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Kukora SK, Mychaliska GB, Weiss EM. Ethical challenges in first-in-human trials of the artificial placenta and artificial womb: not all technologies are created equally, ethically. J Perinatol 2023; 43:1337-1342. [PMID: 37400494 DOI: 10.1038/s41372-023-01713-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 06/07/2023] [Accepted: 06/21/2023] [Indexed: 07/05/2023]
Abstract
Artificial placenta and artificial womb technologies to support extremely premature neonates are advancing toward clinical testing in humans. Currently, no recommendations exist comparing these approaches to guide study design and optimal enrollment eligibility adhering to principles of research ethics. In this paper, we will explore how scientific differences between the artificial placenta and artificial womb approaches create unique ethical challenges to designing first-in-human trials of safety and provide recommendations to guide ethical study design for initial human translation.
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Affiliation(s)
- Stephanie K Kukora
- Division of Neonatology, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA.
- Children's Mercy Bioethics Center, Children's Mercy Hospital, Kansas City, MO, USA.
| | - George B Mychaliska
- Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Elliott Mark Weiss
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA
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2
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Abstract
Children are considered a vulnerable population and have traditionally been excluded from research studies. This exclusion of children in general, and neonates in particular, from clinical research hampers the development of safe and effective therapies in this population. However, research involving children (including infants) is essential to guide therapy and optimize care. Neonatal research is complex, time intensive, difficult and expensive to conduct, and raises some unique ethical considerations. The complexity of research in this population is highlighted by the fear of causing harm to fragile sick infants which has led to the creation of special regulations on the degree of risk exposure permissible in research involving infants. This is further compounded by the inability of infants to provide informed consent or assent and the reliance on obtaining surrogate consent from parents who may themselves be vulnerable and overwhelmed by their infant's illness and the amount of information provided to them. In this review, we discuss the evolution of ethical regulations related to research, the justification for research in infants, and some of the ethical nuances of research in this population.
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Affiliation(s)
- Sunil Krishna
- Department of Pediatrics, University of Illinois College of Medicine, Rockford, IL
| | - Mamta Fuloria
- Division of Neonatology, Department of Pediatrics, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY
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3
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Masse MH, Adhikari NKJ, Théroux X, Battista MC, D'Aragon F, Pinto R, Cohen A, Mayette M, St-Arnaud C, Kho M, Chassé M, Lebrasseur M, Watpool I, Porteous R, Wilcox ME, Lamontagne F. The evolution of mean arterial pressure in critically ill patients on vasopressors before and during a trial comparing a specific mean arterial pressure target to usual care. BMC Anesthesiol 2022; 22:6. [PMID: 34979938 PMCID: PMC8722048 DOI: 10.1186/s12871-021-01529-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/19/2021] [Indexed: 11/24/2022] Open
Abstract
Background In randomized clinical controlled trials, the choice of usual care as the comparator may be associated with better clinician uptake of the study protocol and lead to more generalizable results. However, if care processes evolve to resemble the intervention during the course of a trial, differences between the intervention group and usual care control group may narrow. We evaluated the effect on mean arterial pressure of an unblinded trial comparing a lower mean arterial pressure target to reduce vasopressor exposure, vs. a clinician-selected mean arterial pressure target, in critically ill patients at least 65 years old. Methods For this multicenter observational study using data collected both prospectively and retrospectively, patients were recruited from five of the seven trial sites. We compared the mean arterial pressure of patients receiving vasopressors, who met or would have met trial eligibility criteria, from two periods: [1] at least 1 month before the trial started, and [2] during the trial period and randomized to usual care, or not enrolled in the trial. Results We included 200 patients treated before and 229 after trial initiation. There were no differences in age (mean 74.5 vs. 75.2 years; p = 0.28), baseline Acute Physiology and Chronic Health Evaluation II score (median 26 vs. 26; p = 0.47) or history of chronic hypertension (n = 126 [63.0%] vs. n = 153 [66.8%]; p = 0.41). Mean of the mean arterial pressure was similar between the two periods (72.5 vs. 72.4 mmHg; p = 0.76). Conclusions The initiation of a trial of a prescribed lower mean arterial pressure target, compared to a usual clinician-selected target, was not associated with a change in mean arterial pressure, reflecting stability in the net effect of usual clinician practices over time. Comparing prior and concurrent control groups may alleviate concerns regarding drift in usual practices over the course of a trial or permit quantification of any change. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01529-w.
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Affiliation(s)
- Marie-Hélène Masse
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, Québec, J1H 5N4, Canada
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care Medicine, University of Toronto, 209 Victoria Street, Toronto, Ontario, M5B 1T8, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
| | - Xavier Théroux
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, Québec, J1H 5N4, Canada
| | - Marie-Claude Battista
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, Québec, J1H 5N4, Canada
| | - Frédérick D'Aragon
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, Québec, J1H 5N4, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
| | - Alan Cohen
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, Québec, J1H 5N4, Canada
| | - Michaël Mayette
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, Québec, J1H 5N4, Canada
| | - Charles St-Arnaud
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, Québec, J1H 5N4, Canada
| | - Michelle Kho
- Faculty of Health Sciences, School of Rehabilitation Science, Institute of Applied Health Sciences, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
| | - Michaël Chassé
- Department of Medicine, Université de Montréal, 2900 Boulevard Édouard-Montpetit, Montréal, Québec, H3T 1J4, Canada
| | - Martine Lebrasseur
- Centre de recherche, Centre hospitalier de l'Université de Montréal, 900 rue Saint-Denis, Montréal, Québec, H2X 0A9, Canada
| | - Irene Watpool
- Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, Ontario, K1Y 4E9, Canada
| | - Rebecca Porteous
- Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, Ontario, K1Y 4E9, Canada
| | - M Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, 209 Victoria Street, Toronto, Ontario, M5B 1T8, Canada
| | - François Lamontagne
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, Québec, J1H 5N4, Canada.
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4
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Seykora A, Coleman C, Rosenfeld SJ, Bierer BE, Lynch HF. Steps toward a System of IRB Precedent: Piloting Approaches to Summarizing IRB Decisions for Future Use. Ethics Hum Res 2021; 43:2-18. [PMID: 34676693 DOI: 10.1002/eahr.500106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Institutional review boards (IRBs) have been criticized for inconsistency and lack of transparency in decision-making, problems that undermine both trust in their ability to protect human research participants and respect for their decisions among researchers. The absence of robust documentation of their decisions and the inability or unwillingness to share those decisions together represent a missed opportunity for IRBs to learn from one another and advance debates about challenging ethical issues. The concept of IRB precedent, modeled upon the system of legal precedent, has been proposed as a potential solution to these problems. In theory, an IRB faced with a review decision could look back at previous IRB decisions, either its own or those of other boards, made in similar studies or circumstances to guide the present decision. Some IRBs attempt this informally within their institution, but few examples of a structured system of IRB precedent have been described in the literature, and none has been widely adopted. This article describes a pilot project to summarize IRB decisions in a way that could facilitate their use as precedent by creating a documentation tool that meets four criteria-comprehensiveness, validity, searchability, and efficiency. Though this process turned out to be more challenging than expected, we identified key features of such a tool that holds promise for future development and could promote more consistent, robust IRB decision-making and advance discourse in human research ethics.
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Affiliation(s)
- Andrea Seykora
- Research compliance manager at Kaiser Permanente Northwest at the time of submission
| | | | | | - Barbara E Bierer
- Faculty director at the Multi-Regional Clinical Trials Center of Brigham and Women's Hospital and Harvard and a professor of medicine at Harvard Medical School and Brigham and Women's Hospital
| | - Holly Fernandez Lynch
- John Russell Dickson, MD, Presidential Assistant Professor of Medical Ethics at Perelman School of Medicine at the University of Pennsylvania
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5
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Nicholls SG, Carroll K, Zwarenstein M, Brehaut JC, Weijer C, Hey SP, Goldstein CE, Graham ID, Grimshaw JM, McKenzie JE, Fergusson DA, Taljaard M. The ethical challenges raised in the design and conduct of pragmatic trials: an interview study with key stakeholders. Trials 2019; 20:765. [PMID: 31870433 PMCID: PMC6929346 DOI: 10.1186/s13063-019-3899-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 11/08/2019] [Indexed: 12/20/2022] Open
Abstract
Background There is a concern that the apparent effectiveness of interventions tested in clinical trials may not be an accurate reflection of their actual effectiveness in usual practice. Pragmatic randomized controlled trials (RCTs) are designed with the intent of addressing this discrepancy. While pragmatic RCTs may increase the relevance of research findings to practice they may also raise new ethical concerns (even while reducing others). To explore this question, we interviewed key stakeholders with the aim of identifying potential ethical challenges in the design and conduct of pragmatic RCTs with a view to developing future guidance on these issues. Methods Interviews were conducted with clinical investigators, methodologists, patient partners, ethicists, and other knowledge users (e.g., regulators). Interviews covered experiences with pragmatic RCTs, ethical issues relevant to pragmatic RCTs, and perspectives on the appropriate oversight of pragmatic RCTs. Interviews were coded inductively by two coders. Interim and final analyses were presented to the broader team for comment and discussion before the analytic framework was finalized. Results We conducted 45 interviews between April and September 2018. Interviewees represented a range of disciplines and jurisdictions as well as varying content expertise. Issues of importance in pragmatic RCTs were (1) identification of relevant risks from trial participation and determination of what constitutes minimal risk; (2) determining when alterations to traditional informed consent approaches are appropriate; (3) the distinction between research, quality improvement, and practice; (4) the potential for broader populations to be affected by the trial and what protections they might be owed; (5) the broader range of trial stakeholders in pragmatic RCTs, and determining their roles and responsibilities; and (6) determining what constitutes “usual care” and implications for trial reporting. Conclusions Our findings suggest both the need to discuss familiar ethical topics in new ways and that there are new ethical issues in pragmatic RCTs that need greater attention. Addressing the highlighted issues and developing guidance will require multidisciplinary input, including patient and community members, within a broader and more comprehensive analysis that extends beyond consent and attends to the identified considerations relating to risk and stakeholder roles and responsibilities.
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Affiliation(s)
- Stuart G Nicholls
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.
| | - Kelly Carroll
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Jamie C Brehaut
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Charles Weijer
- Rotman Institute of Philosophy, Western University, London, ON, Canada
| | - Spencer P Hey
- Center for Bioethics, Harvard Medical School and Program on Regulation, Therapeutics, and Law at Brigham and Women's Hospital, Boston, MA, USA
| | - Cory E Goldstein
- Rotman Institute of Philosophy, Western University, London, ON, Canada
| | - Ian D Graham
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,Department of Medicine University of Ottawa, Ottawa Hospital Research Institute (OHRI), ON, Ottawa, Canada
| | - Joanne E McKenzie
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dean A Fergusson
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,Department of Medicine University of Ottawa, Ottawa Hospital Research Institute (OHRI), ON, Ottawa, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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6
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London AJ, Kimmelman J. Clinical Trial Portfolios: A Critical Oversight in Human Research Ethics, Drug Regulation, and Policy. Hastings Cent Rep 2019; 49:31-41. [DOI: 10.1002/hast.1034] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Taljaard M, Weijer C, Grimshaw JM, Ali A, Brehaut JC, Campbell MK, Carroll K, Edwards S, Eldridge S, Forrest CB, Giraudeau B, Goldstein CE, Graham ID, Hemming K, Hey SP, Horn AR, Jairath V, Klassen TP, London AJ, Marlin S, Marshall JC, McIntyre L, McKenzie JE, Nicholls SG, Alison Paprica P, Zwarenstein M, Fergusson DA. Developing a framework for the ethical design and conduct of pragmatic trials in healthcare: a mixed methods research protocol. Trials 2018; 19:525. [PMID: 30261933 PMCID: PMC6161426 DOI: 10.1186/s13063-018-2895-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 08/31/2018] [Indexed: 01/03/2023] Open
Abstract
Background There is a widely recognized need for more pragmatic trials that evaluate interventions in real-world settings to inform decision-making by patients, providers, and health system leaders. Increasing availability of electronic health records, centralized research ethics review, and novel trial designs, combined with support and resources from governments worldwide for patient-centered research, have created an unprecedented opportunity to advance the conduct of pragmatic trials, which can ultimately improve patient health and health system outcomes. Such trials raise ethical issues that have not yet been fully addressed, with existing literature concentrating on regulations in specific jurisdictions rather than arguments grounded in ethical principles. Proposed solutions (e.g. using different regulations in “learning healthcare systems”) are speculative with no guarantee of improvement over existing oversight procedures. Most importantly, the literature does not reflect a broad vision of protecting the core liberty and welfare interests of research participants. Novel ethical guidance is required. We have assembled a team of ethicists, trialists, methodologists, social scientists, knowledge users, and community members with the goal of developing guidance for the ethical design and conduct of pragmatic trials. Methods Our project will combine empirical and conceptual work and a consensus development process. Empirical work will: (1) identify a comprehensive list of ethical issues through interviews with a small group of key informants (e.g. trialists, ethicists, chairs of research ethics committees); (2) document current practices by reviewing a random sample of pragmatic trials and surveying authors; (3) elicit views of chairs of research ethics committees through surveys in Canada, UK, USA, France, and Australia; and (4) elicit views and experiences of community members and health system leaders through focus groups and surveys. Conceptual work will consist of an ethical analysis of identified issues and the development of new ethical solutions, outlining principles, policy options, and rationales. The consensus development process will involve an independent expert panel to develop a final guidance document. Discussion Planned output includes manuscripts, educational materials, and tailored guidance documents to inform and support researchers, research ethics committees, journal editors, regulators, and funders in the ethical design and conduct of pragmatic trials.
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Affiliation(s)
- Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada. .,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
| | - Charles Weijer
- Rotman Institute of Philosophy, Western University, 1151 Richmond Street, London, ON, N6A 5B7, Canada
| | - Jeremy M Grimshaw
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Adnan Ali
- Patient and Family Advisory Council, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jamie C Brehaut
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Marion K Campbell
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Sarah Edwards
- Department of Science and Technology Studies, University College London, 22 Gordon Square, King's Cross, London, WC1H 0AW, UK
| | - Sandra Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, 58 Turner Street, London, E1 2AB, UK
| | - Christopher B Forrest
- Applied Clinical Research Center, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA
| | - Bruno Giraudeau
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, Tours, France.,INSERM CIC1415, CHRU de Tours, Tours, France
| | - Cory E Goldstein
- Rotman Institute of Philosophy, Western University, 1151 Richmond Street, London, ON, N6A 5B7, Canada
| | - Ian D Graham
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Karla Hemming
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Spencer Phillips Hey
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA.,Center for Bioethics, Harvard Medical School, Boston, MA, USA
| | - Austin R Horn
- Rotman Institute of Philosophy, Western University, 1151 Richmond Street, London, ON, N6A 5B7, Canada
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada.,Division of Epidemiology and Biostatistics, Western University, University Hospital, 339 Windermere Road, London, ON, N6A 5A5, Canada
| | - Terry P Klassen
- Children's Hospital Research Institute of Manitoba, 513-715 McDermot Avenue, Winnipeg, MB, R3E 3P, Canada
| | - Alex John London
- Department of Philosophy and Center for Ethics and Policy, Carnegie Mellon University, 150A Baker Hall, Pittsburgh, PA, 15213-3890, USA
| | - Susan Marlin
- Clinical Trials Ontario, 661 University Avenue, MaRS Centre, West Tower, Toronto, ON, M5G 1M1, Canada
| | - John C Marshall
- St. Michael's Hospital, Department of Surgery, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Lauralyn McIntyre
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.,Department of Medicine (Division of Critical Care), University of Ottawa, Ottawa, ON, Canada
| | - Joanne E McKenzie
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Stuart G Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
| | - P Alison Paprica
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Toronto, ON, M5T 3M6, Canada
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Department of Family Medicine Schulich School of Medicine & Dentistry Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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Kim SY. Ethical issues in pragmatic trials of "standard-of-care" interventions in learning health care systems. Learn Health Syst 2018; 2:e10045. [PMID: 31245574 PMCID: PMC6508815 DOI: 10.1002/lrh2.10045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 09/07/2017] [Accepted: 10/12/2017] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Learning health care systems (LHS) hold the promise of improving medical care by systematically and continuously integrating the delivery of medical services with clinical research. One important type of integration would involve embedding trials that compare interventions that are already commonly in use (as "accepted" or "standard of care") into the clinical setting-trials that could cost-effectively improve care. But the traditional requirement of informed consent for clinical trials stands in tension with the conduct of such trials. METHOD Narrative analysis. RESULTS Although some have suggested that the idea of LHS makes the distinction between research and ordinary clinical care obsolete, the distinction remains ethically relevant even when it comes to randomized clinical trials (RCTs) that compare standard-of-care interventions. This paper presents an ethical framework for analyzing standard-of-care RCTs in resolving the tension between such trials and traditional requirements of research ethics. CONCLUSION It is important not to treat all standard-of-care RCTs as a monolithic category of special ethical status. Close attention to ethical issues in specific standard-of-care RCTs is crucial if the LHS movement is to avoid ethical lapses that could be counterproductive to its long term vision.
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Affiliation(s)
- Scott Y.H. Kim
- Department of BioethicsClinical Center, National Institutes of HealthBethesdaMaryland
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9
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Lie RK, Chan FK, Grady C, Ng VH, Wendler D. Comparative effectiveness research: what to do when experts disagree about risks. BMC Med Ethics 2017; 18:42. [PMID: 28629343 PMCID: PMC5477349 DOI: 10.1186/s12910-017-0202-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 06/08/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ethical issues related to comparative effectiveness research, or research that compares existing standards of care, have recently received considerable attention. In this paper we focus on how Ethics Review Committees (ERCs) should evaluate the risks of comparative effectiveness research. MAIN TEXT We discuss what has been a prominent focus in the debate about comparative effectiveness research, namely that it is justified when "nothing is known" about the comparative effectiveness of the available alternatives. We argue that this focus may be misleading. Rather, we should focus on the fact that some experts believe that the evidence points in favor of one intervention, whereas other experts believe that the evidence favors the alternative(s). We will then introduce a case that illustrates this point, and based on that, discuss how ERCs should deal with such cases of expert disagreement. CONCLUSION We argue that ERCs have a duty to assess the range of expert opinions and based on that assessment arrive at a risk judgment about the study under consideration. We also argue that assessment of expert disagreement is important for the assignment of risk level to a clinical trial: what is the basis for expert opinions, how strong is the evidence appealed to by various experts, and how can clinical trial monitoring affect the possible increased risk of clinical trial participation.
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Affiliation(s)
- Reidar K. Lie
- Department of Philosophy, University of Bergen, Sydnesplassen 12, 5020 Bergen, Norway
| | - Francis K.L. Chan
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administration Region, People’s Republic of China
| | - Christine Grady
- Department of Bioethics, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892 USA
| | - Vincent H. Ng
- Department of Mathematics and Science, Northern Virginia Community College, Woodbridge, VA 22191 USA
| | - David Wendler
- Department of Bioethics, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892 USA
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10
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Nunes EV, Lee JD, Sisti D, Segal A, Caplan A, Fishman M, Bailey G, Brigham G, Novo P, Farkas S, Rotrosen J. Ethical and clinical safety considerations in the design of an effectiveness trial: A comparison of buprenorphine versus naltrexone treatment for opioid dependence. Contemp Clin Trials 2016; 51:34-43. [PMID: 27687743 PMCID: PMC5466164 DOI: 10.1016/j.cct.2016.09.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 09/12/2016] [Accepted: 09/25/2016] [Indexed: 10/20/2022]
Abstract
We examine ethical challenges encountered in the design of an effectiveness trial (CTN-0051; X:BOT), comparing sublingual buprenorphine-naloxone (BUP-NX), an established treatment for opioid dependence, to the newer extended-release injectable naltrexone (XR-NTX). Ethical issues surrounded: 1) known poor effectiveness of one possible, commonly used treatment as usual control condition-detoxification followed by counseling without medication; 2) the role of patients' preferences for treatments, given that treatments were clinically approved and available to the population; 3) differences between the optimal "usual treatment" clinical settings for different treatments making it challenging to design a fair comparison; 4) vested interest groups favoring different treatments exerting potential influence on the design process; 5) potentially vulnerable populations of substance users and prisoners; 6) potential therapeutic misconception in the implementation of safety procedures; and 7) high cost of a large trial limiting questions that could be addressed. We examine how the design features underlying these ethical issues are characteristic of effectiveness trials, which are often large trials that compare treatments with varying degrees of existing effectiveness data and familiarity to patients and clinicians, in community-based treatment settings, with minimal exclusion criteria that could involve vulnerable populations. Hence, investigators designing effectiveness trials may wish to remain alert to the possibility of similar ethical issues.
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Affiliation(s)
- Edward V Nunes
- Columbia University Medical Center, New York State Psychiatric Institute, United States.
| | - Joshua D Lee
- NYU School of Medicine, Department of Population Health, United States
| | - Dominic Sisti
- Perelman School of Medicine, University of Pennsylvania, United States
| | - Andrea Segal
- Perelman School of Medicine, University of Pennsylvania, United States
| | - Arthur Caplan
- NYU School of Medicine, Division of Medical Ethics, United States
| | - Marc Fishman
- Johns Hopkins University School of Medicine, Mountain Manor Treatment Program, United States
| | - Genie Bailey
- Warren Alpert Medical School of Brown University, Stanley Street Treatment and Resources, United States
| | | | - Patricia Novo
- NYU School of Medicine, Department of Psychiatry, United States
| | - Sarah Farkas
- NYU School of Medicine, Department of Psychiatry, United States
| | - John Rotrosen
- NYU School of Medicine, Department of Psychiatry, United States
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Kirpalani H, Truog WE, D'Angio CT, Cotten M. Recent controversies on comparative effectiveness research investigations: Challenges, opportunities, and pitfalls. Semin Perinatol 2016; 40:341-347. [PMID: 27423511 PMCID: PMC5222533 DOI: 10.1053/j.semperi.2016.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The purpose of comparative effectiveness research (CER) is to improve health outcomes by developing and disseminating evidence-based information about which currently available interventions and practices are most effective for patients. Randomized Controlled Trials (RCT) are the hallmark of scientific proof, and have been used to compare interventions used in variable ways by different clinicians (comparative effectiveness RCTs, CER-RCTs). But such CER-RCTs have at times generated controversy. Usually the background for the CER-RCT is a range of "standard therapy" or "standard of care." This may have been adopted on observational data alone, or pilot data. At times, such prior data may derive from populations that differ from the population in which the widely variable standard approach is being applied. We believe that controversies related to these CER-RCTs result from confusing "accepted" therapies and "rigorously evaluated therapies." We first define evidence-based medicine and consider how well neonatology conforms to that definition. We then contrast the approach of testing new therapies and those already existing and widely adopted, as in CER-RCTs. We next examine a central challenge in incorporating the control arm within CER-RCTs and aspects of the "titrated" trial. We finally briefly consider some ethical issues that have arisen, and discuss the wide range of neonatology practices that could be tested by CER-RCTs or alternative CER-based strategies that might inform practice. Throughout, we emphasize the lack of awareness of the lay community, and indeed many researchers or commentators, in appreciating the wide variation of standard of care. There is a corresponding need to identify the best uses of available resources that will lead to the best outcomes for our patients. We conclude that CER-RCTs are an essential methodology in modern neonatology to address many unanswered questions and test unproven therapies in newborn care.
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Affiliation(s)
- Haresh Kirpalani
- Professor Pediatrics Division Neonatology, The Children's Hospital of Philadelphia at University Pennsylvania Philadelphia PA USA ; and Emeritus Professor Clinical Epidemiology McMaster University Ontario
| | | | - Carl T. D'Angio
- Professor of Pediatrics and Medical Humanities & Bioethics, Division of Neonatology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Morse RJ, Wilson RF. Realizing Informed Consent in Times of Controversy: Lessons from the SUPPORT Study. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2016; 44:402-418. [PMID: 27587446 DOI: 10.1177/1073110516667938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
This Essay examines the elegantly simple idea that consent to medical treatment or participation in human research must be "informed" to be valid. It does so by using as a case study the controversial clinical research trial known as the Surfactant, Positive Pressure, and Oxygenation Randomized Trial ("SUPPORT"). The Essay begins by charting, through case law and the adoption of the common rule, the evolution of duties to secure fully informed consent in both research and treatment. The Essay then utilizes the SUPPORT study, which sought to pinpoint the level of saturated oxygen that should be provided to extremely low birth weight infants to demonstrate modern complexities and shortcomings of the duty to secure informed consent. This Essay shows how the duty is measured by foreseeability of risks and benefits in human research and why federal regulators believed the trade-offs in risk and benefits from differing oxygen levels administered in the support study were foreseeable. It then explores the contours of the duty to secure informed consent when applied to researchers who also serve as treating physicians, highlighting how common law duties differ in jurisdictions that apply the professional standard and those that apply the patient-centered material risk standard. This Essay provides new insight into what the law must do to make real the notion that [e]very human being of adult years and sound mind has a right to determine what shall be done with his body."
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Affiliation(s)
- Robert J Morse
- Robert J. Morse, J.D., is a graduate of the Class of 2016 at the University of Illinois College of Law. Robin Fretwell Wilson, J.D., is the Roger and Stephany Joslin Professor of Law and Co-Director of the Epstein Program in Health Law and Policy at University of Illinois College of Law
| | - Robin Fretwell Wilson
- Robert J. Morse, J.D., is a graduate of the Class of 2016 at the University of Illinois College of Law. Robin Fretwell Wilson, J.D., is the Roger and Stephany Joslin Professor of Law and Co-Director of the Epstein Program in Health Law and Policy at University of Illinois College of Law
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13
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Dal-Ré R, Omeñaca F, Gracia D. [When the information provided to participants of a comparative effectiveness trial ends up in the court: The opening of Pandora's box?]. Med Clin (Barc) 2016; 147:76-80. [PMID: 26961391 DOI: 10.1016/j.medcli.2016.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Accepted: 01/13/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Rafael Dal-Ré
- Investigación Clínica, Programa BUC (Biociencias UAN+CSIC), Centro de Excelencia Internacional, Universidad Autónoma de Madrid, Madrid, España.
| | - Félix Omeñaca
- Servicio de Neonatología, Departamento de Pediatría, Hospital Universitario La Paz, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, España
| | - Diego Gracia
- Departamento de Medicina Preventiva, Salud Pública e Historia de la Ciencia, Universidad Complutense, Madrid, España
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Abstract
BACKGROUND There are limited data on parental perception of infant participation in minimal risk and minor increase above minimal risk research focusing on the NICU population. The study objective was to assess parental and NICU staff perceptions concerning minimal risk and minor increase above minimal risk in the NICU setting. METHODS Parents of infants and NICU staff were presented with a combination of 4 infant scenarios and 5 hypothetical research procedures. These assessed participants' willingness to allow their infant to participate in research and their attitude towards obligation to assist future children. Linear and hierarchal linear models analyzed the association and interaction effects on the likelihood to consent to research procedures. RESULTS Sixty parents and 30 NICU staff members were surveyed. Parents' acceptability for each of the five research procedures ranged from 31 % to 83 %. Parent gender, age, race/ethnicity, insurance, education and history of previous child in the NICU were not associated with the likelihood to consent to the research procedures. Acceptability for each of the five research procedures among NICU staff ranged from 19 % to 98 %. There were no significant differences between NICU staff's and parents' responses for 4 of 5 research procedures. A minority of parents and nurses (38.3 % and 40 % respectively), compared to a majority of physicians (66.7 %), agreed or strongly agreed that parents have a responsibility to involve their children in low risk medical research in order to help future children, even if this would not help their own child. Lower agreement with obligation to help future children (p < 0.01) and higher education (p = 0.01) were associated with a decreased likelihood to consent to research procedures. CONCLUSION In our study population, common NICU-related research procedures were considered appropriate and acceptable to a diverse group of NICU parents representing a wide range of race/ethnic and socioeconomic strata. Current regulations guiding informed consent for minimal and minor increase over minimal risk research in the NICU environment appear ethically consistent with a diverse group of parents and providers.
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Welch MJ, Lally R, Miller JE, Pittman S, Brodsky L, Caplan AL, Uhlenbrauck G, Louzao DM, Fischer JH, Wilfond B. The ethics and regulatory landscape of including vulnerable populations in pragmatic clinical trials. Clin Trials 2015. [PMID: 26374681 DOI: 10.1177/174074515597701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Policies have been developed to protect vulnerable populations in clinical research, including the US federal research regulations (45 Code of Federal Regulations 46 Subparts B, C, and D). These policies generally recognize vulnerable populations to include pregnant women, fetuses, neonates, children, prisoners, persons with physical handicaps or mental disabilities, and disadvantaged persons. The aim has been to protect these populations from harm, often by creating regulatory and ethical checks that may limit their participation in many clinical trials. The recent increase in pragmatic clinical trials raises at least two questions about this approach. First, is exclusion itself a harm to vulnerable populations, as these groups may be denied access to understanding how health interventions work for them in clinical settings? Second, are groups considered vulnerable in traditional clinical trials also vulnerable in pragmatic clinical trials? We argue first that excluding vulnerable subjects from participation in pragmatic clinical trials can be harmful by preventing acquisition of data to meaningfully inform clinical decision-making in the future. Second, we argue that protections for vulnerable subjects in traditional clinical trial settings may not be translatable, feasible, or even ethical to apply in pragmatic clinical trials. We conclude by offering specific recommendations for appropriately protecting vulnerable research subjects in pragmatic clinical trials, focusing on pregnant women, fetuses, neonates, children, prisoners, persons with physical handicaps or mental disabilities, and disadvantaged persons.
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Affiliation(s)
- Mary Jane Welch
- Human Subjects' Protection, College of Nursing, Rush University Medical Center, Chicago, IL, USA
| | - Rachel Lally
- Columbia University Medical Center, New York, NY, USA
| | - Jennifer E Miller
- Kenan Institute for Ethics, Duke University, Durham, NC, USA Edmond J. Safra Center for Ethics, Harvard University, Cambridge, MA, USA Division of Medical Ethics, NYU Langone Medical Center, New York, NY, USA
| | - Stephanie Pittman
- Human Subjects' Protection, Rush University Medical Center, Chicago, IL, USA
| | - Lynda Brodsky
- Cook County Health & Hospitals System, Chicago, IL, USA
| | - Arthur L Caplan
- Division of Medical Ethics, NYU Langone Medical Center, New York, NY, USA
| | - Gina Uhlenbrauck
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Darcy M Louzao
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | - Benjamin Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, WA, USA Division of Bioethics, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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16
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Kim SYH, Miller FG. Ethical complexities in standard of care randomized trials: A case study of morning versus nighttime dosing of blood pressure drugs. Clin Trials 2015; 12:557-63. [PMID: 26400874 DOI: 10.1177/1740774515607213] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pragmatic trials comparing "standard of care" treatments provide comparative effectiveness data to make practice of medicine more evidence-based. With electronic health records, recruiting and conducting such trials can be relatively inexpensive. But some worry that the traditional research ethics framework poses unnecessary obstacles and is not appropriate for evaluating such clinical trials. This concern is based on the view (which we call the "Standard of Care Principle") that such research is similar to usual clinical practice and therefore does not raise significant ethical issues since everyone in the research study will receive an accepted standard of care treatment. METHODS A case study of a pragmatic randomized clinical trial (Blood Pressure Medication Timing study) comparing morning versus nighttime dosing of antihypertensive medications. The Blood Pressure Medication Timing study has been proposed as a paradigm example of why the Standard of Care Principle obviates the need for traditional levels of ethical scrutiny and how the current regulatory framework poses unnecessary obstacles to research. We provide an ethical analysis of the Blood Pressure Medication Timing study, drawing on the empirical literature as well as on normative analysis. RESULTS The Standard of Care Principle is the main ethical rationale given by commentators for asserting that the Blood Pressure Medication Timing study does not require "significant ethical debate" and by investigators for the assertion that the Blood Pressure Medication Timing study is minimal risk and thus eligible for lessened regulatory requirements. However, the Blood Pressure Medication Timing study raises important ethical issues, including whether it is even necessary, given the considerable randomized clinical trial evidence in support of nighttime dosing, a much larger (N≈17,000) confirmatory randomized clinical trial already in progress, evidence for safety of nighttime dosing, and the cost-free availability of the intervention. Furthermore, the Standard of Care Principle provides a misleading basis for analyzing the informed consent requirements, especially regarding the requirement to disclose alternative courses of treatment that "might be advantageous to the subject." CONCLUSION The Standard of Care Principle is ethically inadequate and misleading even when it is applied to the pragmatic randomized clinical trial proposed as a paradigm case for its application.
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Affiliation(s)
- Scott Y H Kim
- Department of Bioethics, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Franklin G Miller
- Department of Bioethics, National Institutes of Health Clinical Center, Bethesda, MD, USA Weill Cornell Medical College, New York, USA
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Welch MJ, Lally R, Miller JE, Pittman S, Brodsky L, Caplan AL, Uhlenbrauck G, Louzao DM, Fischer JH, Wilfond B. The ethics and regulatory landscape of including vulnerable populations in pragmatic clinical trials. Clin Trials 2015; 12:503-10. [PMID: 26374681 DOI: 10.1177/1740774515597701] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Policies have been developed to protect vulnerable populations in clinical research, including the US federal research regulations (45 Code of Federal Regulations 46 Subparts B, C, and D). These policies generally recognize vulnerable populations to include pregnant women, fetuses, neonates, children, prisoners, persons with physical handicaps or mental disabilities, and disadvantaged persons. The aim has been to protect these populations from harm, often by creating regulatory and ethical checks that may limit their participation in many clinical trials. The recent increase in pragmatic clinical trials raises at least two questions about this approach. First, is exclusion itself a harm to vulnerable populations, as these groups may be denied access to understanding how health interventions work for them in clinical settings? Second, are groups considered vulnerable in traditional clinical trials also vulnerable in pragmatic clinical trials? We argue first that excluding vulnerable subjects from participation in pragmatic clinical trials can be harmful by preventing acquisition of data to meaningfully inform clinical decision-making in the future. Second, we argue that protections for vulnerable subjects in traditional clinical trial settings may not be translatable, feasible, or even ethical to apply in pragmatic clinical trials. We conclude by offering specific recommendations for appropriately protecting vulnerable research subjects in pragmatic clinical trials, focusing on pregnant women, fetuses, neonates, children, prisoners, persons with physical handicaps or mental disabilities, and disadvantaged persons.
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Affiliation(s)
- Mary Jane Welch
- Human Subjects' Protection, College of Nursing, Rush University Medical Center, Chicago, IL, USA
| | - Rachel Lally
- Columbia University Medical Center, New York, NY, USA
| | - Jennifer E Miller
- Kenan Institute for Ethics, Duke University, Durham, NC, USA Edmond J. Safra Center for Ethics, Harvard University, Cambridge, MA, USA Division of Medical Ethics, NYU Langone Medical Center, New York, NY, USA
| | - Stephanie Pittman
- Human Subjects' Protection, Rush University Medical Center, Chicago, IL, USA
| | - Lynda Brodsky
- Cook County Health & Hospitals System, Chicago, IL, USA
| | - Arthur L Caplan
- Division of Medical Ethics, NYU Langone Medical Center, New York, NY, USA
| | - Gina Uhlenbrauck
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Darcy M Louzao
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | - Benjamin Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, WA, USA Division of Bioethics, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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