Uncertainty in clinical research

Regulating Research and experimentation: a view from the U.K

A medical profession which did not seek improved means to conquer disease would be condemned for dereliction of its duty, Members of the public will not accept the current state of the medical arts as finite but feel justified in expecting the development of more effective therapies for illness, and the promotion of improved means of preventive care.

With this assertion, the distinguished academic, Bernard Dickens, places research firmly in the domain of the public interest. Foster agrees, saying that, “[t]o improve medical care as much as we can, if not to perfect it, means that we have to accept the need for research.” Giesen adds a further emphasis to the search for medical advancements, saying that “freedom of research and scientific inquiry is, in itself, an important aspect of open societies.“

Defining and describing benefit appropriately in clinical trials

Institutional review boards (IRBs) and investigators are used to talking about risks of harm. Both low risks of great harm and high risks of small harm must be disclosed to prospective subjects and should be explained and categorized in ways that help potential subjects to understand and weigh them appropriately. Everyone on an IRB has probably spent time at meetings arguing over whether a three-page bulleted list of risk description is helpful or overkill for prospective subjects. Yet only a small fraction of all the time and attention lavished on risk disclosure has been devoted to discussing whether and when potential benefit to subjects can reasonably be claimed and, if so, how it should be described in the consent form and process.

Traditionally, IRBs and regulators have worked to ensure that clear lines can be drawn between research that, by definition, carries no potential for direct benefit — because it uses healthy volunteers or because it is not foreseeably focused on the development of treatments — and research that does have the development of effective treatments as its goal.

Randomized clinical trials in periodontology: ethical considerations

Ethical justification for starting a clinical trial requires at the outset an accurate statement of "no difference" regarding the two or more agents to be compared. This may be expressed as "theoretical equipoise" (no data to support the superiority of one of the agents) or, preferably, as "clinical equipoise" (there are insufficient data to resolve controversy among experts as to which is superior). This presents a problem when a placebo control is proposed, particularly when the outcome measure entails irreversible loss of function; preliminary data often suggest the superiority of the "active agent." Informed consent should ordinarily include the fact that treatment assignments will be accomplished by a process of randomization and, in the case of double-blind designs, that neither the subject nor the investigator will know the subject's treatment assignment until the end of the trial. In general, clinical trials should be monitored by data and safety monitoring boards that have access to unblinded data; they should be guided by stopping rules that should be agreed upon by all concerned before the trial is begun. Women and minorities must be included unless there is strong justification for their exclusion. Care must be taken to balance the competing objectives of validity (the results will be correct), generalizability (the results will be broadly applicable), and efficiency (the study will not be unduly expensive).

Ethics of clinical trials. Do they help the patient?

Ethical justification of a randomized clinical trial requires at the onset that the investigators be able to state an honest null hypothesis regarding the therapies to be compared. For example, in a randomized clinical trial with only two arms (A and B), it is necessary to state that there is no scientifically validated reason to predict that therapy A will prove to be either superior or inferior to therapy B. Moreover, there must be no therapy C known to be superior to A and B unless there is a cogent reason to reject therapy C; the population of research subjects will consist either of those in whom therapy C has been tried without success or individuals who are aware of therapy C and have rejected it for various reasons. Thus, theoretically, the patients enrolled in a randomized clinical trial are assured that they will receive one of the two best known therapies for their condition. At first glance, one might conclude that randomized clinical trials do, in general, help the patient. There are some features of at least some clinical trials, however, that may be detrimental to the interests of some patients. It commonly is said, for example, that patients in randomized clinical trials are deprived of the "good of personal care." The physician-investigator may be constrained by rigid protocol requirements from being responsive to the particular needs and desires of the patient. Additionally, the process of obtaining informed consent to randomized clinical trials may be preemptive: patients who might have chosen palliative care rather than chemotherapy may not be afforded adequate opportunity to make such a choice. Any randomized clinical trial should maximize the likelihood of helping the patient.

Community-based AIDS research

Institutional review boards (IRBs) that review community-based AIDS research, like their counterparts in hospital-based or academic settings, are charged with protecting the rights and welfare of subjects. Fulfilling this charge presents all the challenges that face other IRBs, but with the added urgency of issues particular to the disease and the community setting. Investigators in community-based AIDS research are often primary care providers who have close relationships with their patients; they are not, by and large, trained as clinical investigators. A patient-centered medical ethic may differ in significant ways from knowledge-oriented research ethics. Furthermore, patients with AIDS, living with a disease with no cure or effective long-term treatment, urgently need access to promising drugs and therapies. Community research IRBs thus must grapple with generic research design and ethical issues that assume special salience under these conditions. One can characterize these issues as questions of scientific validity, not ethics, but they are both. The challenge to the IRB is to balance the values of scientific credibility with the moral principles of respect for persons, including autonomy, beneficence, and justice. The experience of the IRB of New York City's Community Research Initiative (CRI) in dealing with this tension may be instructive for others examining the community-based research model. In the process of reviewing protocols, the IRB has developed policies that address issues of research design, subject selection, and confounding variables.