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Shevchenko S, Zhavoronkov A. The Role of Exceptionalism in the Evolution of Bioethical Regulation. Camb Q Healthc Ethics 2024; 33:185-197. [PMID: 37288492 DOI: 10.1017/s0963180123000336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The paper aims to present a critical analysis of the phenomenon and notion of exceptionalism in bioethics. The authors demonstrate that exceptionalism pertains to phenomena that are not (yet) entirely familiar to us and could potentially bear risks regarding their regulation. After an overview of the state of the art, we briefly describe the origins and evolution of the concept, compared to exception and exclusion. In the second step, they look at the overall development debates on genetic exceptionalism, compared to other bioethical debates on exceptionalism, before presenting a detailed analysis of a specific case of early regulation of genetic screening. In the last part, the authors explain the historical background behind the connection between exceptionalism and exclusion in these debates. Their main conclusion is that while the initial stage of the discussion is shaped by the concept of exceptionalism and awareness of risks of exclusion, the later development centers around exceptions that are needed in detailed regulatory procedures.
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Affiliation(s)
| | - Alexey Zhavoronkov
- Institut für Philosophie, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland
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2
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Mambro A, Afshar A, Leone F, Dussault C, Stoové M, Savulescu J, Rich JD, Rowan DH, Sheehan J, Kronfli N. Reimbursing incarcerated individuals for participation in research: A scoping review. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 123:104283. [PMID: 38109837 DOI: 10.1016/j.drugpo.2023.104283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/18/2023] [Accepted: 11/29/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Little is known about global practices regarding the provision of reimbursement for the participation of people who are incarcerated in research. To determine current practices related to the reimbursement of incarcerated populations for research, we aimed to describe international variations in practice across countries and carceral environments to help inform the development of more consistent and equitable practices. METHODS We conducted a scoping review by searching PubMed, Cochrane library, Medline, and Embase, and conducted a grey literature search for English- and French-language articles published until September 30, 2022. All studies evaluating any carceral-based research were included if recruitment of incarcerated participants occurred inside any non-juvenile carceral setting; we excluded studies if recruitment occurred exclusively following release. Where studies failed to indicate the presence or absence of reimbursement, we assumed none was provided. RESULTS A total of 4,328 unique articles were identified, 2,765 were eligible for full text review, and 426 were included. Of these, 295 (69%) did not offer reimbursement to incarcerated individuals. A minority (n = 13; 4%) included reasons explaining the absence of reimbursement, primarily government-level policies (n = 7). Among the 131 (31%) studies that provided reimbursement, the most common form was monetary compensation (n = 122; 93%); five studies (4%) offered possible reduced sentencing. Reimbursement ranged between $3-610 USD in total and 14 studies (11%) explained the reason behind the reimbursements, primarily researchers' discretion (n = 9). CONCLUSIONS The majority of research conducted to date in carceral settings globally has not reimbursed incarcerated participants. Increased transparency regarding reimbursement (or lack thereof) is needed as part of all carceral research and advocacy efforts are required to change policies prohibiting reimbursement of incarcerated individuals. Future work is needed to co-create international standards for the equitable reimbursement of incarcerated populations in research, incorporating the voices of people with lived and living experience of incarceration.
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Affiliation(s)
- Andrea Mambro
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Avideh Afshar
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Frederic Leone
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Camille Dussault
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Mark Stoové
- Burnet Institute, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, United Kingdom; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Josiah D Rich
- Center for Health and Justice Transformation, The Miriam and Rhode Island Hospitals, Departments of Medicine and Epidemiology, Brown University, Providence, Rhode Island, USA
| | - Daniel H Rowan
- Division of Infectious Disease, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | | | - Nadine Kronfli
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; Department of Medicine, Division of Infectious Disease and Chronic Viral Illness Service, McGill University, Montreal, Quebec, Canada.
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Wang X, Su H, Wallach JB, Wagner JC, Braunecker B, Gardner M, Guinn KM, Klevorn T, Lin K, Liu YJ, Liu Y, Mugahid D, Rodgers M, Sixsmith J, Wakabayashi S, Zhu J, Zimmerman M, Dartois V, Flynn JL, Lin PL, Ehrt S, Fortune SM, Rubin EJ, Schnappinger D. Development of an Engineered Mycobacterium tuberculosis Strain for a Safe and Effective Tuberculosis Human Challenge Model. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.11.19.567569. [PMID: 38014062 PMCID: PMC10680849 DOI: 10.1101/2023.11.19.567569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Human challenge experiments could greatly accelerate the development of a tuberculosis (TB) vaccine. Human challenge for tuberculosis requires a strain that can both replicate in the host and be reliably cleared. To accomplish this, we designed Mycobacterium tuberculosis (Mtb) strains featuring up to three orthogonal kill switches, tightly regulated by exogenous tetracyclines and trimethoprim. The resultant strains displayed immunogenicity and antibiotic susceptibility similar to wild-type Mtb under permissive conditions. In the absence of supplementary exogenous compounds, the strains were rapidly killed in axenic culture, mice and nonhuman primates. Notably, the strain that contained three kill switches had an escape rate of less than 10 -10 per genome per generation and displayed no relapse in a SCID mouse model. Collectively, these findings suggest that this engineered Mtb strain could be a safe and effective candidate for a human challenge model.
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Drewett GP. The Case for Human Challenge Trials in COVID-19. JOURNAL OF BIOETHICAL INQUIRY 2023:10.1007/s11673-023-10309-9. [PMID: 37721594 DOI: 10.1007/s11673-023-10309-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 03/12/2023] [Indexed: 09/19/2023]
Abstract
The COVID-19 pandemic has necessitated rapid research to aid in the understanding of the disease and the development of novel therapeutics. One option is to conduct controlled human infection trials (CHITs). In this article I examine the history of deliberate human infection and CHITs and their utilization prior to the COVID-19 pandemic, key ethical considerations of CHITs in the COVID-19 setting, an analysis of the World Health Organization's (WHO) Key criteria for the ethical acceptability of COVID-19 human challenge studies, and a review of the two COVID-19 CHITs that have already commenced, their compliance with the WHO criteria and other ethical considerations.
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Affiliation(s)
- George P Drewett
- Melbourne Law School, University of Melbourne, Parkville, VIC, Australia.
- The Northern Hospital, Epping, VIC, Australia.
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5
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Eberts JD, Zimmer-Harwood P, Elsey JWB, Fraser-Urquhart A, Smiley T. Volunteering for Infection: Participant Perspectives on a Hepatitis C Virus Controlled Human Infection Model. Clin Infect Dis 2023; 77:S224-S230. [PMID: 37579204 PMCID: PMC10425139 DOI: 10.1093/cid/ciad350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
Ethical human subjects research requires participants to be treated safely and respectfully, yet much bioethical debate takes place without participants. We aim to address this gap in the context of controlled human infection model (CHIM) research. Based upon our own experience as study participants, and bolstered by a survey of 117 potential hepatitis C virus CHIM participants, we present ideas to inform efficient, ethical, and scientifically useful study design. We advocate for full protocol transparency, higher compensation, commitment to the rapid dissemination of study results, and proactive efforts to detail risk-minimization efforts as early as possible in the recruitment process, among other measures. We encourage researchers to proactively partner with volunteer advocacy organizations that promote collective representation of volunteers to maximize their agency, and guard against ethical issues arising from healthy human subjects research.
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Affiliation(s)
| | - Paul Zimmer-Harwood
- 1Day Sooner, Lewes, Delaware, USA
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - James W B Elsey
- Surveys and Data Analysis Department, Rethink Priorities, San Francisco, California, USA
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6
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Adams-Phipps J, Toomey D, Więcek W, Schmit V, Wilkinson J, Scholl K, Jamrozik E, Osowicki J, Roestenberg M, Manheim D. A Systematic Review of Human Challenge Trials, Designs, and Safety. Clin Infect Dis 2023; 76:609-619. [PMID: 36219704 PMCID: PMC9938741 DOI: 10.1093/cid/ciac820] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 09/29/2022] [Accepted: 10/07/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Few studies have assessed participant safety in human challenge trials (HCTs). Key questions regarding HCTs include how risky such trials have been, how often adverse events (AEs) and serious adverse events (SAEs) occur, and whether risk mitigation measures have been effective. METHODS A systematic search of PubMed and PubMed Central for articles reporting on results of HCTs published between 1980 and 2021 was performed and completed by 7 October 2021. RESULTS Of 2838 articles screened, 276 were reviewed in full. A total of 15 046 challenged participants were described in 308 studies that met inclusion criteria; 286 (92.9%) of these studies reported mitigation measures used to minimize risk to the challenge population. Among 187 studies that reported on SAEs, 0.2% of participants experienced at least 1 challenge-related SAE. Among 94 studies that graded AEs by severity, challenge-related AEs graded "severe" were reported by between 5.6% and 15.8% of participants. AE data were provided as a range to account for unclear reporting. Eighty percent of studies published after 2010 were registered in a trials database. CONCLUSIONS HCTs are increasingly common and used for an expanding list of diseases. Although AEs occur, severe AEs and SAEs are rare. Reporting has improved over time, though not all papers provide a comprehensive report of relevant health impacts. We found very few severe symptoms or SAEs in studies that reported them, but many HCTs did not report relevant safety data. This study was preregistered on PROSPERO as CRD42021247218.
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Affiliation(s)
| | - Danny Toomey
- 1Day Sooner Research Team, Lewes, Delaware, USA
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | | | | | | | - Keller Scholl
- RAND Corporation, Pardee RAND Graduate School, Santa Monica, California, USA
| | - Euzebiusz Jamrozik
- The Ethox Centre & Wellcome Centre for Ethics and the Humanities, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Monash Bioethics Centre, Monash University, Clayton, VIC, Australia
- Royal Melbourne Hospital Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Joshua Osowicki
- Murdoch Children's Research Institute, Parkville, VIC, Australia
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Parkville, VIC, Australia
| | - Meta Roestenberg
- Department of Parasitology, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, ZAThe Netherlands
| | - David Manheim
- 1Day Sooner Research Team, Lewes, Delaware, USA
- Technion, Israel Institute of Technology, Haifa, Israel
- ALTER, Association for Long Term Existence and Resilience, Rehovot, Israel
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The ethical anatomy of payment for research participants. MEDICINE, HEALTH CARE AND PHILOSOPHY 2022; 25:449-464. [PMID: 35610403 PMCID: PMC9427899 DOI: 10.1007/s11019-022-10092-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/04/2022] [Indexed: 11/18/2022]
Abstract
In contrast to most publications on the ethics of paying research subjects, which start by identifying and analyzing major ethical concerns raised by the practice (in particular, risks of undue inducement and exploitation) and end with a set of—more or less well-justified—ethical recommendations for using payment schemes immune to these problems, this paper offers a systematic, principle-based ethical analysis of the practice. It argues that researchers have a prima facie moral obligation to offer payment to research subjects, which stems from the principle of social beneficence. This principle constitutes an ethical “spine” of the practice. Other ethical principles of research ethics (respect for autonomy, individual beneficence, and justice/fairness) make up an ethical “skeleton” of morally sound payment schemes by providing additional moral reasons for offering participants (1) recompense for reasonable expenses; and (2a) remuneration conceptualized as a reward for their valuable contribution, provided (i) it meets standards of equality, adequacy and non-exploitation, and (ii) it is not overly attractive (i.e., it does not constitute undue inducement for participation or retention, and does not encourage deceptive behaviors); or (2b) remuneration conceptualized as a market-driven price, provided (i) it is necessary and designed to help the study achieve its social and scientific goals, (ii) it does not reinforce wider social injustices and inequalities; (iii) it meets the requirement of non-exploitation; and (iv) it is not overly attractive. The principle of justice provides a strong ethical reason for not offering recompenses for lost wages (or loss of other reasonably expected profits).
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Chi PC, Owino EA, Jao I, Bejon P, Kapulu M, Marsh V, Kamuya D. Ethical considerations around volunteer payments in a malaria human infection study in Kenya: an embedded empirical ethics study. BMC Med Ethics 2022; 23:46. [PMID: 35443642 PMCID: PMC9019790 DOI: 10.1186/s12910-022-00783-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/11/2022] [Indexed: 11/10/2022] Open
Abstract
Human Infection Studies (HIS) have emerged as an important research approach with the potential to fast track the global development of vaccines and treatments for infectious diseases, including in low resource settings. Given the high level of burdens involved in many HIS, particularly prolonged residency and biological sampling requirements, it can be challenging to identify levels of study payments that provide adequate compensation but avoid 'undue' levels of inducement to participate. Through this embedded ethics study, involving 97 healthy volunteers and other research stakeholders in a malaria HIS programme in Kenya, and using in-depth interviews, focus group discussions and observations during and after a malaria HIS, we give a grounded account of ethical issues emerging in relation to study payments in this setting. While careful community, national, international scientific and ethics review processes meant that risks of serious harm were highly unlikely, the levels of motivation to join HIS seen could raise concerns about study payments being too high. Particular value was placed on the reliability, rather than level, of study payment in this setting, where subsistence livelihoods are common. Study volunteers were generally clear about the study aims at the point of recruitment, and this knowledge was retained over a year later, although most reported experiencing more burdens than anticipated at enrolment. Strict study screening procedures, regular clinical and laboratory monitoring of volunteers, with prompt treatment with antimalarial at predetermined endpoints suggested that the risks of serious harm were highly unlikely. Ethical concerns emerged in relation to volunteers' attempts to conceal symptoms, hoping to prolong residency periods and increase study payments; and volunteers making decisions that compromised important family relationships and personal values. Our findings support an interpretation that, although study volunteers were keen to join the study to access cash payments, they also paid attention to other features of the study and the general clinical research landscape, including levels of risk associated with study participation. Overall, our analysis shows that the ethical concerns emerging from the study payments can be addressed through practical measures, hinged on reducing burdens and strengthening communication, raising important issues for research policy and planning.
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Affiliation(s)
- Primus Che Chi
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya.
| | - Esther Awuor Owino
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Irene Jao
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Philip Bejon
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University Oxford, Oxford, UK
| | - Melissa Kapulu
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University Oxford, Oxford, UK
| | - Vicki Marsh
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University Oxford, Oxford, UK
| | - Dorcas Kamuya
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University Oxford, Oxford, UK
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9
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Blumenthal-Barby J, Ubel P. Payment of COVID-19 challenge trials: underpayment is a bigger worry than overpayment. JOURNAL OF MEDICAL ETHICS 2021; 47:585-586. [PMID: 33046591 PMCID: PMC7551739 DOI: 10.1136/medethics-2020-106901] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/01/2020] [Indexed: 05/27/2023]
Affiliation(s)
| | - Peter Ubel
- Fuqua Business School, Duke University, Durham, North Carolina, USA
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10
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Bradfield OM, Giubilini A. Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers. JOURNAL OF MEDICAL ETHICS 2021; 47:medethics-2020-107175. [PMID: 33975928 PMCID: PMC8257552 DOI: 10.1136/medethics-2020-107175] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/27/2021] [Accepted: 03/30/2021] [Indexed: 05/06/2023]
Abstract
Seven COVID-19 vaccines are now being distributed and administered around the world (figure correct at the time of submission), with more on the horizon. It is widely accepted that healthcare workers should have high priority. However, questions have been raised about what we ought to do if members of priority groups refuse vaccination. Using the case of influenza vaccination as a comparison, we know that coercive approaches to vaccination uptake effectively increase vaccination rates among healthcare workers and reduce patient morbidity if properly implemented. Using the principle of least restrictive alternative, we have developed an intervention ladder for COVID-19 vaccination policies among healthcare workers. We argue that healthcare workers refusing vaccination without a medical reason should be temporarily redeployed and, if their refusal persists after the redeployment period, eventually suspended, in order to reduce the risk to their colleagues and patients. This 'conditional' policy is a compromise between entirely voluntary or entirely mandatory policies for healthcare workers, and is consistent with healthcare workers' established professional, legal and ethical obligations to their patients and to society at large.
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Affiliation(s)
- Owen M Bradfield
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Alberto Giubilini
- Oxford Uehiro Centre for Practical Ethics & Wellcome Centre for Ethics and the Humanities, University of Oxford, Oxford, UK
- University of Oxford, Oxford, UK
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Manheim D, Wiȩcek W, Schmit V, Morrison J. Exploring Risks of Human Challenge Trials For COVID-19. RISK ANALYSIS : AN OFFICIAL PUBLICATION OF THE SOCIETY FOR RISK ANALYSIS 2021; 41:710-720. [PMID: 33942351 PMCID: PMC8207107 DOI: 10.1111/risa.13726] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Human challenge trials (HCTs) are a potential method to accelerate development of vaccines and therapeutics. However, HCTs for COVID-19 pose ethical and practical challenges, in part due to the unclear and developing risks. In this article , we introduce an interactive model for exploring some risks of a severe acute respiratory syndrome coronavirus-2 (SARS-COV-2) dosing study, a prerequisite for any COVID-19 challenge trials. The risk estimates we use are based on a Bayesian evidence synthesis model which can incorporate new data on infection fatality risks (IFRs) to patients, and infer rates of hospitalization. The model estimates individual risk, which we then extrapolate to overall mortality and hospitalization risk in a dosing study. We provide a web tool to explore risk under different study designs. Based on the Bayesian model, IFR for someone between 20 and 30 years of age is 15.1 in 100,000, with a 95% uncertainty interval from 11.8 to 19.2, while risk of hospitalization is 130 per 100,000 (100-160). However, risk will be reduced in an HCT via screening for comorbidities, selecting lower-risk population, and providing treatment. Accounting for this with stronger assumptions, we project the fatality risk to be as low as 2.5 per 100,000 (1.6-3.9) and the hospitalization risk to be 22.0 per 100,000 (14.0-33.7). We therefore find a 50-person dosing trial has a 99.74% (99.8-99.9%) chance of no fatalities, and a 98.9% (98.3-99.3%) probability of no cases requiring hospitalization.
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Affiliation(s)
- David Manheim
- 1DaySooner, Wilmington, DE, USA
- Health and Risk Communication Research Center, University of Haifa, School of Public Health, Haifa, Israel
| | - Witold Wiȩcek
- 1DaySooner, Wilmington, DE, USA
- WAW Statistical Consulting Ltd., UK
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Giubilini A, Savulescu J. Stopping exploitation: Properly remunerating healthcare workers for risk in the COVID-19 pandemic. BIOETHICS 2021; 35:372-379. [PMID: 33550626 PMCID: PMC8014134 DOI: 10.1111/bioe.12845] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 10/12/2020] [Accepted: 12/09/2020] [Indexed: 05/22/2023]
Abstract
We argue that we should provide extra payment not only for extra time worked but also for the extra risks healthcare workers (and those working in healthcare settings) incur while caring for COVID-19 patients-and more generally when caring for patients poses them at significantly higher risks than normal. We argue that the extra payment is warranted regardless of whether healthcare workers have a professional obligation to provide such risky healthcare. Payment for risk would meet four essential ethical requirements. First, assuming healthcare workers do not have a professional obligation to take on themselves the risks, payments in the form of incentives would preserve autonomy in deciding what risks to take on oneself. Second, even assuming that healthcare workers do have a professional obligation to take on themselves the risks, payments for risk would create fair working conditions by avoiding exploitation. Third, payments for risk would make it more likely that public healthcare systems can discharge their institutional responsibility to provide healthcare in circumstances where healthcare workers may otherwise (perhaps legitimately) opt out. Fourth, payments for risk would guarantee an efficient healthcare system in pandemic situations. Finally, we address two likely objections that some might raise against our proposal, particularly with regard to incentives, namely that such payments or incentives can themselves be coercive and that they represent a form of undue inducement.
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Affiliation(s)
- Alberto Giubilini
- Oxford Uehiro Centre for Practical EthicsUniversity of OxfordOxfordUnited Kingdom of Great Britain and Northern Ireland
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics and Wellcome Centre for Ethics and HumanitiesUniversity of OxfordOxfordUK
- Visiting Professorial Fellow in Biomedical EthicsMurdoch Childrens Research InstituteMelbourneAustralia
- Distinguished Visiting International Professorship in LawUniversity of MelbourneMelbourneAustralia
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Lynch HF, Darton TC, Levy J, McCormick F, Ogbogu U, Payne RO, Roth AE, Shah AJ, Smiley T, Largent EA. Promoting Ethical Payment in Human Infection Challenge Studies. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2021; 21:11-31. [PMID: 33541252 DOI: 10.1080/15265161.2020.1854368] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
To prepare for potential human infection challenge studies (HICS) involving SARS-CoV-2, we convened a multidisciplinary working group to address ethical questions regarding whether and how much SARS-CoV-2 HICS participants should be paid. Because the goals of paying HICS participants, as well as the relevant ethical concerns, are the same as those arising for other types of clinical research, the same basic framework for ethical payment can apply. This framework divides payment into reimbursement, compensation, and incentives, focusing on fairness and promoting adequate recruitment and retention as counterweights to concerns about undue inducement. Within the basic framework, several factors are especially salient for HICS, and for SARS-CoV-2 HICS in particular, including the nature of participant confinement, anticipated discomfort, risks and uncertainty, participant motivations, and trust. These factors are reflected in a payment worksheet created to help sponsors, researchers, and ethics reviewers systematically develop and assess ethically justifiable payment amounts.
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Savulescu J. Good reasons to vaccinate: mandatory or payment for risk? JOURNAL OF MEDICAL ETHICS 2021; 47:78-85. [PMID: 33154088 PMCID: PMC7848060 DOI: 10.1136/medethics-2020-106821] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/20/2020] [Accepted: 10/22/2020] [Indexed: 05/09/2023]
Abstract
Mandatory vaccination, including for COVID-19, can be ethically justified if the threat to public health is grave, the confidence in safety and effectiveness is high, the expected utility of mandatory vaccination is greater than the alternatives, and the penalties or costs for non-compliance are proportionate. I describe an algorithm for justified mandatory vaccination. Penalties or costs could include withholding of benefits, imposition of fines, provision of community service or loss of freedoms. I argue that under conditions of risk or perceived risk of a novel vaccination, a system of payment for risk in vaccination may be superior. I defend a payment model against various objections, including that it constitutes coercion and undermines solidarity. I argue that payment can be in cash or in kind, and opportunity for altruistic vaccinations can be preserved by offering people who have been vaccinated the opportunity to donate any cash payment back to the health service.
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Affiliation(s)
- Julian Savulescu
- Faculty of Philosophy, University of Oxford, Oxford, UK
- Murdoch Childrens Research Institute, Parkville, Victoria, Australia
- Melbourne Law School, University of Melbourne, Melbourne, Victoria, Australia
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15
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Mtunthama Toto N, Gooding K, Kapumba BM, Jambo K, Rylance J, Burr S, Morton B, Gordon SB, Manda-Taylor L. "At first, I was very afraid"-a qualitative description of participants' views and experiences in the first Human Infection Study in Malawi. Wellcome Open Res 2021; 6:89. [PMID: 35187267 PMCID: PMC8825950 DOI: 10.12688/wellcomeopenres.16587.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2021] [Indexed: 12/26/2022] Open
Abstract
Background: Human infection studies (HIS) involve deliberately infecting healthy volunteers with a pathogen in a controlled environment to understand infection and support the development of effective vaccines or treatments. HIS research is expanding to many low and middle-income settings to accelerate vaccine development. Given the implementation of the first HIS research to establish the experimental human pneumococcal carriage model's feasibility, we sought to understand the participant's opinions and experiences. Methods: We used a qualitative, descriptive approach to understand participants perceptions and experiences on HIS participation. Sixteen healthy adult participants were invited to participate in in-depth exit interviews to discuss their experiences, motivations and concerns. Results: Our findings showed that the likelihood of participation in HIS research rests on three essential conditions: motivation to participate, compensation and advocacy. The motivation and decision to participate was based on reasons including altruism, patriotism, monetary and material incentives, and while compensation was deemed appropriate, concerns about unanticipated research-related risks were raised. Participant advocate groups were recommended for increasing awareness and educating others in the broader community about HIS research. Conclusions: Participants' experiences of HIS in Malawi provide the basis of what can be acceptable in HIS research in lower-income countries and areas where study procedures could be adjusted.
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Affiliation(s)
- Neema Mtunthama Toto
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, +265, Malawi
| | | | - Blessings M. Kapumba
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, +265, Malawi
| | - Kondwani Jambo
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, +265, Malawi
- Clinical Services, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Jamie Rylance
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, +265, Malawi
- Clinical Services, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Sarah Burr
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, +265, Malawi
- Clinical Services, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Ben Morton
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, +265, Malawi
- Clinical Services, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Stephen B. Gordon
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, +265, Malawi
- Clinical Services, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
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16
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Mtunthama Toto N, Gooding K, Kapumba BM, Jambo K, Rylance J, Burr S, Morton B, Gordon SB, Manda-Taylor L. "At first, I was very afraid"-a qualitative description of participants' views and experiences in the first Human Infection Study in Malawi. Wellcome Open Res 2021; 6:89. [PMID: 35187267 PMCID: PMC8825950 DOI: 10.12688/wellcomeopenres.16587.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Human infection studies (HIS) involve deliberately infecting healthy volunteers with a pathogen in a controlled environment to understand infection and support the development of effective vaccines or treatments. HIS research is expanding to many low and middle-income settings to accelerate vaccine development. Given the implementation of the first HIS research to establish the experimental human pneumococcal carriage model's feasibility, we sought to understand the participant's opinions and experiences. Methods: We used a qualitative, descriptive approach to understand participants perceptions and experiences on HIS participation. Sixteen healthy adult participants were invited to participate in in-depth exit interviews to discuss their experiences, motivations and concerns. Results: Our findings showed that the likelihood of participation in HIS research rests on three essential conditions: motivation to participate, compensation and advocacy. The motivation and decision to participate was based on reasons including altruism, patriotism, monetary and material incentives, and while compensation was deemed appropriate, concerns about unanticipated research-related risks were raised. Participant advocate groups were recommended for increasing awareness and educating others in the broader community about HIS research. Conclusions: Participants' experiences of HIS in Malawi provide the basis of what can be acceptable in HIS research in lower-income countries and areas where study procedures could be adjusted.
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Affiliation(s)
- Neema Mtunthama Toto
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, +265, Malawi
| | | | - Blessings M. Kapumba
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, +265, Malawi
| | - Kondwani Jambo
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, +265, Malawi
- Clinical Services, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Jamie Rylance
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, +265, Malawi
- Clinical Services, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Sarah Burr
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, +265, Malawi
- Clinical Services, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Ben Morton
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, +265, Malawi
- Clinical Services, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Stephen B. Gordon
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, +265, Malawi
- Clinical Services, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
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17
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Jamrozik E, Selgelid MJ. Should practice and policy be revised to allow for risk-proportional payment to human challenge study participants? JOURNAL OF MEDICAL ETHICS 2020; 46:835-836. [PMID: 33154089 PMCID: PMC7719901 DOI: 10.1136/medethics-2020-106900] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 10/19/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Euzebiusz Jamrozik
- Monash Bioethics Centre, Monash University, Clayton, Victoria, Australia
- Ethox & Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, United Kingdom
- Royal Melbourne Hospital Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael J Selgelid
- Monash Bioethics Centre, Monash University, Clayton, Victoria, Australia
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18
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Payne R. Commentary on 'Payment in challenge studies: ethics, attitudes and a new payment for risk model'. JOURNAL OF MEDICAL ETHICS 2020; 46:829-830. [PMID: 33154091 DOI: 10.1136/medethics-2020-106975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 10/06/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Ruth Payne
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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19
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Gelinas L. On measuring attitudes about payment for research. JOURNAL OF MEDICAL ETHICS 2020; 46:833-834. [PMID: 33234545 DOI: 10.1136/medethics-2020-106996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/19/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Luke Gelinas
- Advarra Inc, Columbia, Maryland, USA
- Multi-Regional Clinical Trials Center of Brigham and Women's Hospital and Harvard, Cambridge, Massachusetts, USA
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20
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Ambuehl S, Ockenfels A, Roth AE. Payment in challenge studies from an economics perspective. JOURNAL OF MEDICAL ETHICS 2020; 46:831-832. [PMID: 33115857 PMCID: PMC7719898 DOI: 10.1136/medethics-2020-106891] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 09/29/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Sandro Ambuehl
- Department of Economics, University of Zurich, Zurich, Switzerland
| | - Axel Ockenfels
- Department of Economics, University of Cologne, Köln, Germany
| | - Alvin E Roth
- Department of Economics, Stanford University, Stanford, California, USA
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21
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Fernandez Lynch H, Largent EA. Compensating for research risk: permissible but not obligatory. JOURNAL OF MEDICAL ETHICS 2020; 46:827-828. [PMID: 33051381 DOI: 10.1136/medethics-2020-106829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 09/18/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Holly Fernandez Lynch
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Emily A Largent
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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22
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Grimwade O, Savulescu J, Giubilini A, Oakley J, Nussberger AM. Fair go: pay research participants properly or not at all. JOURNAL OF MEDICAL ETHICS 2020; 46:837-839. [PMID: 33234546 DOI: 10.1136/medethics-2020-107060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 11/12/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Olivia Grimwade
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Melbourne Law School, University of Melbourne, Melbourne, Victoria, Australia
| | - Alberto Giubilini
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
- Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, United Kingdom
| | - Justin Oakley
- Monash Bioethics Centre, Monash University, Melbourne, Victoria, Australia
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