The Challenge of Selecting Participants Fairly in High-Demand Clinical Trials

Ethical challenges for a new generation of early-phase pediatric gene therapy trials

After decades of setbacks, gene therapy (GT) is experiencing major breakthroughs. Five GTs have received US regulatory approval since 2017, and over 900 others are currently in development. Many of these GTs target rare pediatric diseases that are severely life-limiting, given a lack of effective treatments. As these GTs enter early-phase clinical trials, specific ethical challenges remain unresolved in three domains: evaluating risks and potential benefits, selecting participants fairly, and engaging with patient communities. Drawing on our experience as clinical investigators, basic scientists, and bioethicists involved in a first-in-human GT trial for an ultrarare pediatric disease, we analyze these ethical challenges and offer points to consider for future GT trials.

Advantages of Using Lotteries to Select Participants for High-Demand Covid-19 Treatment Trials

As hospitals have experienced a surge of Covid‐19 patients, investigators of Covid‐19 treatment trials face a difficult problem: when an institution has more eligible and interested patients than trial slots, who should be enrolled? Defining a clear strategy for selecting participants for “high‐demand” Covid‐19 treatment trials is important to avoid ad hoc and potentially biased decision‐making by local investigators, which could inadvertently compromise a trial's social value, participants’ interests, or fairness. In this article, we propose a set of ethical criteria for evaluating participant‐selection strategies for such trials. We argue that the pandemic context—in particular, great urgency to develop safe and effective treatments, uncertainty surrounding Covid‐19, and strain on the health care system that limits the time and effort available for trial enrollment—favors participant‐selection strategies that optimize the ease of enrollment and, ideally, social value. A lottery and, where possible, a weighted lottery have important advantages in these respects.