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Isaacson S, Kuczynski K, Ormsby N, Peay HL, Rennie S, Cadigan RJ, Kroon E, Phanuphak N, Ananworanich J, Jupimai T, Prueksakaew P, Henderson GE. Decision making for invasive and non-invasive optional procedures within an acute HIV research cohort in Bangkok. Contemp Clin Trials Commun 2023; 31:101054. [PMID: 36636463 PMCID: PMC9829688 DOI: 10.1016/j.conctc.2022.101054] [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: 08/09/2022] [Revised: 11/16/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022] Open
Abstract
Clinical research regularly includes required, nontherapeutic procedures to answer research questions. Optional procedures usually offer minimal or no personal benefit and may involve harms and burdens. Members from the Bangkok SEARCH010/RV254 HIV research cohort of individuals acutely HIV-infected are recruited to six optional procedures varying in invasiveness: leukapheresis, genital secretions collection, lumbar puncture, brain MRI/MRS/DTI, colon biopsy, and lymph node biopsy. We surveyed cohort members about their first recruitment for each procedure to examine factors associated with decision making and attitudes about compensation. 406 members (68%) completed the survey. Reported procedure participation ranged from 71% (MRI) to 27% (lymph node biopsy). Respondents underwent 0-6 procedure types (median 3). Ordinal regression indicated that lower perceived HIV impact and HIV remission trial participation were associated with more procedures completed. Reports of decision difficulty varied, and feeling pressured by research staff was low overall. Notably, those who declined procedures and those who underwent more invasive procedures reported greater decision difficulty and perceived pressure. Most respondents felt compensation amounts were appropriate, although opinions differed by procedure, and for some procedures, between people who agreed and declined. There is limited literature regarding consent to and attitudes about optional research procedures. Researchers must consider how to best support voluntary decisions for procedures with little personal benefit, particularly in lower-income or marginalized populations. In this longitudinal research cohort, perceived pressure to participate may be a concern, although our finding of variation in participation rates corresponding to invasiveness is reassuring. Data from different research contexts would provide important comparators.
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Affiliation(s)
- Sinéad Isaacson
- Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kristine Kuczynski
- Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nuchanart Ormsby
- Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Holly L. Peay
- RTI International, Research Triangle Park, Durham, NC, USA
| | - Stuart Rennie
- Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - R. Jean Cadigan
- Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Eugène Kroon
- SEARCH, Institute of HIV Research and Innovation, Bangkok, Thailand
| | | | - Jintanat Ananworanich
- Department of Global Health, Amsterdam University Medical Centers, University of Amsterdam, And Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
| | - Thidarat Jupimai
- Center of Excellence in Pediatric Infectious Diseases and Vaccines Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Gail E. Henderson
- Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Corresponding author.
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Walker RL, MacKay D, Waltz M, Lyerly AD, Fisher JA. Ethical Criteria for Improved Human Subject Protections in Phase I Healthy Volunteer Trials. Ethics Hum Res 2022; 44:2-21. [PMID: 36047278 PMCID: PMC9931499 DOI: 10.1002/eahr.500139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Phase I healthy volunteer trials test the safety and tolerability of investigational pharmaceuticals. In them, participants are exposed to study-drug risks without the possibility of direct medical benefit and typically must spend days or weeks in a residential research facility. Monetary payments are used to incentivize enrollment and compensate participants for their time. Together, these features of phase I healthy volunteer trials create a research context that differs markedly from most other clinical research, including by enrolling disproportionate numbers of economically disadvantaged people of color as participants. Due to these unique trial features and participation patterns, traditional biomedical research oversight offers inadequate ethical and policy guidance for phase I healthy volunteer research. This article details five ethical criteria crafted to be responsive to the particularities of this type of research: translational science value, fair opportunity and burden sharing, fair compensation for service, experiential welfare, and enhanced voice and recourse.
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Affiliation(s)
- Rebecca L Walker
- Professor of social medicine and of philosophy at the University of North Carolina at Chapel Hill
| | - Douglas MacKay
- Associate professor of public policy at the University of North Carolina at Chapel Hill
| | - Margaret Waltz
- Research associate in the Department of Social Medicine at the University of North Carolina at Chapel Hill
| | - Anne D Lyerly
- Professor of social medicine and on the core faculty in the Center for Bioethics at the University of North Carolina at Chapel Hill
| | - Jill A Fisher
- Professor of social medicine and on the core faculty in the Center for Bioethics at the University of North Carolina at Chapel Hill
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The ethical anatomy of payment for research participants. MEDICINE, HEALTH CARE AND PHILOSOPHY 2022; 25:449-464. [PMID: 35610403 PMCID: PMC9427899 DOI: 10.1007/s11019-022-10092-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/04/2022] [Indexed: 11/18/2022]
Abstract
In contrast to most publications on the ethics of paying research subjects, which start by identifying and analyzing major ethical concerns raised by the practice (in particular, risks of undue inducement and exploitation) and end with a set of—more or less well-justified—ethical recommendations for using payment schemes immune to these problems, this paper offers a systematic, principle-based ethical analysis of the practice. It argues that researchers have a prima facie moral obligation to offer payment to research subjects, which stems from the principle of social beneficence. This principle constitutes an ethical “spine” of the practice. Other ethical principles of research ethics (respect for autonomy, individual beneficence, and justice/fairness) make up an ethical “skeleton” of morally sound payment schemes by providing additional moral reasons for offering participants (1) recompense for reasonable expenses; and (2a) remuneration conceptualized as a reward for their valuable contribution, provided (i) it meets standards of equality, adequacy and non-exploitation, and (ii) it is not overly attractive (i.e., it does not constitute undue inducement for participation or retention, and does not encourage deceptive behaviors); or (2b) remuneration conceptualized as a market-driven price, provided (i) it is necessary and designed to help the study achieve its social and scientific goals, (ii) it does not reinforce wider social injustices and inequalities; (iii) it meets the requirement of non-exploitation; and (iv) it is not overly attractive. The principle of justice provides a strong ethical reason for not offering recompenses for lost wages (or loss of other reasonably expected profits).
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Kalbaugh CA, Kalbaugh JM, McManus L, Fisher JA. Healthy volunteers in US phase I clinical trials: Sociodemographic characteristics and participation over time. PLoS One 2021; 16:e0256994. [PMID: 34492044 PMCID: PMC8423261 DOI: 10.1371/journal.pone.0256994] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/20/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Increasing the diversity of research participants is an important focus of clinical trials. However, little is known regarding who enrolls as healthy volunteers in Phase I clinical trials, which test the safety and tolerability of investigational new drugs. Despite the risk, healthy volunteers can derive no medical benefit from their participation, and they are financially compensated for enrolling. OBJECTIVE This study's purpose is to describe sociodemographic characteristics and clinical trial participation histories of healthy people who enroll in US Phase I trials. METHODS The HealthyVOICES Project (HVP) is a longitudinal study of healthy individuals who have enrolled in Phase I trials. We describe self-reported sociodemographic information and Phase I trial history from HVP recruitment (May-December 2013) through the project's end three years later (December 2016). Trial experiences are presented as medians and quartiles. RESULTS The HVP included 178 participants. Nearly three-fourths of participants were male, and two-thirds were classified as racial and ethnic minorities. We found that some groups of participants were more likely to have completed a greater number of clinical trials over a longer timeframe than others. Those groups included participants who were male, Black, Hispanic, 30-39-years-old, unemployed, had received vocational training in a trade, or had annual household incomes of less than $25,000. Additionally, the greater the number of clinical trials participants had completed, the more likely they were to continue screening for new trials over the course of three years. Participants who pursued clinical trials as a full-time job participated in the greatest number of trials and were the most likely to continuing screening over time. IMPLICATIONS Participation as a healthy volunteer in US Phase I trials is driven by social inequalities. Disadvantaged groups tend to participate in a greater number of clinical trials and participate longer than more privileged groups.
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Affiliation(s)
- Corey A. Kalbaugh
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States of America
- Department of Bioengineering, Clemson University, Clemson, SC, United States of America
| | - Julianne M. Kalbaugh
- Department of Social Medicine and Center for Bioethics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Lisa McManus
- Department of Sociology, Wake Technical Community College, Raleigh, NC, United States of America
| | - Jill A. Fisher
- Department of Social Medicine and Center for Bioethics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
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Lynch HF, Darton TC, Levy J, McCormick F, Ogbogu U, Payne RO, Roth AE, Shah AJ, Smiley T, Largent EA. Promoting Ethical Payment in Human Infection Challenge Studies. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2021; 21:11-31. [PMID: 33541252 DOI: 10.1080/15265161.2020.1854368] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
To prepare for potential human infection challenge studies (HICS) involving SARS-CoV-2, we convened a multidisciplinary working group to address ethical questions regarding whether and how much SARS-CoV-2 HICS participants should be paid. Because the goals of paying HICS participants, as well as the relevant ethical concerns, are the same as those arising for other types of clinical research, the same basic framework for ethical payment can apply. This framework divides payment into reimbursement, compensation, and incentives, focusing on fairness and promoting adequate recruitment and retention as counterweights to concerns about undue inducement. Within the basic framework, several factors are especially salient for HICS, and for SARS-CoV-2 HICS in particular, including the nature of participant confinement, anticipated discomfort, risks and uncertainty, participant motivations, and trust. These factors are reflected in a payment worksheet created to help sponsors, researchers, and ethics reviewers systematically develop and assess ethically justifiable payment amounts.
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Fisher JA, Wood MM, Monahan T. Speculating on Precarious Income: Finance Cultures and the Risky Strategies of Healthy Volunteers in Clinical Drug Trials. JOURNAL OF CULTURAL ECONOMY 2020; 14:464-484. [PMID: 34239602 PMCID: PMC8259560 DOI: 10.1080/17530350.2020.1850504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 11/05/2020] [Indexed: 06/13/2023]
Abstract
Speculation has become a normalized occupational strategy and quotidian economic rationality that extends throughout society. Although there are many contemporary articulations of speculation, this article focuses on contract labor as a domain of financialization. Seen through this lens, contract labor can be understood as a speculative investment strategy wherein individuals leverage whatever assets they have at their disposal-savings, time, bodily health-to capture economic advantages. In particular, we explore the speculative practices of healthy individuals who enroll in pharmaceutical drug trials as their primary or critical source of income. Mobilizing speculative logics to maximize the money they can earn from their clinical trial participation, these contract workers employ what we term a future-income-over-immediate-pay calculus. This speculative calculus valorizes fictional projections of significant long-term future income over present financial opportunities. For the economically precarious individuals in our study, we argue that rather than effectively increasing their income, speculation on contract work serves a compensatory function, providing an important-but ultimately inadequate-sense of control over market conditions that thrive upon workers' economic insecurity.
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Affiliation(s)
- Jill A Fisher
- Department of Social Medicine & Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Megan M Wood
- Department of Communication, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Torin Monahan
- Department of Communication, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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