Informed consent

Reflexive research ethics in fetal tissue xenotransplantation research

For biomedical research in which the only involvement of the human subject is the provision of tissue or organ samples, a blanket consent, i.e., consent to use the tissue for anything researchers wish to do, is considered by many to be adequate for legal and Institutional Review Board (IRB) requirements. Alternatively, a detailed informed consent provides patients or study participants with more thorough information about the research topic. We document here the beliefs and opinions of the research staff on informed consent and the discussion-based reflexive research ethics process that we employed in our fetal tissue xenotransplantion research on the impact of environmental exposures on fetal development. Reflexive research ethics entails the continued adjustment of research practice according to relational and reflexive understandings of what might be beneficent or harmful. Such reflexivity is not solely an individual endeavor, but rather a collective relationship between all actors in the research process.

Indications and requirements for the use of prerandomization

BACKGROUND AND OBJECTIVE

Although in effectiveness studies, the conventional randomized trial, in which informed consent is obtained before randomization, is the first choice, this design is not the panacea for all research questions. To counter contamination problems, prerandomization designs might be an alternative. Prerandomization implies that the randomization takes place before seeking informed consent, and because of this, prerandomization designs are controversial among ethicists, health lawyers, methodologists, and clinicians. However, in the Netherlands, these designs are becoming more accepted since the Dutch State Secretary of Health, Welfare and Sport decided that, under certain circumstances, prerandomization is admissible and not in conflict with the law.

RESULTS

Based on well-defined indications and requirements, guidelines for the optimal application of prerandomization designs are presented. Designs in which prerandomization is used are outlined; methodological considerations useful when conducting trials using conventional designs or prerandomization designs are discussed, in addition to ethical and judicial aspects.

CONCLUSION

In certain situations, prerandomization designs have an essential contribution to achieve evidence-based medicine. Banning prerandomization a priori implies that information about the effectiveness of numerous public health and medical interventions will not be forthcoming. Therefore, every design should be based on a balance between maximizing the potential for patient autonomy and minimizing the bias caused by contamination. This balance cannot be reached by formulating general rules, but an independent group of experts, like members of research ethics committee (REC), should decide whether this balance is acceptable.

Evaluation of the quality of informed consent in a vaccine field trial in a developing country setting

BACKGROUND

Informed consent is an ethical and legal requirement for research involving human participants. However, few studies have evaluated the process, particularly in Africa. Participants in a case control study designed to identify correlates of immune protection against tuberculosis (TB) in South Africa. This study was in turn nested in a large TB vaccine efficacy trial. The aim of the study was to evaluate the quality of consent in the case control study, and to identify factors that may influence the quality of consent. Cross-sectional study conducted over a 4 month period.

METHODS

Consent was obtained from parents of trial participants. These parents were asked to complete a questionnaire that contained questions about the key elements of informed consent (voluntary participation, confidentiality, the main risks and benefits, etc.). The recall (success in selecting the correct answers) and understanding (correctness of interpretation of statements presented) were measured.

RESULTS

The majority of the 192 subjects interviewed obtained scores greater than 75% for both the recall and understanding sections. The median score for recall was 66%; interquartile range (IQR) = 55%-77% and for understanding 75% (IQR = 50%-87%). Most (79%) were aware of the risks and 64% knew that they participated voluntarily. Participants who had completed Grade 7 at school and higher were more likely (OR = 4.94; 95% CI = 1.57 - 15.55) to obtain scores greater than 75% for recall than those who did not. Participants who were consented by professional nurses who had worked for more than two years in research were also more likely (OR = 2.62; 95% CI = 1.35-5.07) to obtain such scores for recall than those who were not.

CONCLUSION

Notwithstanding the constraints in a developing country, in a population with low levels of literacy and education, the quality of informed consent found in this study could be considered as building blocks for establishing acceptable standards for public health research. Education level of respondents and experience of research staff taking the consent were associated with good quality informed consent.

What do they know?: a content analysis of women's perceptions of trial information

OBJECTIVE

To examine interpretations of study information by women participating in ORACLE, a trial of antibiotics in preterm labour.

DESIGN

Questionnaire survey sent to women recruited to the ORACLE trial.

SETTING

United Kingdom.

POPULATION

A questionnaire was sent to 3074 ORACLE participants in a purposively selected sample of 55 collaborating maternity units, chosen to reflect a range of regions and of district general and teaching hospitals.

METHODS

Content analysis was applied to verbatim text provided in response to an open question. Responses were also compared with a framework based on key points about the purpose of ORACLE. Closed questions were analysed using descriptive statistics.

MAIN OUTCOME MEASURES

Participants' interpretations of the purpose of the study.

RESULTS

A response rate of 61% was achieved, and 1462 participants provided written answers to a specific question on why the study was being carried out. Content analysis suggested that the information leaflet was highly valued as a source of information about the trial. There was evidence that women's interpretations of the purpose of the trial were not identical to those that the investigators intended. Of the five key points about the trial described in the information leaflet, 400 (27%) participants reported one key point, 550 (38%) two key points, 229 (16%) three key points and 23 (1.5%) four key points. None reported five key points and it was not possible to classify 46 responses (3%). Vague, confused understanding or poor recall were evident in 204 (14%) of responses.

CONCLUSION

Although the ORACLE trial was run as a model of good practice at the time, this study suggests that it may not be possible to demonstrate full understanding of trial purpose and design by all participants. Emphasis should be on the provision of full information that involves consumers in its design and evaluation.

Exposing the body--baring the soul

It is often considered important that clothing should not be visible in a good medical photograph. Medical illustrators offer the clinical professionalism to allow most of their patients to feel comfortable being photographed. For some patients, however, consenting to medical photography involves more than a temporary embarrassment. This paper seeks to explore some of the religious and cultural beliefs that the medical photographer may be asking the patient to compromise in the studio.

Some ethical and design challenges of screening programs and screening tests

BACKGROUND

There are many examples of inadequate screening studies because of design faults and consent problems.

ISSUES

Informed consent is the right of each person engaged in a clinical interaction, including service and research involvement in presymptomatic screening. Any screening approach must answer questions of efficacy, effectiveness, availability and efficiency. Accurate information, presented in clear language, must state a realistic assessment of the limitations, harms and benefits of the screening, including the consequences of false positive and false negative tests. There must be no coercive element in obtaining consent. Written and oral information should be presented. It is also important to recognize cultural differences between societies that emphasize individual autonomy and those in which autonomy derives from membership of a family, group or community, thus requiring different strategies to protect the vulnerable. Testing for genetic disorders presents additional challenges, partly due to the presence of relatively small numbers of affected individuals in the population, but also because of the complexity of counseling, confidentiality issues and the potential for social, insurance or employment discrimination.

CONCLUSIONS

It is becoming increasingly difficult to present the data for many screening procedures in ways that can be understood by possible participants, and at the same time deal clearly with the costs to society and the efficacy and efficiency of the tests.

Randomized controlled trials: the control group dilemma revisited

In some randomised controlled trials the nature of the therapy means that subjects cannot or should not be blinded. Such studies need careful design. Particular attention needs to be given to the choice of control group and the nature of the informed consent obtained from subjects, because these affect the precise research question being addressed. A survey of published studies was carried to investigate how these issues had been tackled. The paper summarizes key findings from the survey. If the research question is about the specific effect of a therapy sometimes a good case can be made for a second control group which is 'attention-controlled'. There is a need for more detailed justifications of such design decisions in published studies.

Ethics and clinical trials

The current reference guideline about ethics in clinical trials is the Declaration of Helsinki of human rights in medical research. Three major principles are emphasised: respect of the patient to accept or not to participate in a trial, the constraints and the presumed risks must be acceptable for patients included in a study, and vulnerable subjects should not participate in studies. The investigator is responsible for obtaining a free and well-informed consent from patients before their inclusion in a study. Where possible, a new drug should always first be compared to placebo in order to prove its superiority. Else, a small-sized trial comparing a new drug versus a reference treatment can lead to an erroneous conclusion of absence of difference. Moreover, good results or improvement are obtained in at least 30% of cases with placebo, whatever the disease. The use of placebo is unethical in life-threatening diseases and when an effective proved drug exists. The use of placebo is ethical in severe diseases with no efficient drug, in some severe diseases even when an active reference treatment is available, and in all moderate and functional diseases. In order to detect flawed studies, most journals now ask for any manuscript submitted and reporting results of a randomised clinical trial to join a checklist in order to verify the quality of the trial. Finally, it remains the responsibility of the doctor to decide whether or not a protocol is ethical, to participate or not and to include patients or not.