Placebo orthodoxy in clinical research. I: Empirical and methodological myths

Ethics in placebo-controlled, acute treatment trials in schizophrenia: Two rival ethical frameworks

Placebo-controlled, acute treatment trials in schizophrenia enroll acutely symptomatic persons, randomize them to receive placebo or antipsychotic medication for several weeks, and evaluate whether symptoms improve. These trials can have scientific benefits, especially when they test drugs with novel mechanisms of action. However, the use of placebo is ethically problematic inasmuch as standard treatment is withheld and participants are subjected to prolonged psychotic symptoms and associated risks. We propose that both deontological (duty-based) and utilitarian analyses are relevant, that it may be impossible to satisfy the ideals of both frameworks, and that researchers who conduct these trials will unavoidably encounter ethical tension and criticism even when they give careful attention to ethical aspects of study design.

Taking the principle of the primacy of the human being seriously

This paper targets an orphan topic in research ethics, namely the so called principle of the primacy of the human being, which states that the interests of the human subject should always take precedence over the interests of science and society. Although the principle occupies the central position in the majority of international ethical and legal standards for biomedical research, it has been commented in the literature mainly in passing. With a few notable exceptions, there is little in-depth discussion about the meaning and role of the principle. Several authors note that the principle is vogue, ambiguous and apparently conflicting with the accepted practice of conducting non-beneficial research on individuals unable to give consent. There are opinions that it is just "a vacuous figure of speech" and should be abandoned. This paper argues that the primacy principle is far from being "a vacuous figure of speech", rather it should be seen as a threefold concept: a fundamental interpretative rule, a procedural rule, and a substantive rule aimed at protecting research subjects from instrumental treatment and unacceptable risks. This interpretation tracks back to the principle regulatory and normative origins in the Declaration of Helsinki of 1975, but also acknowledges changes in research ethics and practice, which took place at the turn on the twentieth and twenty-first centuries. Thus, the proposed reading of the principle is not only original, but also historically grounded and normatively fruitful. It provides a fresh and ethically rich perspective on extensively debated, but still controversial problem of an upper limit of permissible risks in non-beneficial studies.

A historical review of placebo-controlled, relapse prevention trials in schizophrenia: The loss of clinical equipoise

Recent ethical critiques have proposed that placebo-controlled, relapse prevention trials in schizophrenia are no longer justifiable and are therefore unethical. This review provides an historical perspective on the justifications for these trials and how arguments evolved over several decades. We identified 87 placebo-controlled, relapse prevention trials published over the last seventy years and examined the purpose for each trial. We found that first-generation trials had compelling justifications, yet these arguments changed considerably over time. Second-generation trials offered comparatively weaker-and sometimes no-justifications for their conduct. Without clear and compelling justifications for a given trial, it is not ethical to continue using this study design.

Effect of a New Synergistic Combination of Low Doses of Acetylsalicylic Acid, Caffeine, Acetaminophen, and Chlorpheniramine in Acute Low Back Pain

The present paper continues a more complex research related to the increased synergism in terms of both anti-inflammatory and analgesic effect obtained by the addition of chlorpheniramine (CLF) to the common acetylsalicylic acid (ASA), acetaminophen (PAR), and caffeine (CAF) combination. This synergistic effect was previously highlighted both in vitro in rat models and in vivo in the treatment of migraine. The aim of the research was to further evaluate the analgesic effect of a synergistic low-dose ASA-PAR-CAF-CLF combination in the treatment of low back pain, in a parallel, multiple-dose, double-blind, active controlled clinical trial. A number of 89 patients with low back pain of at least moderate intensity were randomly assigned to receive Algopirin^® (ALG), a combinational product containing 125 mg ASA, 75 mg PAR, 15 mg CAF, and 2 mg CLF, or PAR 500 mg, a drug recognized by American Pain Society as "safe and effective" in the treatment of low back pain. One tablet of the assigned product was administered three times a day for seven consecutive days. The patients evaluated their pain level using a Visual Analog Scale prior to administration, and at 1, 2, 4, and 6 h after the morning dose. Time course of effect was similar in structure and size for both treatments. Pain relief appeared rapidly and steadily increased over 4 h after drug administration. Differential pain curves of ALG and PAR were very similar and comparable with the previously determined ALG analgesia pattern in migraine. Differences between the daily mean pain scores were not statistically significant for the two treatments. Similar results were obtained for the Sum of Pain Intensity Differences (SPID) for 0-4 h and 0-6 h intervals as well as for the time course of the proportion of patients with at least 30% and at least 50% pain relief. In conclusion, in spite of very small doses of active components, ALG proved equally effective to the standard low back pain treatment and therefore a viable therapeutic alternative, mainly for patients with gastrointestinal and hepatic sensitivity. Trial Registration: www.ClinicalTrials.gov, identifier EudraCT No.: 2015-002314-74.

Placebo Groups in Research on the Effectiveness of ABA Therapeutic Techniques

Behavior analysts have shown that a single-subject experimental design (SSED) is a useful tool for identifying the effectiveness of specific therapeutic techniques, whereas researchers outside applied behavior analysis (ABA) maintain that randomized placebo-controlled trials (RPCT) provide the most definite test of efficacy. In this paper the possible benefits that could result from supporting SSED studies by placebo control groups are discussed. However, the use of placebo groups in psychotherapy research arouses considerable controversy and many researchers argue against it. The main aim of this paper is to clarify theoretical and methodological problems associated with using placebo groups in psychotherapy research and to demonstrate that these problems can be solved if the assumptions on which they are based are reformulated. The article also discusses ethical issues about the use of placebo groups in research on the effectiveness of psychotherapy.

Placebo orthodoxy and the double standard of care in multinational clinical research

It has been almost 20 years since the field of bioethics was galvanized by a controversial series of multinational AZT trials employing placebo controls on pregnant HIV-positive women in the developing world even though a standard of care existed in the sponsor countries. The trove of ethical investigations that followed was thoughtful and challenging, yet an important and problematic methodological assumption was left unexplored. In this article, I revisit the famous "double standard of care" case study in order to offer novel consideration of the placebo orthodoxy that underlies much of the ethical debate. This majority view found in medical research is that placebo-controlled trials are methodologically superior to comparative trials that use active controls. I challenge this orthodoxy and argue that lives were unnecessarily lost in these trials as a result. Furthermore, current HIV research on vaccines and microbicides is now poised to repeat the error of subscribing to the placebo orthodoxy.

Attitude of epilepsy patients and their attendants for participating in research on status epilepticus

To evaluate the reason joining in status epilepticus (SE) trial by epilepsy patients and attendants and their preferences for types of trials and consent. The participants were interviewed after giving a SE case summary. Their demographic details, reason of consenting or non-consenting and preference of trials and type of consent were noted. The responses of the patients and attendants were compared. 77 subjects participated and 47 (61 %) were willing to participate in the trial mainly due to self-interest (treatment by specialist, best treatment and treatment availability only by trial). The reasons for unwilling were apprehension and lack of will. The participants preferred a head-to-head trial over a placebo-controlled (21 vs. 3), proxy consent rather than waived consent (16 vs. 6) and preconsent (16 vs. 3). These responses were not different between patients and attendants. 61 % subjects were willing to participate in SE trial especially in head-to-head trial with proxy consent.

When ethics constrains clinical research: trial design of control arms in "greater than minimal risk" pediatric trials

For more than three decades clinical research in the United States has been explicitly guided by the idea that ethical considerations must be central to research design and practice. In spite of the centrality of this idea, attempting to balance the sometimes conflicting values of advancing scientific knowledge and protecting human subjects continues to pose challenges. Possible conflicts between the standards of scientific research and those of ethics are particularly salient in relation to trial design. Specifically, the choice of a control arm is an aspect of trial design in which ethical and scientific issues are deeply entwined. Although ethical quandaries related to the choice of control arms may arise when conducting any type of clinical trials, they are conspicuous in early phase gene transfer trials that involve highly novel approaches and surgical procedures and have children as the research subjects. Because of children's and their parents' vulnerabilities, in trials that investigate therapies for fatal, rare diseases affecting minors, the scientific and ethical concerns related to choosing appropriate controls are particularly significant. In this paper we use direct gene transfer to the central nervous system to treat late infantile neuronal ceroid lipofuscinosis to illustrate some of these ethical issues and explore possible solutions to real and apparent conflicts between scientific and ethical considerations.

Evaluating equivalence and noninferiority trials

PURPOSE

The conceptual issues related to the design of equivalence and non-inferiority trials and considerations for interpreting the findings of such trials are described.

SUMMARY

Comparative effectiveness research (CER) has recently gained importance in the evaluation of different treatment alternatives. Large, prospective, randomized controlled trials (RCTs) conducted with patient populations under routine practice conditions can yield high-quality CER results. A Phase III RCT, usually conducted for establishing superiority of one treatment over another, is called a superiority trial, and the statistical test associated with it is known as a superiority test. In a pragmatic equivalence trial, a researcher aims to test if two treatments are identical (within a specified range) with respect to some predefined clinical criteria. Pragmatic noninferiority trials aim to show if a test therapy is no worse than a standard therapy with respect to achieving the primary treatment outcome. A nonsignificant result obtained from a superiority test does not indicate that the two treatment options are similar. In other words, the lack of evidence of superiority does not guarantee a lack of difference in the performance shown by the therapies. A researcher can only demonstrate identical effects of two treatments in an equivalence trial. In a noninferiority trial, the test therapy is preferred when there is evidence about its benefits over the standard treatment in terms of secondary outcomes such as cost, adherence, and adverse effects.

CONCLUSION

Equivalence and noninferiority trials are designed differently from superiority trials. The overall quality of equivalence and noninferiority studies depends on study design and the manner in which the results are reported.

Placebo-controlled trials in pediatric urology: a cautionary view from an ethical perspective

The ethical dispute regarding placebo-controlled trials is discussed in this review. Important issues, such as clinical equipoise, fiduciary obligation and middle ground theory, are examined in the context of pediatric urology clinical research. After reviewing the literature, the authors summarize specific indications for placebo-controlled trials in pediatric urology, and emphasize that physicians have ethical and moral obligations to patients, in the sense that one should carefully plan and conduct such trials in order to gain clinically important information without exposing children to undue risks.

Ethical, Scientific, and Regulatory Perspectives Regarding the Use of Placebos in Cancer Clinical Trials

Purpose

To examine the ethical, scientific, and regulatory issues in the design and conduct of placebo-controlled cancer clinical trials.

Methods

Several content experts contributed to this article.

Results

Specific criteria can be applied to determine the appropriate use of placebos in oncology drug development. Placebo controls may be justified to prove efficacy of a new treatment in diseases with high placebo response rates; in conditions that wax and wane in severity, have spontaneous remissions, or have an uncertain and unpredictable course; when existing therapies are minimally effective or have serious adverse effects; or in the absence of effective therapy. Use of placebos may also be justified to assure blinding of physicians and patients regarding treatment assignment so as to minimize bias in assessment of study end points. If a trial meets these methodologic criteria, it must then fulfill additional criteria to be considered ethical. These criteria include full disclosure to patients and an assurance that participants randomly assigned to placebo are not substantially more likely than those in active treatment group(s) to die; suffer irreversible morbidity, disability, or other substantial harms; suffer reversible but serious harm; or suffer severe discomfort.

Conclusion

We conclude that placebo-controlled oncology trials are scientifically feasible, ethically justifiable, and may be necessary or desirable to meet regulatory standards for drug approval. Using cross-over or randomized withdrawal trial designs, requiring inclusion of state-of-the-art palliative care, and developing valid and acceptable surrogates for survival are critical strategies to address some of the ethical dilemmas associated with placebo-controlled trials.

Subjective evaluations of research participation by persons with mental illness

The present study focuses on the subjective experience of psychiatric patients who participate in psychobiological research, based on patients' self-reported evaluations of the experience. We studied 313 persons with mental illness admitted to an inpatient research unit. Each participant was administered the Patient Satisfaction Questionnaire, a structured self-report questionnaire designed to assess satisfaction with research participation and clinical care. Individuals who completed the research protocol were significantly more satisfied globally and more likely to express that treatment had been effective. Factors contributing to willingness to participate in future research included favorable perceptions of: (a) psychoeducation, (b) safety, and (c) comfort level with research procedures. Research participants were willing to participate in future research regardless of their perception of medication efficacy. This study emphasizes the importance of understanding the opinions of persons with mental illness who participate in research. Overall, the data suggest that persons with mental illness find psychiatric research to be beneficial. Although therapeutic misconception cannot be ruled out given the methodology used, at the very least the data indicate no sign that subjects found research participation to be harmful. Further studies should explore the source of this perception and attempt to separate the effect of "therapeutic misconception" from possible real benefit of protocol-driven assessment and treatment in a reputable clinical environment.

Prevalence and factors associated with use of placebo control groups in randomized controlled trials in psoriasis: A cross-sectional study

BACKGROUND

The ethics and science of using placebo control groups in clinical trials have been widely debated. Few studies, however, have examined factors associated with choice of control group.

OBJECTIVE

Our aim was to assess the prevalence of use of placebo controls in randomized controlled trials in psoriasis and to identify factors associated with use of placebo controls in these trials.

METHODS

This is a cross-sectional study of randomized controlled trials in psoriasis published from January 1, 2001 to December 20, 2005 and indexed in the Cochrane Central Register of Controlled Trials. We extracted data on types of control groups used, design issues (number of patients enrolled, primary end point), disease characteristics (psoriasis type and severity), and extrascientific issues (trial location, funding source, and year of publication). We used bivariable and multivariable logistic regression to determine factors associated with use of a placebo control group.

RESULTS

Of 194 citations, 187 were available for review. One hundred thirty-five trials from 134 articles in 38 journals met inclusion criteria. Eighty-three trials (61.5%) enrolling 8171 subjects (41.7%) used active controls only, and 52 trials (38.5%) enrolling 11,406 subjects (58.3%) used placebo controls. Adjusted for trial location and funding source, trials significantly more likely to have used placebo controls included those conducted in the United States (odds ratio [OR], 5.79; 95% confidence interval [CI], 2.45-13.68; P < .001) and those funded by pharmaceutical companies (OR, 2.61; 95% CI, 1.19-5.73; P = .02). Predicted frequencies of placebo use ranged from 77.6% (industry-funded, conducted trials in the United States) to 18.6% (non-industry-funded trials not conducted in the United States).

LIMITATIONS

Our searches may not have identified all published trials, and we did not have access to data from unpublished trials.

CONCLUSIONS

Use of placebo controls has been more common in psoriasis trials conducted in the United States and funded by pharmaceutical companies. The findings suggest that ethical and scientific issues related to choice of control group in psoriasis trials are interpreted markedly differently depending on trial location and funding source.

Moral reasoning as a model for health promotion

The paper describes a model of moral reasoning used to guide the conduct of health researchers and recommends that this model be applied in health promotion. It argues that this model is a more appropriate and sound way of thinking about the means and ends of health education, with implications for both research and practice. When faced with ethical dilemmas about the most appropriate course of action in health research, investigators and bioethicists conduct normative analyses to identify good reasons for choosing one option over another. These reasons provide the grounds for determining what one should do, and for changing past practices in light of new moral considerations. Since the research community seems to think that this is a good way to guide and change their own behavior, this model of moral reasoning appears to have relevance and potential application to the field of health education, which engages in analogous processes of seeking to inform and change the behaviors of the lay public. The article sets this approach in the context of a humanistic understanding of human motivation and presents two case examples to illustrate the process of moral reasoning. The humanistic model outlined here helps to explain why health promotion has not made much progress in developing effective behavior change programs and it offers a more promising prospect for demonstrating success by identifying a broader range of relevant outcomes. The paper concludes by recommending that greater attention be paid to the ethical dimensions of human agency in order to develop a more coherent body of knowledge to advance both research and practice in health promotion.

Laparoscopy and reported pain among patients with endometriosis

OBJECTIVE

To compare the effectiveness of sharp excision of endometriosis with sham surgical excision in alleviating endometriosis-associated pain for up to 1 year following surgery.

METHODS

Patients requiring a laparoscopy for severe pelvic pain were eligible. If endometriosis was visually identified at laparoscopy, a biopsy of a representative lesion was taken. The women were then randomized either to have all remaining endometriosis excised with laparoscopic scissors (the excision group) or to have no further surgical treatment (the control group). Patients were asked to complete daily pain scales for 1 month preoperatively and quarterly for 1 year postoperatively. Subjects were blinded to their treatment allocation for 1 year.

RESULTS

Twenty-nine women underwent laparoscopy and biopsy and were randomized to have excision or no treatment of endometriosis. The excision and control groups were similar in age, parity, and revised American Society for Reproductive Medicine stage of disease. Sixteen women completed the full year of follow-up: 9 in the excision group, and 7 in the control group. Overall, recorded pain was significantly reduced at 1 year (P < 0.05), with no significant difference between the excision and control groups.

CONCLUSION

Laparoscopy with diagnostic biopsy alone is associated with a significant reduction in pain for up to 1 year postoperatively. Although the study lacked sufficient statistical power to exclude an effect of excision, pain relief in each group was similar. These results indicate a potential benefit of sham surgical procedures in assessing novel surgical interventions.

Timing invitations to participate in clinical research: preliminary versus informed consent

This article addresses the impact of the potential conflict between the roles of physicians who are both clinicians and researchers on the recruitment of persons into research trials. It has been proposed (1) that a physician breaches inter-role confidentiality when he or she uses information gathered in his or her clinical role to inform patients about trials for which they may be eligible and (2) that clinician-researchers should adopt a model of preliminary consent to be approached about research prior to commencing a clinical relationship. This article argues that even if we grant the legitimacy of inter-role confidentiality (which is open to question), there are circumstances in which other obligations physicians bear override the obligation of inter-role confidentiality. Moreover, it is argued that the practice of preliminary consent is morally suspect and that such consent cannot be deemed valid. The article concludes with a series of recommendations of ways in which the legitimate concern regarding the conflicting roles of clinician-researchers can be addressed in the recruitment stage of research.

[Research ethics and the use of placebo: status of the debate in Canada]

The question of the use of the placebo is one of the most controversial in the field of the ethics of research today. The use of the placebo remains the standard practice of biomedical research in spite of the fact that various revisions of the Helsinki Declaration have sought to limit its use. In Canada, the Tri-council policy statement: Ethical conduct for research involving humans adopted a very restrictive position with respect to the use of placebos, precisely defining the situations in which its use would meet the demands of ethical research. The positions taken by the various ethical decision-making bodies are, however, hardly shared by regulatory bodies such as the Food and drug administration (FDA), the Council for international organization of medical sciences (CIOMS) or the European agency for the evaluation of medicinal products (EMEA). This divergence of opinions reveals two quite different conceptions of what constitutes the ethical. In the case of decision-making bodies in the ethical field, it is clearly medicine's Hippocratic Oath which explains their reluctance to use placebos. The first responsibility of the doctor is to "do no harm" to his or her patient. This duty is inherent to the medical profession and as such is not grounded in the view of medicine as a contract for care. In the case of regulatory bodies, it is the vision of "medicine as contract" which is in view; and it is this notion that justifies the use of placebos once free and informed consent has been obtained. It is also worth noting that these regulatory bodies make frequent use of arguments based on utilitarian ends. In an unprecedented move, the World medical association published in October 2001 a clarification note about the use of placebos. An analysis of this text raises the question about its real meaning: clarification or concession?

Equivalence and noninferiority trials - are they viable alternatives for registration of new drugs? (III)

The scientific community's reliance on active-controlled trials is steadily increasing, as widespread agreement emerges concerning the role of these trials as viable alternatives to placebo trials. These trials present substantial challenges with regard to design and interpretation as their complexity increases, and the potential need for larger sample sizes impacts the cost and time variables of the drug development process. The potential efficacy and safety benefits derived from these trials may never be demonstrated by other methods. Active-controlled trials can develop valuable data to inform both prescribers and patients about the dose- and time-dependent actions of any new drug and can contribute to the management and communication of risks associated with the relevant therapeutic products.

Ethics in psychiatric research: study design issues

OBJECTIVE

To identify and discuss ethical aspects of study design issues in psychiatric research.

METHOD

We conducted a literature review and conceptual analysis of study design in psychiatric research focusing on placebo, medication tapering and withdrawal (washout), and symptom provocation (challenge) designs.

RESULTS

While advances in the care and treatment of persons with psychiatric disorders are crucial to the improved well-being of this stigmatized and often forgotten population, past abuses demonstrate the importance of the thoughtful application of ethical principles in the conduct of research. Some ethical issues have particular relevance to psychiatric research arising primarily from the specific vulnerabilities of those with mental illness and the risks posed by some research methodologies. Accordingly, sensitivity is required in the design of psychiatric research.

CONCLUSION

Placebo, challenge, and washout study designs can present particular risks in the population of persons with mental illness. These issues are described and suggestions offered to promote the ethical design of psychiatric research.

Placebo in the investigation of psychotropic drugs, especially antidepressants

The paper presents major ethical, legal and methodological problems related to the use of placebo in mental disorders, especially in depression. It is pointed out that although authoritative groups of experts and numerous publications in the field of psychopharmacology indicate advisability of the double blind design with placebo in clinical trials of antidepressants, in recent years there have been more and more voices questioning legitimacy of this method. Objections of an ethical nature are raised, and reliability of this approach is put into doubt from the methodological viewpoint. These issues are discussed in more detail in the paper. Available alternative solutions should be implemented in psychotropic drug studies. The author shares these objections and doubts of an ethical nature, and believes that the placebo procedure is not a necessity in clinical trials of antidepressants.

Using empirical data to inform the ethical evaluation of placebo controlled trials

There has been considerable debate about the ethical acceptability of using placebo-controls in clinical research. Although this debate has been rich in rhetoric, considering that much of this research is predicated upon the assumption that data from this research is vital to clinical decision-making, it is ironic that researchers have introduced little data into these discussions. Using some published research concerning the use of placebo-controls in clinical research in hypertension and psychiatric drug trials, I suggest some ways that such data might be incorporated into the ethical analysis concerning placebo use in clinical trials. This approach promises to be important for enhancing conceptual and scientific understanding as well as public policy decision-making.

Informed consent and the use of placebo in Poland: ethical and legal aspects

The concept of informed consent was one of the most fruitful ideas that deeply changed the relationships between physicians and their patients from paternalism to respect for the personal autonomy of subjects needing professional medical care. The great progress in medicine, also involving the pharmaceutical industry, has created an increasing need to perform different clinical and experimental trials. The evolution of clinical research in the last decades has influenced strongly the design of these studies. One of the most important changes in this field has been the use of placebo groups in double-blind controlled studies. The controversies have involved not only the use of placebo when standard or proven treatment was available, but also some specific problems concerning the procedure of obtaining informed consent in such trials. This paper briefly presents the evolution of informed consent in Poland as well as different ethical and legal problems concerning informed consent and the use of placebo controls in clinical trials.

Active-control clinical trials to establish equivalence or noninferiority: methodological and statistical concepts linked to quality

The randomized, double-blind, placebo-controlled trial is the optimum method for clinical evaluation of new treatments, as assessed by clinicians and statisticians. However, if a known standard of therapy exists, it may be difficult to prove that a new therapy is superior. Equivalence and noninferiority clinical trial designs are now frequently utilized in clinical medical research. This article reviews the statistical differences between superiority, equivalence, and noninferiority design schemes, which pose specific ethical questions and have important implications for interpretation and clinical application of trial results. A guideline is proposed as a standard approach for reporting to facilitate qualitative assessment of the methodology of these trials.

Is the use of placebo controls ethically permissible in clinical trials of agents intended to reduce fractures in osteoporosis?

Substantial progress has been made in developing treatments that reduce the risk of fractures in osteoporosis. However, available treatments are only partially effective, they are not widely used, and there is need to search for more effective means of fracture prevention. Currently known effective means of reducing fractures were found using randomized placebo-controlled trials. The use of placebo controls in clinical trials has been a subject of significant controversy in recent years. The Declaration of Helsinki revision of October 2000 caused great concern among clinical investigators about the future use of placebo controls if known effective therapeutic agents are available. A working group of ethicists, clinical trial design experts, and clinical investigators examined the current state of knowledge of osteoporosis treatment and trials. They concluded that if placebo controls put subjects at substantial risk of serious outcomes, they are not ethically permissible. Placebo controls in osteoporosis trials with fracture as the measured outcome are permissible only under narrowly defined conditions. Placebo controls may be used if competent, well-informed patients refuse approved therapies for sound reasons, there is a reasonable basis for substantial disagreement or lack of consensus among professionals about whether approved treatments are better than placebos, or subjects are refractory to known effective agents. Active control trials are permissible and desirable if they can be designed and conducted in ways that overcome the interpretive difficulties often associated with such trials.

Non-inferiority trials: design concepts and issues - the encounters of academic consultants in statistics

Placebo-controlled trials are the ideal for evaluating medical treatment efficacy. They allow for control of the placebo effect and are most efficient, requiring the smallest numbers of patients to detect a treatment effect. A placebo control is ethically justified if no standard treatment exists, if the standard treatment has not been proven efficacious, there are no risks associated with delaying treatment or escape clauses are included in the protocol. Where possible and justified, they should be the first choice for medical treatment evaluation. Given the large number of proven effective treatments, placebo-controlled trials are often unethical. In these situations active-controlled trials are generally appropriate. The non-inferiority trial is appropriate for evaluation of the efficacy of an experimental treatment versus an active control when it is hypothesized that the experimental treatment may not be superior to a proven effective treatment, but is clinically and statistically not inferior in effectiveness. These trials are not easy to design. An active control must be selected. Good historical placebo-controlled trials documenting the efficacy of the active control must exist. From these historical trials statistical analysis must be performed and clinical judgement applied in order to determine the non-inferiority margin M and to assess assay sensitivity. The latter refers to establishing that the active drug would be superior to the placebo in the setting of the present non-inferiority trial (that is, the constancy assumption). Further, a putative placebo analysis of the new treatment versus the placebo using data from the non-inferiority trial and the historical active versus placebo-controlled trials is needed. Useable placebo-controlled historical trials for the active control are often not available, and determination of assay sensitivity and an appropriate M is difficult and debatable. Serious consideration to expansions of and alternatives to non-inferiority trials are needed.

Surgical "placebo" controls

OBJECTIVE

To set ethical guidelines on the use of surgical placebo controls in the design of surgical trials.

BACKGROUND DATA

Ethical concerns recently arose from surgical trials where subjects in the control arm underwent surgical procedures that had the appearance of a therapeutic intervention, but during which the essential therapeutic maneuver was omitted. Although there are ethical guidelines on the use of a placebo in drug trials, little attention has been paid to the use of a surgical placebo control in surgical trials.

METHODS

The Council on Ethical and Judicial Affairs developed ethical guidelines based on a wide literature search and consultation with experts.

RESULTS

Surgical placebo controls should be limited to studies of new surgical procedures aimed at treating diseases that are not amenable to other surgical therapies, and are reasonably anticipated to be susceptible to substantial placebo effects. If the standard nonsurgical treatment is efficacious and acceptable to the patient, then it must be offered as part of the study design.

CONCLUSIONS

Surgical placebo controls should be used only when no other trial design will yield the requisite data and should always be accompanied by a rigorous informed consent process and a careful consideration of the related risks and benefits. The recommended ethical guidelines were adopted as AMA ethics policy and are now incorporated in the AMA's Code of Medical Ethics.

I need a placebo like I need a hole in the head

In this issue of the Journal of Law, Medicine & Ethics Peter Clark provides a comprehensive and sound ethical analysis of clinical trials examining the treatment of advanced Parkinson's disease with fetal tissue transplantation. These studies raise profound questions about how clinical trials of surgical interventions ought to be conducted. At stake is not only the ethical basis of such trials, but differing views as to the proper role of science in medicine and its limitations.

Experience with the broader debate on the ethical permissibility of placebo controls has taught us that the choice of control treatment is an aspect of trial design in which ethical and scientific issues overlap. Accordingly, I will highlight, and perhaps expand upon, three issues raised by Clark: What scientific questions ought clinical trials of surgical interventions ask? How should the ethical analysis of risk for such trials be conceived? And, are surgical patients a vulnerable population?

Placebos, placebo effect, and the response to the healing situation: the evolution of a concept

In spite of its impressive progress, medicine has been strongly criticized for relying on its modern biomedical tradition to the neglect of the psychosocial aspects of health. This neglect may account for patients' dissatisfaction and eventual use of alternative health approaches. The concept of placebo has sustained dramatic "protean" metamorphoses through the ages. For centuries, placebos have been regarded as powerful deceptive therapies. From the middle of the twentieth century, however, conventional medicine has used placebos as methodologic tools to distinguish the specific from the nonspecific ingredients in treatments. In modern medical research, the double-blind, placebo-controlled, randomized clinical trial has been established as the gold standard for the assessment of any new treatment. Recently a new trend regarding placebos seems to have emerged. The placebo and other nonspecific effects elicited by the "healing situation" have been independently subjected to scientific study. Progress in this area may promote useful clinical applications, enabling physicians to broaden their perspectives on the healing process. We present the historical changes of the concept of placebo and the ethical issues raised by their use.

The ethics of social risk reduction in the era of the biological brain

In keeping with our transdisciplinary orientation, in this article we try to do several things at once. We address research on preventing mental illness and its relation to existing conceptions of public health, a topic to which insufficient attention has been paid in the era of the biological brain, while using this case study to illustrate the limits of conventional approaches in bioethics. After identifying the crucial need for methodological self-consciousness in prevention research and policy, we explore the implications as they relate to (i) the values embedded in the choice of research designs and strategies, and (ii) contrasting intellectual starting points regarding the biological plausibility of preventing mental illness. We then draw attention to the need for more thoughtful analysis of the appropriate role and limits of economics in making choices about prevention of mental illness.

The ethics of drug research in children

The obligation of society to improve the welfare of its members requires the conduct of paediatric drug trials. Nevertheless, research activities must satisfy obligations to individual participants. The obligation to protect the welfare of children requires that nontherapeutic research procedures generally involve no more than minimal risk. It also requires that randomisation occurs only when the relative merits of therapeutic procedures remain unsettled among the relevant community of experts. The duty to respect the developing autonomy of children requires that they be included in decision-making about research participation in a manner consistent with the level of their decision-making capacity. However, when children lack mature decision-making capacities, the duty of parents to protect their welfare may properly constrain their choices. Justice requires that the benefits and burdens of research be distributed in a manner that assures equal opportunity for all children. Vulnerable children should receive special protection against the burdens of nontherapeutic research procedures. The benefits of participating in clinical trials should be available to all children with serious illnesses for which current treatment is unsatisfactory. Justice also requires that initiatives be undertaken to rectify current shortcomings in the scope of paediatric drug research. Striking an appropriate balance between obligations to conduct research and to protect the interests of participants is essential to the moral integrity of paediatric drug research.

The ethical analysis of risk

The institutional review board (IRB) is the social-oversight mechanism charged with protecting research subjects. Performing this task competently requires that the IRB scrutinize informed-consent procedures, the balance of risks and potential benefits, and subject-selection procedures in research protocols. Unfortunately, it may be said that IRBs are spending too much time editing informed-consent forms and too little time analyzing the risks and potential benefits posed by research. This time mismanagement is clearly reflected in the research ethics literature. A review of articles published between 1979 and 1990 in IRB: A Review of Human Subjects Research, for example, reveals a large number of articles on informed consent and confidentiality (142 articles) and considerably fewer on the assessment of risks and potential harms (40), study design (20), and subject-selection procedures (5).

Placebo-controlled trials in schizophrenia: are they ethical? Are they necessary?

The current controversy as to the proper role of the placebo control in the evaluation of new treatments for schizophrenia requires an analysis that is sensitive to both ethical and scientific issues. Clinical equipoise, widely regarded as the moral foundation of the randomized controlled trial (RCT), requires the use of best available treatment as the control in RCT. Scientific criticisms of the use of an active control are examined and none present an insuperable barrier to the use of an active control. Indeed, scrutiny of the most recent argument for the use of placebo controls, 'assay sensitivity', suggests that the use of placebo may be the cause of the problem pointed to. Scientific, regulatory, ethical and legal advantages of the use of an active control are described. While the use of a placebo control may be acceptable in carefully defined circumstances, in most cases the use of an active control in schizophrenia research is ethically and scientifically preferable.