The human subjects trade: ethical and legal issues surrounding recruitment incentives

Comparing pharmaceutical company payments in the four UK countries: a cross-sectional and social network analysis

OBJECTIVES

To examine the characteristics of pharmaceutical payments to healthcare and patient organisations in the four UK countries. Compare companies spending the most; types of organisations receiving payments and types of payments in the four countries. Measure the extent to which companies target payments at the same recipients in each country and whether it differs depending on the type of recipient.

DESIGN

Cross-sectional comparative and social network analysis.

SETTING

England, Scotland, Wales, Northern Ireland.

PARTICIPANTS

100 donors (pharmaceutical companies) reporting payments to 4229 recipients (healthcare organisations and patient organisations) in 2015.

MAIN OUTCOME MEASURES

For each country: payment totals and distribution; average number of common recipients between companies; share of payments to organisations fulfilling different roles in the health ecosystem and payments for different activities.

RESULTS

Companies prioritised different types of recipient and different types of activity in each country. There were significant differences in the distribution of payments across the four countries, even for similar types of recipients. Recipients in England and Wales received smaller individual payments than in Scotland and Northern Ireland. Overall, targeting shared recipients occurred most frequently in England, but was also common in certain pockets of each country's health ecosystem. We found evidence of reporting errors in Disclosure UK.

CONCLUSIONS

Our findings suggest a strategic approach to payments tailored to countries' policy and decision-making context, indicating there may be specific vulnerabilities to financial conflicts of interest at subnational level. Payment differences between countries may be occurring in other countries, particularly those with decentralised health systems and/or high levels of independence across its decision-making authorities. We call for a single database containing all recipient types, full location details and published with associated descriptive and network statistics.

Conflicts of Interest in Human Subject Research: The Insufficiency of U.S. and International Standards

Researchers, as well as individuals and institutions that oversee their conduct, sometimes have conflicts of interest that weaken or render ineffective efforts to protect human research subjects. This article analyzes United States and international standards used to address conflicts of interest and reviews evidence regarding compliance. It finds current standards are insufficient and recommends that the federal government and international organizations adopt stronger legal standards that require resolving most significant conflicts of interest and specifying how to manage conflicts of interest not resolved.

Potential for physician communication to build favorable medication beliefs among older adults with hypertension: A cross-sectional survey

Older adults suffering from hypertension form firm medication beliefs through lifetime medication management, which significantly affect their medication adherence and treatment outcomes. Understanding whether the patient-physician communication has the potential to change medication beliefs will help design an effective communication strategy to foster favorable medication beliefs. This study aims to determine whether the patient-physician communication is associated with medication beliefs among older adults with hypertension and controls socio-demographics and clinical characteristics. Further, it examines how the association varies with two different types of medication beliefs (medication overuse and harm) for each domain of communication (informative and interpersonal). A self-administered cross-sectional survey was conducted for members of seven senior centers in a metropolitan area of the United States between August and December of 2013. A total of 211 senior members suffering from hypertension completed the questionnaire, which included the Primary Care Assessment Survey (PCAS) and the Beliefs about Medicines Questionnaire (BMQ). The former had two domains of patient-physician communication—informative and interpersonal—while the latter measured medication harm and overuse beliefs. Interpersonal patient-physician communication significantly explained the medication overuse beliefs (β = -0.28, p < 0.05), whereas neither interpersonal nor informative communication significantly explained the medication harm beliefs. Females (β = 1.29, p < 0.01) and participants with higher education (β = 2.66, p = 0.02) more strongly believed that medications are overprescribed. However, participants with low income more strongly believed that medications are harmful. Patient-physician communication, if it touches upon interpersonal aspects, has the potential to change medication overuse beliefs among older adults with hypertension. Identification of the significant factors which affect medication beliefs, will inform the design of a patient-centric communication program that fosters favorable medication beliefs among geriatric hypertensive patients.

A review of quality of life after predictive testing for and earlier identification of neurodegenerative diseases

The past decade has witnessed an explosion of evidence suggesting that many neurodegenerative diseases can be detected years, if not decades, earlier than previously thought. To date, these scientific advances have not provoked any parallel translational or clinical improvements. There is an urgency to capitalize on this momentum so earlier detection of disease can be more readily translated into improved health-related quality of life for families at risk for, or suffering with, neurodegenerative diseases. In this review, we discuss health-related quality of life (HRQOL) measurement in neurodegenerative diseases and the importance of these "patient reported outcomes" for all clinical research. Next, we address HRQOL following early identification or predictive genetic testing in some neurodegenerative diseases: Huntington disease, Alzheimer's disease, Parkinson's disease, Dementia with Lewy bodies, frontotemporal dementia, amyotrophic lateral sclerosis, prion diseases, hereditary ataxias, Dentatorubral-pallidoluysian atrophy and Wilson's disease. After a brief report of available direct-to-consumer genetic tests, we address the juxtaposition of earlier disease identification with assumed reluctance toward predictive genetic testing. Forty-one studies examining health-related outcomes following predictive genetic testing for neurodegenerative disease suggested that (a) extreme or catastrophic outcomes are rare; (b) consequences commonly include transiently increased anxiety and/or depression; (c) most participants report no regret; (d) many persons report extensive benefits to receiving genetic information; and (e) stigmatization and discrimination for genetic diseases are poorly understood and policy and laws are needed. Caution is appropriate for earlier identification of neurodegenerative diseases but findings suggest further progress is safe, feasible and likely to advance clinical care.

Challenging assumptions about minority participation in US clinical research

Although extensive research addresses minorities' low participation in clinical research, most focuses almost exclusively on therapeutic trials. The existing literature might mask important issues concerning minorities' participation in clinical trials, and minorities might actually be overrepresented in phase I safety studies that require the participation of healthy volunteers. It is critical to consider the entire spectrum of clinical research when discussing the participation of disenfranchised groups; the literature on minorities' distrust, poor access, and other barriers to trial participation needs reexamination. Minority participation in clinical trials is an important topic in public health discussions because this representation touches on issues of equality and the elimination of disparities, which are core values of the field.

Commentary: Per capita payments in clinical trials: reasonable costs versus bounty hunting

Paying more for clinical research than the cost of doing the work may create a conflict of interest that could lead to overzealous recruitment, putting participants and scientific integrity at risk. Thus, although various policies prohibit "finder's fees" simply for recruiting patients, paying the actual costs for research is permissible. Whereas industry-sponsored research routinely pays for the costs of each patient enrolled, the line between reasonable and excessive costs merits more attention. In academic medical centers (AMCs), institutional review boards and conflict of interest committees usually are not involved in reviewing research budgets to determine whether per capita payments are excessive. Also, the costs for clinical services in research are not standardized. Instead, budgets are negotiated both internally, among departments within research institutions, and externally, between researchers and sponsors. Sometimes, rates paid by sponsors exceed what researchers usually receive or are actually paid for particular services, generating a surplus. Nevertheless, the authors see only limited cause for concern because, at the AMCs with which the authors are familiar, any monetary surplus generally remains within the research enterprise to cover unanticipated budget shortfalls or to support research staff in the future during lean times. In addition, the surplus from research budgets is not shared directly with individual investigators. However, further investigation is needed to determine whether practices outside AMCs pose greater concerns.

Oversight of financial conflicts of interest in commercially sponsored research in academic and nonacademic settings

BACKGROUND

Studies of conflicts of interest in clinical research have focused on academic centers, but most clinical research takes place in nonacademic settings.

OBJECTIVE

To compare oversight and management of investigators' financial relationships in academic and nonacademic research settings.

DESIGN, SETTING, AND PARTICIPANTS

Survey of officials at 199 sites that contributed participants to commercially sponsored phase 3 clinical trials published in JAMA or the New England Journal of Medicine in 2006 and 2007.

MEASUREMENTS AND MAIN RESULTS

Response rates were 66% for academic medical centers, 37% for nonacademic medical centers (inpatient), and 27% for outpatient nonacademic sites. Almost all academic medical centers (97%) and most nonacademic medical centers (87%) followed written conflict-of-interest policies, whereas 44% of outpatient nonacademic sites had written policies (P < 0.001). Academic and nonacademic medical centers relied mainly on internal institutional review boards (69% and 71%, respectively); outpatient nonacademic sites relied primarily on independent institutional review boards (59%; P < 0.001).

CONCLUSIONS

Nonacademic sites have substantially different approaches to the oversight and management of financial relationships in commercially sponsored clinical research than academic medical centers. These differences warrant more attention to how financial relationships are monitored in community research settings.

Vulnerability in clinical research with patients in pain: a risk analysis

Some have characterized patients living with intractable pain as a vulnerable population in both clinical and research settings. Labeling the population as vulnerable, however, does not provide clarity regarding the potential risks that they face when they participate in research. Instead, research vulnerability for patients in pain is a function of an interaction between their pain conditions and elements of the research enterprise. Therefore, the identification of potential risks requires consideration not only of characteristics of patients with chronic pain, but also consideration of features of researchers, the quality of institutional oversight, and the medical/social environment within which the research is conducted. This paper provides an analysis of those risks and provides some suggestions as to how the risks might be better managed.

Clinical trials in Canada: whose interests are paramount?

More than 80 percent of clinical drug trials in Canada are funded by the pharmaceutical industry. This article evaluates the overall state of clinical trials in Canada and looks at the interplay between public and private interests. Health Canada has adopted standards developed by the International Conference on Harmonization, a body that is heavily influenced by industry. Commercial interests are increasingly involved in recruiting patients into clinical trials and in running these trials. It is in industry's interests to conduct drug tests on people for which it is easiest to see benefits. These interests are not fundamentally challenged by Health Canada's policy of issuing nonmandatory guidelines on who should and should not be included in clinical trials. The outcome of clinical trials is heavily influenced by commercial sponsorship, with the result that trials may favor corporate interests rather than the interests of the public. How Health Canada deals with that possibility is not known, because of its strict policy of treating clinical trial data as private property. If clinical trials are to serve the purpose for which they are designed, developing reliable and objective information about new drugs, then commercial interests cannot be allowed to take precedence over health interests.

Running an ethical trial 60 years after the Nuremberg Code

The Nuremberg Code has served as a foundation for ethical clinical research since its publication 60 years ago. This landmark document, developed in response to the horrors of human experimentation done by Nazi physicians and investigators, focused crucial attention on the fundamental rights of research participants and on the responsibilities of investigators. Although the Nuremberg Code has provided an important framework for discussions on the requirements of ethical clinical research, and has resulted in the development of other initiatives-eg, the Declaration of Helsinki and the Belmont Report-designed to ensure the rights and safety of human beings taking part in medical research, knowledge of both past events and the current complexity of research suggests further improvements are necessary in the existing approaches to human clinical research.

Regulating the market in human research participants

Lemmens and Miller critically examine "finder's fees" and other recruitment incentives issued to physicians for successfully referring patients to clinical trial investigators.

Guidelines on the ethics of clinical research in anaesthesia

PURPOSE OF REVIEW

This review will identify ethical issues arising from conflicts of interest in sponsored clinical trials, and the need for compliance with recent privacy legislation. It will guide investigators facing ethical dilemmas that compromise the integrity of their research because of conflicts of interest or a flawed consent process. Authors will learn about changes in journal editorial policies that will require registration of clinical trials and consent for publication of case reports.

RECENT FINDINGS

Recently, ethics review committees and clinical investigators have violated research ethical guidelines and authors have ignored journal policies on disclosure of data in multicentre clinical trials. Published reports show selective reporting of data from clinical trials that biases the body of evidence available for clinical decision-making. Privacy laws legislate that patient consent for the use of their health information, other than for their clinical care, must be obtained explicitly.

SUMMARY

Clinical trial registration and the need for consent for publication of case reports aim to restore and improve the integrity of biomedical publication. Journal policies that incorporate these changes may be persuasive in interpreting privacy laws, in a practical way, to protect patients from harm. It is difficult to eliminate all ethical problems with sponsored trials and government regulatory drug-approval processes may require review.

The social and cultural shaping of medical evidence: case studies from pharmaceutical research and obstetric science

Most critiques of evidence-based medicine (EBM) focus on the scientific shortcomings of the technique. Social scientists are more likely to criticize EBM for it ideological biases, a criticism that makes sociological sense but is difficult to substantiate. Using data from our studies of (1) the influence of pharmaceutical companies on the conduct and reporting of clinical trials, and (2) obstetric science in the Netherlands (where nearly one-third of births occur at home) we show how the evidence of evidence-based medicine is shaped by forces both structural and cultural. The threats to objective evidence are many, and, if EBM is to be true to its own principles, it must take these threats into account.

Conflict of interest: Legal and ethical aspects

Conflicts of interest arise when those who owe conscientious duties to others appear to have personal interests that might tempt them to subordinate those duties to their self-interest. Conflicts of interest are distinguishable from conflicts of commitment, which arise when individuals bear two or more mutually exclusive duties to others. If persons in conflicts of interest favor their self-interest, they may violate binding legal duties such as fiduciary duties. Conflicts arise when, for instance, medical practitioners refer their patients to other practitioners in exchange for payments (fee splitting), and when they gain secondary incomes such as from testing patients' samples in laboratories in which they hold ownership or investment interests. Financial dealings with commercial sponsors may place researchers in apparent conflicts of interest with research subjects. When conflicts of interest are unavoidable, they may be resolved by appropriate disclosure.