From protection to entitlement: selecting research subjects for early phase clinical trials involving breakthrough therapies

Risky first-in-human clinical trials on medically fragile persons: owning the moral cost

The purpose of a first-in-human (FIH) clinical trial is to gather information about how the drug or device affects and interacts with the human body: its safety, side effects, and (potential) dosage. As such, the primary goal of a FIH trial is not participant benefit but to gain knowledge of drug or device efficacy, i.e., baseline human safety knowledge. Some FIH clinical trials carry significant foreseeable risk to participants with little to no foreseeable participant benefit. Participation in such trials would be a bad deal for participants, and the research is considered justifiable because of the promise of significant potential social benefit. I argue that there is an ethical tension inherent in risky FIH research and that researchers should fairly compensate risky FIH trial participants. This does not make the risk-benefit outcome more favorable for participants; rather, it amounts to a collective reckoning with the ethical tension inherent in the research.

First Ready, First to Go: Ethical Priority-Setting of Allogeneic Stem Cell Transplant at a Major Cancer Centre

Medical advancements have now made it possible to provide allogeneic stem cell transplantation (allo-SCTs) to older patients and use stem cells from less well-matched donors. This has resulted in access to a life-saving modality for a greater number of patients with imminent life-threatening illnesses. However, resources have not always kept pace with innovation and expanded volumes. During the summer of 2015 in the province of Ontario, Canada, inadequate resources contributed to a capacity crisis, resulting in extended wait-lists for allo-SCT across the province. This situation presented unique ethical challenges, including the need for ongoing negotiations with health system partners and nimble process management to ensure timely delivery of care. This article reports on the process one organization used to determine how to equitably allocate scarce allo-SCT resources. With the ever-expanding landscape of new and emerging medical technologies, our experience has implications for the ethics of translating other increasingly expensive health technologies to clinical care.

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.

Integrative Approaches to Cancer Immunotherapy

Cancer immunotherapy aims to arm patients with cancer-fighting immunity. Many new cancer-specific immunotherapeutic drugs have gained approval in the past several years, demonstrating immunotherapy's efficacy and promise as an anticancer modality. Despite these successes, several outstanding questions remain for cancer immunotherapy, including how to make immunotherapy more efficacious in a broader range of cancer types and patients, and how to predict which patients will respond or not respond to therapy. We present a case for integrative systems approaches that will answer these questions. This involves applying mechanistic and statistical modeling, establishing consistent and widely adopted experimental tools to generate systems-level data, and creating sustained mechanisms of support. If implemented, these approaches will lead to major advances in cancer treatment.

Trials and tribulations: The highs and lows of running cystic fibrosis drug studies

So many new trials of drugs for CF are being conducted each year it can be difficult to keep up. Yet, almost as numerous are the review articles written about them. I have chosen therefore to use this paper to discuss some of the difficult ethical issues arising during trials, in particular how to fairly distribute opportunities to participate. Some of these issues may be specific to countries like my own with very limited access to genotype-specific CFTR modulators, others may apply more generally. We have made enormous progress as a community over the recent past, but there is still much more to do before all our patients are reaping health and quality of life benefits.

Ethical issues in competing clinical trials

The proliferation of clinical trials in the last decade and the relatively limited number of experienced clinical trial sites in comparison has created in some sites an environment of clinical trial abundance. As clinical trial protocols typically restrict patients from concurrent clinical trial participation, and patients may be eligible for more than one trial at any given time, selecting the best trial for an individual patient requires evaluation of not only the merits of the individual trials but also patient preferences. This article highlights some potential ethical issues which should be considered when clinical trials are raised as a treatment option and when patients are eligible for more than one trial at the time of evaluation.

Ethical Guidance for Selecting Clinical Trials to Receive Limited Space in an Immunotherapy Production Facility

Our aims are to (1) set forth a multiprinciple system for selecting among clinical trials competing for limited space in an immunotherapy production facility that supplies products under investigation by scientific investigators; (2) defend this system by appealing to justice principles; and (3) illustrate our proposal by showing how it might be implemented. Our overarching aim is to assist manufacturers of immunotherapeutic products and other potentially breakthrough experimental therapies with the ethical task of prioritizing requests from scientific investigators when production capacity is limited.

Management of Adolescent-Parent Dyads' Discordance for Willingness to Participate in a Reproductive Health Clinical Trial

The objective of this study is to understand the resolution of discordance between adolescent-parent dyads about participation in research. Adolescent (14-17 years) and parent dyads were recruited from NYC pediatric clinics to assess attitudes toward research participation. A subset of dyads participated in videotaped discussions about participation in a hypothetical study. Videos from dyads that held strongly discordant opinions about participation ( n = 30) were content-coded and analyzed using a thematic framework approach. Strategies used to resolve discordance included asserting authority, granting autonomy, or recognizing inaccurate assumptions using a variety of communication behaviors. Missed opportunities to enroll initially discordant dyads may be avoided by allowing time for adolescents and parents to elicit information, clarify a situation, or convince the other.