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Götzelmann TG, Strech D, Kahrass H. The full spectrum of ethical issues in dementia research: findings of a systematic qualitative review. BMC Med Ethics 2021; 22:32. [PMID: 33771131 PMCID: PMC8004446 DOI: 10.1186/s12910-020-00572-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 12/21/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND When including participants with dementia in research, various ethical issues arise. At present, there are only a few existing dementia-specific research guidelines (Committee for Medicinal Products for Human Use in Clinical investigation of medicines for the treatment Alzheimer's disease (Internet). https://www.ema.europa.eu/en/clinical-investigation-medicines-treatment-alzheimers-disease ; Food and Drug Administration, Early Alzheimer's Disease: Developing Drugs for Treatment Guidance for Industry [Internet]. http://www.fda.gov/regulatory-information/search-fda-guidance-documents/alzheimers-disease-developing-drugs-treatment-guidance-industy ), necessitating a more systematic and comprehensive approach to this topic to help researchers and stakeholders address dementia-specific ethical issues in research. A systematic literature review provides information on the ethical issues in dementia-related research and might therefore serve as a basis to improve the ethical conduct of this research. This systematic review aims to provide a broad and unbiased overview of ethical issues in dementia research by reviewing, analysing, and coding the latest literature on the topic. METHODS We conducted a systematic review in PubMed and Google Scholar (publications in English between 2007 and 2020, no restrictions on the type of publication) of literature on research ethics in dementia research. Ethical issues in research were identified by qualitative text analysis and normative analysis. RESULTS The literature review retrieved 110 references that together mentioned 105 ethical issues in dementia research. This set of ethical issues was structured into a matrix based on the eight major principles from a pre-existing framework on biomedical ethics (Emanuel et al. An Ethical Framework for Biomedical Research. in The Oxford textbook of clinical research ethics, Oxford University Press, Oxford, 2008). Consequently, subcategories were created and further categorized into dementia stages and study phases. CONCLUSIONS The systematically derived matrix helps raise awareness and understanding of the complex topic of ethical issues in dementia research. The matrix can be used as a basis for researchers, policy makers and other stakeholders when planning, conducting and monitoring research, making decisions on the legal background of the topic, and creating research practice guidelines.
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Affiliation(s)
- Tim G Götzelmann
- Institute for History, Ethics and Philosophy in Medicine, OE 5450, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Daniel Strech
- QUEST Center, Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178, Berlin, Germany
| | - Hannes Kahrass
- Institute for History, Ethics and Philosophy in Medicine, OE 5450, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Wu N, Su Y. Variations in the oxytocin receptor gene and prosocial behavior: moderating effects of situational factors. Integr Zool 2019; 13:687-697. [PMID: 29851255 DOI: 10.1111/1749-4877.12336] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Humans are the most prosocial primate species and they often exhibit high levels of prosocial behavior toward genetically unrelated individuals. Traditional evolutionary theories are not sufficient to explain the individual differences and mechanisms related to prosociality. In this study, we focused on the gene-situation interaction in prosocial behaviors, and the patterns of genotype variance related to cooperation and comforting in different situations. We explored the interaction between the oxytocin receptor (OXTR) gene and situations, and the genotype variance under low and high prosociality situations between outgroup and ingroup recipients in a sample of 422 Chinese males. Prosociality was tested by measuring the prosocial tendencies, and prosocial behaviors were tested in cooperation and comforting tasks. OXTR single nucleotide polymorphisms (SNPs) were genotyped using polymerase chain reaction-restriction fragment length polymorphism analysis. The results suggested that the relationship between OXTR SNPs (specifically rs13316193, rs1042778 and rs237887) and prosocial behavior varied across different situations, and that the associations were moderated by the recipient's identity and the prosocial cost. Our findings indicate the action of a moderating mechanism between the OXTR gene and prosocial behaviors according to situational factors.
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Affiliation(s)
- Nan Wu
- Teachers College of Beijing Union University, Peking University, Beijing, China.,School of Psychological and Cognitive Sciences and Beijing Key Laboratory of Behavior and Mental Health, Peking University, Beijing, China
| | - Yanjie Su
- School of Psychological and Cognitive Sciences and Beijing Key Laboratory of Behavior and Mental Health, Peking University, Beijing, China
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Garcia-Ptacek S, Dahlrup B, Edlund AK, Wijk H, Eriksdotter M. The caregiving phenomenon and caregiver participation in dementia. Scand J Caring Sci 2018; 33:255-265. [PMID: 30488971 PMCID: PMC7432177 DOI: 10.1111/scs.12627] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 09/27/2018] [Indexed: 12/01/2022]
Abstract
Background Dementia presents barriers to the collaboration between individuals and the healthcare system. Caregivers perform multiple functions helping patients with basic and instrumental activities but also communicating and mediating the dyads’ needs within the broader social group. Interventions focusing on caregivers show that caregiver burden can be reduced, improving patient outcomes in a cost‐effective way, but the generalisation of these findings is limited by several factors such as low participation rates of caregivers in studies. There is a global push to increase patient participation in health care, but this can be difficult for patients with dementia. Caregiver participation has arisen as a substitute, but there is a lack of standardised definitions, goals and outcome measurement tools for this participation. Methods In 2015, the Swedish Association of Local Authorities and Regions commissioned a study on possibilities of increasing caregiver participation within the Swedish Dementia Registry (SveDem). This discussion paper updates and adapts that report, aiming to broadly summarise the caregiving phenomenon in order to provide a backdrop for clinicians seeking to understand the legal, ethical and practical considerations of caregiver participation in dementia. Relevant literature on caregiver participation is presented, and its definition, extent and practical implementation are discussed. Discussion The Swedish legal framework compels care providers to facilitate patient and caregiver participation in dementia and provides support to caregivers through the local level of government, but further work is needed to clarify and define the extension and form that this participation must take in clinical practice. Advanced directives are one step in extending patient participation to the period of advanced dementia. Conclusion Little research exists on caregiver participation. There is a need to develop a framework for caregiver and patient participation to determine the extent, type and form that such participation should take in health care, research and quality initiatives pertaining to persons with dementia.
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Affiliation(s)
- Sara Garcia-Ptacek
- Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Karolinska Institutet, Huddinge, Sweden.,Department of Internal Medicine, Section for Neurology, Södersjukhuset, Stockholm, Sweden
| | - Beth Dahlrup
- Department of Health Sciences, Division of Geriatric Medicine, Lund University, Lund, Sweden
| | - Ann-Katrin Edlund
- Aging Theme, SveDem, Svenska Demensregistret, Karolinska University Hospital, Huddinge, Sweden
| | - Helle Wijk
- Aging Theme, SveDem, Svenska Demensregistret, Karolinska University Hospital, Huddinge, Sweden.,Institute of Health and Care Science, Gothenburg University, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg, Sweden
| | - Maria Eriksdotter
- Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Karolinska Institutet, Huddinge, Sweden.,Aging Theme, SveDem, Svenska Demensregistret, Karolinska University Hospital, Huddinge, Sweden.,Department of Geriatric Medicine/Aging Theme, Karolinska University Hospital, Huddinge, Sweden
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Shepherd V, Hood K, Sheehan M, Griffith R, Jordan A, Wood F. Ethical understandings of proxy decision making for research involving adults lacking capacity: A systematic review (framework synthesis) of empirical research. AJOB Empir Bioeth 2018; 9:267-286. [PMID: 30321110 DOI: 10.1080/23294515.2018.1513097] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Research involving adults lacking mental capacity relies on the involvement of a proxy or surrogate, although this raises a number of ethical concerns. Empirical studies have examined attitudes towards proxy decision-making, proxies' authority as decision-makers, decision accuracy, and other relevant factors. However, a comprehensive evidence-based account of proxy decision-making is lacking. This systematic review provides a synthesis of the empirical data reporting the ethical issues surrounding decisions made by research proxies, and the development of a conceptual framework of proxy decision-making for research. METHODS A systematic review was conducted according to PRISMA guidelines. Databases including MEDLINE, EMBASE, and CINAHL were searched using a combination of search terms, and empirical data from eligible studies were retrieved. The review followed the framework synthesis approach to refine and develop a conceptual framework. RESULTS Thirty-four studies were included in the review. Two dimensions of proxy decision-making emerged. The ethical framing criteria of decision-making used by proxies: use of a substituted judgement, use of a best interests approach, combination of substituted judgement and best interests, and 'something else', and the active elements of proxy decision-making: 'knowing the person', patient-proxy relationship, accuracy of the decision, and balancing risks, benefits and burdens, and attitudes towards proxy decision-making. Interactions between the framing criteria and the elements of decision-making are complex and contextually-situated. CONCLUSIONS The findings from this systematic review challenge the accepted reductionist account of proxy decision-making. Decision-making by research proxies is highly contextualized and multifactorial in nature. The choice of proxy and the relational features of decision-making play a fundamental role: both in providing the proxy's authority as decision-maker, and guiding the decision-making process. The conceptual framework describes the relationship between the framing criteria used by the proxy, and the active elements of decision-making. Further work to develop, and empirically test the proposed framework is needed.
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Affiliation(s)
- Victoria Shepherd
- a Division of Population Medicine , Cardiff University , Cardiff , UK
- b Centre for Trials Research , Cardiff University , Cardiff , UK
| | - Kerenza Hood
- b Centre for Trials Research , Cardiff University , Cardiff , UK
| | - Mark Sheehan
- c Ethox Centre , University of Oxford, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery , Oxford , UK
| | - Richard Griffith
- d College of Human and Health Sciences , Swansea University , Swansea , UK
| | - Amber Jordan
- a Division of Population Medicine , Cardiff University , Cardiff , UK
| | - Fiona Wood
- a Division of Population Medicine , Cardiff University , Cardiff , UK
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Decisions and attitudes regarding participation and proxy in clinical trials among patients with impaired cognitive function. DEMENTIA 2017; 18:2049-2061. [DOI: 10.1177/1471301217737413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Medical decision-making capacity is impaired in Alzheimer’s disease and mild cognitive impairment. Medical decision-making capacity depends on many different cognitive functions and varies due to situation and cognitive, social, and emotional status of the patient. Our aim was to analyze dementia patients’ capacity to estimate risks and benefits in different clinical trials and determine how cognitive decline affects their attitude toward possible participation and proxy consent. Methods Groups: Alzheimer’s disease (n = 20), mild cognitive impairment (n = 21) and healthy controls (n = 33). Two hypothetical clinical trials, a standardized interview and three visual analogue scales were used to investigate decisions, estimations, reasoning, and attitudes. Results A general positive attitude toward participation in clinical trials was shown among all groups. Both patients and controls motivated possible participation as “own-benefit” in the low-risk trial and to “help-others” in the high-risk trial. Individuals who accepted to participate in the high-risk trial scored lower in medical decision-making capacity in comparison to participants who would not have participated (p < .01). Patients in the Alzheimer’s disease but not mild cognitive impairment and healthy control groups underestimated risks and overestimated benefits in the high-risk/low-benefit trial (p < .05). A family member was most frequently chosen as possible proxy (91%). Conclusions Medical decisions and research consent should be interpreted with caution in patients who are already in early stages of dementia, as the patients’ acceptance to participate in high-risk trials may be due an insufficient decisional capacity and risk analysis, accelerated by a general desire to make good to society. We emphasize the use of a standardized tool to evaluate medical decisional capacity in clinical research.
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Substitute consent practices in the face of uncertainty: a survey of Canadian researchers in aging. Int Psychogeriatr 2013; 25:1821-30. [PMID: 23927951 DOI: 10.1017/s1041610213001336] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND In Canada and elsewhere, research policies require researchers to secure consent from a legally authorized representative (LAR) for prospective participants unable to consent. Few jurisdictions, however, offer a clear legislative basis for LAR identification. We investigated Canadian researchers' practices regarding the involvement of decisionally incapacitated participants and tested whether reported practices were associated with (1) researchers' understanding of the law on third-party authorization of research and (2) their comfort with allowing a family member to consent on behalf of an incapacitated relative. METHODS We surveyed researchers in aging from four Canadian provinces about their practices with prospective participants deemed incapable of consent, their understanding of relevant law, and comfort with family consent for research purposes. Understanding and comfort were measured with research vignettes that briefly described hypothetical studies in which an adult who lacks the capacity to consent was invited to participate. RESULTS Many respondents reported soliciting consent from a family member (45.7% for low-risk studies and 10.7% for serious risks studies), even in jurisdictions where such authority is uncertain at law. Researchers' tendency to solicit family consent was associated with their comfort in doing so, but not with their understanding of the law on substitute consent for research. CONCLUSIONS Findings underscore the need to clarify who may authorize an incapacitated adult's participation in research. Meanwhile, people should inform their relatives of their desire to participate or not in research in the event of incapacity, given researchers' tendency to turn to family for consent, even where not supported by law.
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Bravo G, Arcand M, Blanchette D, Boire-Lavigne AM, Dubois MF, Guay M, Hottin P, Lane J, Lauzon J, Bellemare S. Promoting advance planning for health care and research among older adults: a randomized controlled trial. BMC Med Ethics 2012; 13:1. [PMID: 22221980 PMCID: PMC3328256 DOI: 10.1186/1472-6939-13-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 01/05/2012] [Indexed: 01/25/2023] Open
Abstract
Background Family members are often required to act as substitute decision-makers when health care or research participation decisions must be made for an incapacitated relative. Yet most families are unable to accurately predict older adult preferences regarding future health care and willingness to engage in research studies. Discussion and documentation of preferences could improve proxies' abilities to decide for their loved ones. This trial assesses the efficacy of an advance planning intervention in improving the accuracy of substitute decision-making and increasing the frequency of documented preferences for health care and research. It also investigates the financial impact on the healthcare system of improving substitute decision-making. Methods/Design Dyads (n = 240) comprising an older adult and his/her self-selected proxy are randomly allocated to the experimental or control group, after stratification for type of designated proxy and self-report of prior documentation of healthcare preferences. At baseline, clinical and research vignettes are used to elicit older adult preferences and assess the ability of their proxy to predict those preferences. Responses are elicited under four health states, ranging from the subject's current health state to severe dementia. For each state, we estimated the public costs of the healthcare services that would typically be provided to a patient under these scenarios. Experimental dyads are visited at home, twice, by a specially trained facilitator who communicates the dyad-specific results of the concordance assessment, helps older adults convey their wishes to their proxies, and offers assistance in completing a guide entitled My Preferences that we designed specifically for that purpose. In between these meetings, experimental dyads attend a group information session about My Preferences. Control dyads attend three monthly workshops aimed at promoting healthy behaviors. Concordance assessments are repeated at the end of the intervention and 6 months later to assess improvement in predictive accuracy and cost savings, if any. Copies of completed guides are made at the time of these assessments. Discussion This study will determine whether the tested intervention guides proxies in making decisions that concur with those of older adults, motivates the latter to record their wishes in writing, and yields savings for the healthcare system. Trial Registration ISRCTN89993391
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Affiliation(s)
- Gina Bravo
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC, Canada.
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