participants is essential to the moral integrity of paediatric drug research.

Consistency of atypical antipsychotic superiority to placebo in recent clinical trials

BACKGROUND

The use of control placebos in clinical trials of new antipsychotic medications is increasingly under examination. The active controlled equivalence study could offer a potential alternative design. First, however, it must be clear that any proposed standard control agent has been consistently superior to placebo in previous studies.

METHODS

Through a Freedom of Information Act request, we identified nine placebo-controlled trials of risperidone, olanzapine, or quetiapine.

RESULTS

Meta-analysis indicated that the pooled estimate of the true population effect size +/- SE was 0.46 +/- 0.06 for categorical response rates and >0.53 +/- 0.07 for the continuous Brief Psychiatric Rating Scale change score outcome measure. If the desired detectable effect size is set very conservatively at a 95% confidence lower bound for the estimate of true effect size, statistical power for random samples of 80 per group drawn from a population of subjects similar to that of the nine meta-analyzed studies is.67 for categorical response rates and >.82 for the continuous measure, based on one-sided alpha =.05.

CONCLUSIONS

These data suggest substantial confidence that a therapeutic dose of an atypical antipsychotic will be statistically superior to placebo in an adequately sized randomized trial, when reporting a continuous measure as the principal outcome.

Of clones, stem cells, and children: issues and challenges in human research ethics

In the past 3 years, five scientific stories captivated the media and public attention: a sheep, Dolly, was cloned in Scotland; two scientific teams in the United States reported that they had isolated human stem cells; Jesse Gelsinger, an 18-year-old patient, died in a gene transfer experiment at the University of Pennsylvania; Vanderbilt University reported that it is providing fetal surgery for meningomyelocele; and researchers announced that a herd of previously cloned cows appears to be genetically younger than had been expected. These reports illustrate important issues in the ongoing discussion about research on children; indeed some of them challenge the breadth of the definition of research on children. This article, originally presented at an International Symposium sponsored by UNESCO on Bioethics and the Rights of the Child, describes how the National Bioethics Advisory Commission (NBAC) addressed two of these subjects-cloning and stem cell research-and identifies five challenges that science and society must address in the face of such emerging research technologies.

Ethics. Protecting communities in biomedical research

Although for the last 50 years, ethicists dealing with human experimentation have focused primarily on the need to protect individual research subjects and vulnerable groups, biomedical research, especially in genetics, now requires the establishment of standards for the protection of communities. We have developed such a strategy, based on five steps. (i) Identification of community characteristics relevant to the biomedical research setting, (ii) delineation of a typology of different types of communities using these characteristics, (iii) determination of the range of possible community protections, (iv) creation of connections between particular protections and one or more community characteristics necessary for its implementation, and (v) synthesis of community characteristics and possible protections to define protections appropriate for each type of community. Depending on the particular community, consent and consultation, consultation alone, or no added protections may be required for research.