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Bittlinger M, Bicer S, Peppercorn J, Kimmelman J. Ethical Considerations for Phase I Trials in Oncology. J Clin Oncol 2022; 40:3474-3488. [PMID: 35275736 DOI: 10.1200/jco.21.02125] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Phase I trials often represent the first occasion where new cancer strategies are tested in patients. Various developments in cancer biology, methodology, regulation, and medical ethics have altered the ethical landscape of such trials. We provide a narrative review of contemporary ethical challenges in design, conduct, and reporting of phase I cancer trials and outline recommendations for addressing each. We organized our review around four topics, supplementing the first three with scoping reviews: (1) benefit/risk, (2) research biopsies, (3) therapeutic misconception and misestimation, and (4) reporting. The main ethical challenges of conducting phase I trials stem from three issues. First, phase I trials often involve higher research burden and scientific uncertainty compared with other cancer trials. Second, many patients arrive at phase I trials at a transitional point in their illness trajectory where they have exhausted standard survival-extending options. Third, phase I trial results play a major role in informing downstream drug development and regulatory decisions. Together, these issues create distinct pressures for study design, ethical review, informed consent, and reporting. Developments in methodology, regulation, cancer biology, and ethical awareness have helped mitigate some of these challenges, while introducing others. We conclude our review with a series of recommendations regarding trial design, ethical review, consent, and reporting. We also outline several unresolved questions that, if addressed, would strengthen the ethical foundation of phase I cancer trials.
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Affiliation(s)
- Merlin Bittlinger
- Studies of Translation, Ethics and Medicine (STREAM), Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada
| | - Selin Bicer
- Studies of Translation, Ethics and Medicine (STREAM), Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada
| | | | - Jonathan Kimmelman
- Studies of Translation, Ethics and Medicine (STREAM), Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada
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2
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Kane PB, Bittlinger M, Kimmelman J. Individualized therapy trials: navigating patient care, research goals and ethics. Nat Med 2021; 27:1679-1686. [PMID: 34642487 DOI: 10.1038/s41591-021-01519-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/26/2021] [Indexed: 02/08/2023]
Abstract
'Individualized therapy' trials (sometimes called n-of-1 trials) use patients as their own controls to evaluate treatments. Here we divide such trials into three categories: multi-crossover trials aimed at individual patient management, multi-crossover trial series and pre-post trials. These trials all customize interventions for patients; however, the latter two categories also aim to inform medical practice and thus embody tensions between the goals of care and research that are typical of other types of clinical trials. In this Perspective, we discuss four domains where such tensions play out-clinical equipoise, informed consent, reporting and funding, and we provide recommendations for addressing each.
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Affiliation(s)
- Patrick Bodilly Kane
- Studies in Translation, Ethics and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada
| | - Merlin Bittlinger
- Studies in Translation, Ethics and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada
| | - Jonathan Kimmelman
- Studies in Translation, Ethics and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada.
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3
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Steel R. Reconceptualising risk-benefit analyses: the case of HIV cure research. JOURNAL OF MEDICAL ETHICS 2020; 46:212-219. [PMID: 31732681 DOI: 10.1136/medethics-2019-105548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/25/2019] [Accepted: 10/08/2019] [Indexed: 06/10/2023]
Abstract
Modern antiretroviral therapies (ART) are capable of suppressing HIV in the bloodstream to undetectable levels. Nonetheless, people living with HIV must maintain lifelong adherence to ART to avoid the re-emergence of the infection. So despite the existence and efficacy of ART, there is still substantial interest in development of a cure. But HIV cure trials can be risky, their success is as of yet unlikely, and the medical gain of being cured is limited against a baseline of ART access. The medical prospect associated with participation in cure research thus look poor. Are the risks and burdens that HIV cure research places on participants so high that it is unethical, at present, to conduct it? In this paper, I answer 'no'. I start my argument by describing a foundational way of thinking about the ethical justification for regulatory limits on research risk; I then apply this way of thinking to HIV cure trials. In offering this analysis, I confine my attention to studies enrolling competent adults and I also do not consider risks research may pose to third parties or society. Rather, my concern is to engage with the thought that some trials are so risky that performing them is an ethically unacceptable way to treat the participants themselves. I reject this thought and instead argue that there is no level of risk, no matter how high, that inherently mistreats a participant.
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Affiliation(s)
- Robert Steel
- Clinical Center Department of Bioethics, National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
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4
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Kimmelman J. Phase I trials as therapeutic options: (usually) a betrayal of evidence-based medicine. Nat Rev Clin Oncol 2020; 16:719-720. [PMID: 31471566 DOI: 10.1038/s41571-019-0264-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Jonathan Kimmelman
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada.
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5
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Dubé K, Dee L, Evans D, Sylla L, Taylor J, Brown B, Miller V, Corneli A, Skinner A, Greene SB, Tucker JD, Rennie S. Perceptions of Equipoise, Risk-Benefit Ratios, and "Otherwise Healthy Volunteers" in the Context of Early-Phase HIV Cure Research in the United States: A Qualitative Inquiry. J Empir Res Hum Res Ethics 2017; 13:3-17. [PMID: 28984168 DOI: 10.1177/1556264617734061] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Early-phase HIV cure research is conducted against a background of highly effective antiretroviral therapy, and involves risky interventions in individuals who enjoy an almost normal life expectancy. To explore perceptions of three ethical topics in the context of HIV cure research-(a) equipoise, (b) risk-benefit ratios, and (c) "otherwise healthy volunteers"-we conducted 36 in-depth interviews (IDIs) with three groups of purposively selected key informants: clinician-researchers ( n = 11), policy-makers and bioethicists ( n = 13), and people living with HIV (PLWHIV; n = 12). Our analysis revealed variability in perceptions of equipoise. Second, most key informants believed there was no clear measure of risk-benefit ratios in HIV cure research, due in part to the complexity of weighing (sometimes unknown) risks to participants and (sometimes speculative) benefits to science and society. Third, most clinician-researchers and policy-makers/bioethicists viewed potential HIV cure study participants as "otherwise healthy volunteers," but this perception was not shared among PLWHIV in our study.
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Affiliation(s)
- Karine Dubé
- 1 UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Lynda Dee
- 2 AIDS Action Baltimore, MD, USA.,3 Delaney AIDS Research Enterprise Community Advisory Board, San Francisco, CA, USA.,4 amfAR Institute for HIV Cure Research CAB, San Francisco, CA, USA
| | - David Evans
- 3 Delaney AIDS Research Enterprise Community Advisory Board, San Francisco, CA, USA.,5 Project Inform, San Francisco, CA, USA
| | | | - Jeff Taylor
- 7 Collaboratory of AIDS Researchers for Eradication, Palm Springs, CA, USA
| | | | | | - Amy Corneli
- 10 Duke Clinical Research Institute, Durham, NC, USA
| | - Asheley Skinner
- 1 UNC Gillings School of Global Public Health, Chapel Hill, NC, USA.,10 Duke Clinical Research Institute, Durham, NC, USA
| | - Sandra B Greene
- 1 UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Joseph D Tucker
- 11 UNC Project China, Guangzhou, China.,12 UNC Institute of Global Health and Infectious Diseases, Chapel Hill, NC, USA
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6
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Allon I, Ben-Yehudah A, Dekel R, Solbakk JH, Weltring KM, Siegal G. Ethical issues in nanomedicine: Tempest in a teapot? MEDICINE, HEALTH CARE, AND PHILOSOPHY 2017; 20:3-11. [PMID: 27522374 DOI: 10.1007/s11019-016-9720-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Nanomedicine offers remarkable options for new therapeutic avenues. As methods in nanomedicine advance, ethical questions conjunctly arise. Nanomedicine is an exceptional niche in several aspects as it reflects risks and uncertainties not encountered in other areas of medical research or practice. Nanomedicine partially overlaps, partially interlocks and partially exceeds other medical disciplines. Some interpreters agree that advances in nanotechnology may pose varied ethical challenges, whilst others argue that these challenges are not new and that nanotechnology basically echoes recurrent bioethical dilemmas. The purpose of this article is to discuss some of the ethical issues related to nanomedicine and to reflect on the question whether nanomedicine generates ethical challenges of new and unique nature. Such a determination should have implications on regulatory processes and professional conducts and protocols in the future.
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Affiliation(s)
- Irit Allon
- Chief Scientists Office, Ministry of Health, 39 Yirmiyahu St., Jerusalem, Israel.
- Department of Oral Pathology and Oral Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Ahmi Ben-Yehudah
- Chief Scientists Office, Ministry of Health, 39 Yirmiyahu St., Jerusalem, Israel
| | - Raz Dekel
- Head of Occupational Medicine Services, Ministry of Health, Tel Aviv, Israel
| | - Jan-Helge Solbakk
- Centre for Medical Ethics Faculty, Medicine University of Oslo, Oslo, Norway
| | | | - Gil Siegal
- University of Virginia School of Law, Charlottesville, VA, USA
- Gertner Institute of Public Policy, Ministry of Health, Ono Academic College, Kiryat Ono, Israel
- Center for Health Law, Bioethics and Health Policy, Ono Academic College, Kiryat Ono, Israel
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Kimmelman J, Henderson VC. Assessing risk/benefit for trials using preclinical evidence: a proposal. JOURNAL OF MEDICAL ETHICS 2016; 42:50-3. [PMID: 26463620 PMCID: PMC4854630 DOI: 10.1136/medethics-2015-102882] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 09/20/2015] [Indexed: 05/07/2023]
Abstract
Moral evaluation of risk/benefit in early phase studies requires assessing the clinical promise of a candidate intervention using preclinical evidence. Yet, there is little to guide ethics committees, investigators, sponsors or other stakeholders morally charged with making these assessments ('evaluators'). In what follows, we draw on published guidelines for preclinical study design to develop a structured process for assessing the clinical promise of new interventions. In the first step, evaluators gather all relevant preclinical studies, assess the magnitude of treatment effects and determine clinical promise in light of various threats to valid clinical inference. In the second step, evaluators adjust the assessments of clinical promise from preclinical studies by examining how other agents in the same reference class-and supported by similar evidence-have fared in clinical development. Assessments of clinical promise can then be fed into the moral evaluation of risk and benefit in early phase trials. Though our approach has limitations, it offers a systematic and transparent method for assessing risk/benefit in early phase trials of novel interventions.
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Affiliation(s)
- Jonathan Kimmelman
- corresponding author: Studies for Translation, Research, Ethics, and Medicine (STREAM) Group, Biomedical Ethics Unit/Social Studies of Medicine, McGill University, 3647 Peel St., Montréal, QC, H3A 1X1, Canada, ph: 1-514-398-3306; mobile: 1-514-953-3306; fax: 1-514-398-8349, ; Preference for communication: By email
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8
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Niemansburg SL, Habets MGJL, Dhert WJA, van Delden JJM, Bredenoord AL. Participant selection for preventive Regenerative Medicine trials: ethical challenges of selecting individuals at risk. JOURNAL OF MEDICAL ETHICS 2015; 41:914-916. [PMID: 26340912 DOI: 10.1136/medethics-2014-102625] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 08/17/2015] [Indexed: 06/05/2023]
Abstract
The innovative field of Regenerative Medicine (RM) is expected to extend the possibilities of prevention or early treatment in healthcare. Increasingly, clinical trials will be developed for people at risk of disease to investigate these RM interventions. These individuals at risk are characterised by their susceptibility for developing clinically manifest disease in future due to the existence of degenerative abnormalities. So far, there has been little debate about the ethical appropriateness of including such individuals at risk in clinical trials. We discuss three main challenges of selecting this participant model for testing RM interventions: the challenge of achieving a proportional risk-benefit balance; complexities in the trial design in terms of follow-up and sample size; and the difficulty of obtaining informed consent due to the many uncertainties. We conclude that selecting the model is not ethically justifiable for first-in-man trials with RM interventions due to the high risks and uncertainties. However, the model can be ethically appropriate for testing the efficacy of RM interventions under the following conditions: interventions should be low risk; the degenerative abnormalities (and other risk factors) should be strongly related with disease within a short time frame; robust preclinical evidence of efficacy needs to be present; and the informed consent procedure should contain extra safeguards with regard to communication on uncertainties.
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Affiliation(s)
- Sophie L Niemansburg
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michelle G J L Habets
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wouter J A Dhert
- Department of Orthopedics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johannes J M van Delden
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Annelien L Bredenoord
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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9
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Henderson GE. The ethics of HIV "cure" research: what can we learn from consent forms? AIDS Res Hum Retroviruses 2015; 31:56-63. [PMID: 25406579 DOI: 10.1089/aid.2014.0219] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The advent of HIV "cure" research has generated enormous attention, but also concern about its potential to engender false hope, leading to overestimation of benefits and underestimation of risks, and about recruiting relatively healthy participants to studies with uncertain or serious risks. Currently, little is known about potential ethical problems in the ways that informed consent for HIV cure research is described to potential participants. As a first step to address this question, early phase, HIV "cure" research consent forms were analyzed to assess how study aims and potential risks and benefits are presented. Thirteen consent forms from a diverse group of clinical studies were selected to represent the major categories of cure research, including 11 interventional (gene transfer, vaccine intensification, treatment interruption, and latency reversing) and two observational. Consent forms were coded using seven categories, abstracting data on study purpose and design, participant selection criteria, presentation of risks and benefits of participation, and potential return of research results. Findings demonstrate variation and deficiencies that merit attention, but that can largely be addressed by turning to existing guidance about early phase research and specific study designs from other research contexts. The most challenging of these is ensuring that clear, specific, and consistent language is used to describe study aims, risks, benefits, and possible return of results. Informed consent for HIV "cure" research represents an opportunity to apply relevant existing guidance, measure the effectiveness of its application, and develop standardized best-practice policies for consent forms and processes.
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Affiliation(s)
- Gail E. Henderson
- Department of Social Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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10
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Abstract
Translation of cancer gene transfer confronts many familiar-and some distinctive-ethical challenges. In what follows, I survey three major ethical dimensions of cancer gene transfer development. Subheading 1 centers on the ethics of planning, designing, and reporting animal studies. Subheading 2 describes basic elements of human subjects protection as pertaining to cancer gene transfer. In Subheading 3, I describe how cancer gene transfer researchers have obligations to downstream consumers of the evidence they produce.
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Affiliation(s)
- Jonathan Kimmelman
- Studies in Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit/McGill University, 3647 Peel Street, Montreal, QC, Canada, H3A 1X1,
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11
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Abstract
Clinical trial reforms aimed at boosting phase 2 positive predictivity may involve ethical and social trade-offs.
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Affiliation(s)
- Spencer Phillips Hey
- Studies for Translation, Ethics, and Medicine Group (STREAM), Biomedical Ethics Unit, McGill University, Montreal, QC H3A 1X1, Canada
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12
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Napier S. Challenging research on human subjects: justice and uncompensated harms. THEORETICAL MEDICINE AND BIOETHICS 2013; 34:29-51. [PMID: 23378154 DOI: 10.1007/s11017-013-9241-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Ethical challenges to certain aspects of research on human subjects are not uncommon; examples include challenges to first-in-human trials (Chapman in J Clin Res Bioethics 2(4):1-8, 2011), certain placebo controlled trials (Anderson in J Med Philos 31:65-81, 2006; Anderson and Kimmelman in Kennedy Inst Ethics J 20(1):75-98, 2010) and "sham" surgery (Macklin in N Engl J Med 341:992-996, 1999). To date, however, there are few challenges to research when the subjects are competent and the research is more than minimal risk with no promise of direct benefit. The principal reason given for allowing research that is more than minimal risk without benefit is that we should respect the autonomy of competent subjects. I argue that though the moral intuitions informing respect for autonomy are sound, there is another set of intuitions regarding what we take to be just treatment of another when one agent knowingly causes or allows suffering on another agent. I argue that concerns generated by commutative justice serve as limitations on permissible research. I highlight our intuitions informing this notion of justice by appealing to work done on theodicy; what counts as a morally sufficient reason for God to allow suffering in humans is applicable also to the researcher-subject relationship. I conclude that all human subjects who are exposed to more than minimal risk research should enjoy the same actual protections (e.g., subpart D) as those given subjects who cannot consent.
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Affiliation(s)
- Stephen Napier
- Department of Philosophy, Villanova University, SAC 108, 800 Lancaster Ave., Villanova, PA 19085, USA.
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13
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Kimmelman J. A theoretical framework for early human studies: uncertainty, intervention ensembles, and boundaries. Trials 2012; 13:173. [PMID: 22999017 PMCID: PMC3551836 DOI: 10.1186/1745-6215-13-173] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 09/07/2012] [Indexed: 11/13/2022] Open
Abstract
Clinical development of novel therapeutics begins with a coordinated sequence of early phase clinical trials. Such early human studies confront a series of methodological and ethical challenges. In what follows, I propose a theoretical framework for early human studies aimed at informing the negotiation of these challenges. At the outset of clinical development, researchers confront a virtually undifferentiated landscape of uncertainty with respect to three variables: outcomes, their probability of occurrence, and operation dimensions needed to effectuate favorable outcomes. Early human trials transform this uncertain landscape into one where there are grounds for belief about risk and benefit for various combined operation dimensions. To accomplish this, studies set out with two aims. First, they identify a set of operation dimensions that, when combined as a package (intervention ensemble), elicits a reasonable probability of a target outcome. Second, they define the boundaries of dimension values within an intervention ensemble. This latter aim entails exposing at least some volunteers in early studies to treatments that are inactive or excessive. I provide examples that illustrate the way early human studies discover and delimit intervention ensembles, and close by offering some implications of this framework for ethics, methodology, and efficiency in clinical development of new interventions.
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Affiliation(s)
- Jonathan Kimmelman
- Biomedical Ethics Unit/Experimental Medicine, McGill University, 3647 Peel Street, Montreal, QB H3A 1X1, Canada.
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14
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Greek R, Pippus A, Hansen LA. The Nuremberg Code subverts human health and safety by requiring animal modeling. BMC Med Ethics 2012; 13:16. [PMID: 22769234 PMCID: PMC3532312 DOI: 10.1186/1472-6939-13-16] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Accepted: 05/14/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The requirement that animals be used in research and testing in order to protect humans was formalized in the Nuremberg Code and subsequent national and international laws, codes, and declarations. DISCUSSION We review the history of these requirements and contrast what was known via science about animal models then with what is known now. We further analyze the predictive value of animal models when used as test subjects for human response to drugs and disease. We explore the use of animals for models in toxicity testing as an example of the problem with using animal models. SUMMARY We conclude that the requirements for animal testing found in the Nuremberg Code were based on scientifically outdated principles, compromised by people with a vested interest in animal experimentation, serve no useful function, increase the cost of drug development, and prevent otherwise safe and efficacious drugs and therapies from being implemented.
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Affiliation(s)
- Ray Greek
- Americans For Medical Advancement, 2251 Refugio Rd, Goleta, CA 93117, USA
| | - Annalea Pippus
- Americans For Medical Advancement, 2251 Refugio Rd, Goleta, CA 93117, USA
| | - Lawrence A Hansen
- Department of Neurosciences and Pathology, University of California, San Diego, Mail Code 062, 9500 Gilman Drive (MTF 351), La Jolla, CA, 92093-0624, USA
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15
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de Melo-Martín I, Sondhi D, Crystal RG. Novel therapies, high-risk pediatric research, and the prospect of benefit: learning from the ethical disagreements. Mol Ther 2012; 20:1095-102. [PMID: 22652997 PMCID: PMC3369294 DOI: 10.1038/mt.2012.90] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Inmaculada de Melo-Martín
- Division of Medical Ethics, Department of Public Health, Weill Cornell Medical College, New York, New York, USA
| | - Dolan Sondhi
- Department of Genetic Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Ronald G Crystal
- Department of Genetic Medicine, Weill Cornell Medical College, New York, New York, USA
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16
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Abstract
Equipoise is widely endorsed as a necessary requirement for ethical design and conduct of randomized controlled trials. Nevertheless, I argue in this article that the equipoise principle suffers from fundamental defects. In particular, equipoise provides flawed ethical guidance for placebo-controlled trials and for decisions to terminate trials early based on interim data relating to benefit. The problems with equipoise are traced to a "therapeutic orientation to clinical trials," which conflates the ethics of clinical research with the ethics of medical care. Because of this mistaken therapeutic orientation, equipoise fails to adequately account for the central purpose of randomized trials in providing evidence sufficient to guide health policy decisions relating to licensing new treatments and insurance coverage. I conclude that it is time to dispense with equipoise. The principles of research ethics are sufficient to provide adequate guidance to protect subjects and to promote socially valuable research without any appeal to equipoise.
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Solbakk JH, Zoloth L. The tragedy of translation: the case of "first use" in human embryonic stem cell research. Cell Stem Cell 2011; 8:479-81. [PMID: 21549323 DOI: 10.1016/j.stem.2011.04.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Who should go first in phase-I human trials when neither risks nor benefits can be estimated? By assessing concerns raised by Bretzner et al. (2011), we highlight a tragic dimension underlying all such trials. We discuss strategies to avoid the pitfalls of ethical hubris by promoting fidelity and trust.
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Affiliation(s)
- Jan Helge Solbakk
- Centre for Medical Ethics, Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway.
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18
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Target populations for first-in-human embryonic stem cell research in spinal cord injury. Cell Stem Cell 2011; 8:468-75. [PMID: 21549321 DOI: 10.1016/j.stem.2011.04.012] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Geron recently announced that it had begun enrolling patients in the world's first-in-human clinical trial involving cells derived from human embryonic stem cells (hESCs). This trial raises important questions regarding the future of hESC-based therapies, especially in spinal cord injury (SCI) patients. We address some safety and efficacy concerns with this research, as well as the ethics of fair subject selection. We consider other populations that might be better for this research: chronic complete SCI patients for a safety trial, subacute incomplete SCI patients for an efficacy trial, and perhaps primary progressive multiple sclerosis (MS) patients for a combined safety and efficacy trial.
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Berry JD, Cudkowicz ME. New considerations in the design of clinical trials for amyotrophic lateral sclerosis. CLINICAL INVESTIGATION 2011; 1:1375-1389. [PMID: 22545191 PMCID: PMC3335743 DOI: 10.4155/cli.11.127] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Amyotrophic lateral sclerosis is a devastating neurodegenerative disease caused by loss of motor neurons. Its pathophysiology remains unknown, but progress has been made in understanding its genetic and biochemical basis. Clinical trialists are working to translate basic science successes into human trials with more efficiency, in the hope of finding successful treatments. In the future, new preclinical models, including patient-derived stem cells may augment transgenic animal models as preclinical tools. Biomarker discovery projects aim to identify markers of disease onset and progression for use in clinical trials. New trial designs are reducing study time, improving efficiency and helping to keep pace with the increasing rate of basic and translational discoveries. Ongoing trials with novel designs are paving the way for amyotrophic lateral sclerosis clinical research.
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Affiliation(s)
- James D Berry
- Massachusetts General Hospital, Department of Neurology, Neurology Clinical Trials Unit, 149 Thirteenth Street, Suite 2274, Charlestown, MA 02129, USA
| | - Merit E Cudkowicz
- Massachusetts General Hospital, Department of Neurology, Neurology Clinical Trials Unit, 149 Thirteenth Street, Suite 2274, Charlestown, MA 02129, USA
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20
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Kimmelman J, Duckworth K, Ramsay T, Voss T, Ravina B, Emborg ME. Risk of surgical delivery to deep nuclei: a meta-analysis. Mov Disord 2011; 26:1415-21. [PMID: 21574186 DOI: 10.1002/mds.23770] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Revised: 03/21/2011] [Accepted: 04/04/2011] [Indexed: 11/10/2022] Open
Abstract
Many novel strategies aimed at neuroprotection or neurorestoration involve surgical delivery of agents to deep nuclei along multiple trajectories. Using intracerebral hemorrhage on a per-trajectory basis as our primary end point, we quantified the level of surgical risk associated with agent delivery to deep nuclei. Secondarily, we quantified other event rates and examined relationships between intracerebral hemorrhage and 8 variables related to patient and practice characteristics. Meta-analytic techniques were used to pool complication rates reported in published articles involving deep brain stimulator electrode implantation or infusion of vectors, tissues, or trophic factors. One hundred nine studies were included in our analysis, comprising 6237 patients and 9890 trajectories to deep nuclei. The estimated per-trajectory intracerebral hemorrhage rate was 1.57% (95% confidence interval, 1.26%-1.95%). The proportion of trajectories leading to permanent or serious neurological deficits was 0.41% (0.28%-0.60%). The estimated mortality rate per trajectory was 0.14% (0.07%-0.29%). No relationship between intracerebral hemorrhage and sex, age, duration of disease, or exclusion of patients with surgical complications was observed; a significant positive relationship was observed with the use of microelectrode recording and a significant negative relationship with putamenal delivery. Our results show a significant difference in intracerebral hemorrhage rates between inoculations and electrode implantation. Our findings suggest that studies involving multiple trajectories to deep nuclei involve a high level of risk. However, inoculations may be significantly safer than electrode implantation. Our analysis has implications for the ethics of preclinical research, independent review of risk, subject selection, and adverse event reporting.
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Affiliation(s)
- Jonathan Kimmelman
- Biomedical Ethics Unit, Department of Social Studies of Medicine, McGill University, Montreal, Quebec, Canada.
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Affiliation(s)
- Jonathan Kimmelman
- Biomedical Ethics Unit, Department of Social
Studies of Medicine, McGill University, Montreal, Quebec, Canada
| | - Alex John London
- Department of Philosophy, Carnegie Mellon
University, Pittsburgh, Pennsylvania, United States of America
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