Measuring coercion to participate in research within a doubly vulnerable population: initial development of the coercion assessment scale

Coerced consent in clinical research: study protocol for a randomized controlled trial

BACKGROUND

Despite the low-risk nature of participation in most clinical anesthesia trials, subject recruitment on the same day as surgery is often restricted due to the concerns of researchers and local research ethics boards that same-day consent may not afford adequate time and opportunity for patients to weigh and make decisions, as well as perceptions of patient vulnerability immediately prior to surgery that could impact the voluntary nature and the rigor of the informed consent process. However, specialties such as anesthesiology, critical care, interventional radiology, and emergency medicine have a varied pattern of practice and patient acquaintance that does not typically afford the luxury of time or, in many cases, advance consent for participation in research. Indeed, the initial encounter between anesthesiologists and patients undergoing elective procedures routinely occurs on the day of surgery. Concerns of coercion related to same-day consent for clinical anesthesia research trials have not been borne out in the literature, and represent a significant obstacle to clinical researchers, as well as to the patients who are denied opportunities for potential benefit through participation in research studies.

METHODS

We describe the protocol for a prospective randomized controlled trial examining the voluntariness of patient consent, solicited either in advance of surgery or on the same day, to participate in an anesthesia research study at Women's College Hospital. One hundred fourteen patients scheduled to undergo ambulatory anterior cruciate ligament repair facilitated by general anesthesia with an adductor canal block will be randomized for recruitment either (a) in the pre-operative assessment clinic before the day of surgery or (b) on the day of surgery, to be approached for consent to participate in a fabricated research study of adjunct medications in adductor canal blocks. Regardless of allocation, patients in both groups will receive the same routine standard of care and will complete a post-operative questionnaire to signal perceptions of undue influence in the process of providing informed consent for the fabricated trial.

DISCUSSION

This study will inform trial design and practice guidelines surrounding the amount of time patients ought to be afforded in order to make durable decisions to participate (or not) in clinical research studies. This is expected to impact trial recruitment in a variety of clinical settings where researchers have only brief opportunities to interface with patients.

TRIAL REGISTRATION

The trial was registered prospectively on the Open Science Framework (OSF), registration #46twc, on 2023-Mar-17.

Measuring Contraceptive Autonomy at Two Sites in Burkina Faso: A First Attempt to Measure a Novel Family Planning Indicator

There is growing consensus in the family planning community around the need for novel measures of autonomy. Existing literature highlights the tension between efforts to pursue contraceptive targets and maximize uptake on the one hand, and efforts to promote quality, person-centeredness, and contraceptive autonomy on the other hand. Here, we pilot a novel measure of contraceptive autonomy, measuring it at two Health and Demographic Surveillance System sites in Burkina Faso. We conducted a population-based survey with 3,929 women of reproductive age, testing an array of new survey items within the three subdomains of informed choice, full choice, and free choice. In addition to providing tentative estimates of the prevalence of contraceptive autonomy and its subdomains in our sample of Burkinabè women, we critically examine which parts of the proposed methodology worked well, what challenges/limitations we encountered, and what next steps might be for refining, improving, and validating the indicator. We demonstrate that contraceptive autonomy can be measured at the population level but a number of complex measurement challenges remain. Rather than a final validated tool, we consider this a step on a long road toward a more person-centered measurement agenda for the global family planning community.

Court-Mandated Patients' Perspectives on the Psychotherapist's Dual Loyalty Conflict - Between Ally and Enemy

BACKGROUND

Mental health professionals working in correctional contexts engage a double role to care and control. This dual loyalty conflict has repeatedly been criticized to impede the development of a high-quality alliance. As therapeutic alliance is a robust predictor of outcome measures of psychotherapy, it is essential to investigate the effects of this ethical dilemma.

METHODS

This qualitative interview study investigates patients' perceptions of their therapists' dual role conflict in court-mandated treatment settings. We interviewed 41 older incarcerated persons using a semi-structured interview guide, the interviews were subsequently analyzed following thematic analysis.

RESULTS

We first present the patients' perceptions of their treating psychotherapist's dual loyalty conflict, which was linked to their overall treatment experience. In a second step, we outline the study participants' reasons for this judgment, which were most commonly linked to feelings of trust or betrayal. More specifically, they named certain therapist characteristics and activities that enabled them to develop a trustful therapeutic alliance, which we grouped into four topics: (1) respecting the patient's pace and perceived coercion; (2) patient health needs to be first priority; (3) clarity in roles and responsibilities; and (4) the art of communication - between transparency and unchecked information sharing.

DISCUSSION

Developing a high quality alliance in mandatory offender treatment is central due to its relationship with recovery and desistance. Our findings show that some therapists' characteristics and activities attenuate the negative impact of their double role on the development and maintenance of the alliance. To increase the effectiveness of court-mandated treatments, we need to support clinicians in dealing with their dual role to allow the formation of a high quality therapeutic alliance. Our qualitative interview study contributed to this much-needed empirical research on therapist' characteristics promoting a trustful relationship in correctional settings.

The Opportunity Cost of Compulsory Research Participation: Why Psychology Departments Should Abolish Involuntary Participant Pools

Psychology departments often require undergraduates to participate in faculty and graduate research as part of their course or face a penalty. Involuntary participant pools (human subject pools) in which students are compulsorily enrolled are objectively coercive. Students have less autonomy than other research participants because they face a costly alternative task or the penalties that accompany failure to meet a course requirement if they choose not to participate. By contrast, other research participants are free to refuse consent without cost or penalty. Some researchers claim that the educational value of participation justifies the requirement. They treat coercion as a cost that can be outweighed by the benefits to students. This paper argues that such an approach is flawed because coercion is not like other costs and that educational value is inherently low relative to personal study or classroom time. The unethical nature of involuntary participation is best demonstrated with an opportunity cost analysis. This shows that students are forced to sacrifice higher value alternatives that they have paid to do and undertake a lower value activity that principally benefits others. Faculty have a conflict of interest as they are the beneficiaries of student coercion in their role as researchers and responsible for student achievement in their role as teachers. Voluntary participant pools can resolve this conflict but at the cost of reducing the supply of participants. A change in departmental research conduct is required to restore the autonomy of students who are competent adults and not legitimate subjects of paternalism when it comes to research participation.

Offering Payment in Clinical Research: Enrolling Individuals With or at Risk for Opioid Use Disorder

Offering payment is an important means of facilitating research participation. Yet, offers of payment raise ethical challenges that may be heightened when prospective participants suffer from or are at risk for opioid use disorder (OUD). We surveyed principal investigators (PIs) conducting research in this population to characterize the relative importance they assign to various ethical and practical factors when designing offers of payment and also analyzed descriptions of payment in both their study advertisements and consent forms. Overall, we found that, despite literature suggesting heightened ethical concerns for this population, practical factors related to payment were more influential for PIs than either ethical factors or factors unique to individuals with or at risk for OUD. Our findings can help inform the development of ethical, effective recruitment and retention strategies for research in this population.

Participant incentives in rehabilitation research: a pilot study of researchers' perspectives

BACKGROUND

Despite the use of research incentives in the recruitment and retention of participants for research studies, there remains debate over the acceptable use of participant incentives in research. There appears to be a paucity of guidelines that can assist researchers in demonstrating practically how incentives may be ethically used in research.

OBJECTIVE

This single site pilot study explored the experiences of key stakeholders involved in rehabilitation research to highlight what may constitute acceptable practices for incentives.

METHODS

A qualitative inquiry with use of semi-structured interviews with four key informants from a single site was undertaken. Data was audio-recorded and analysed thematically using deductive reasoning.

RESULTS

The findings reflect a description of what incentives constitute; the issues around undue inducement and use of incentives in practice. Participants' offered their perceptions on perceived acceptable versus unacceptable practices in the use incentives in research. Participants shared their concern over research incentives being used to sway participation in research rather than reimburse participants for their expenses or offering a token of appreciation.

CONCLUSION

There is a need for education of practitioners and researchers to develop skill to aid researchers to evaluate the ethical dilemmas related to the use of incentives in research.

Enrolling in Clinical Research While Incarcerated: What Influences Participants' Decisions?

As a 2006 Institute of Medicine report highlights, surprisingly little empirical attention has been paid to how prisoners arrive at decisions to participate in modern research. With our study, we aimed to fill this gap by identifying a more comprehensive range of factors as reported by prisoners themselves during semistructured interviews. Our participants described a diverse range of motives, both favoring and opposing their eventual decision to join. Many are well-recognized considerations among nonincarcerated clinical research participants, including a desire for various forms of personal benefit, altruism, and concern about study risks and inconveniences. However, a number of influences seem unique to prisoners. Participants did not report that they were not coerced into enrolling, and they have even been under pressure not to enroll. However, many sought to enroll in order to obtain access to better health care, raising a concern about whether they were unfairly exploited.

Incarcerated Women's Experiences and Perceptions of Participating in Research

The research process within prisons has largely considered researchers' perspectives. Only one known study explicitly examined incarcerated persons' perceptions and no known studies have explored incarcerated persons' experiences with research on sensitive topics. This study examines incarcerated women's experiences with participating in research on victimization. A thematic analysis was conducted on responses to open-ended questions about participating in a research study from 227 women in two prisons who participated in a study about victimization. Women prisoners were overwhelmingly positive about participating in the research study with the vast majority willing to participate in a future study. Participants believed participating in the study provided opportunities for them to share their story, heal, reflect, grow, and help others. Some women mentioned that discussing certain topics created uncomfortable emotions and memories. Participants perceived benefits of participating in research. Implications for research in prisons are presented.

Seeing Beyond the Margins: Challenges to Informed Inclusion of Vulnerable Populations in Research

Although the importance of including vulnerable populations in medical research is widely accepted, identifying how to achieve such inclusion remains a challenge. Ensuring that the language of informed consent is comprehensible to this group is no less of a challenge. Although a variety of interventions show promise for increasing the comprehensibility of informed consent and increasing a climate of exchange, consensus is lacking on which interventions should be used in which situations and current regulations provide little guidance. We argue that the notion of individual autonomy — a foundational principle of informed consent — may be too narrow for some vulnerable populations by virtue of its failure to acknowledge their unique histories and current circumstances. It has a different meaning for members of structured groups like American Indians than for unstructured groups, such as African Americans, whose complicated histories foster group identity. Ensuring broad participation in research and selecting appropriate methods for obtaining informed consent — namely, methods aligned with the source of vulnerability and level of risk — require new ways of thinking that might produce guidelines for matching informed consent models and processes with subpopulations.

Personal Control Over Decisions to Participate in Research by Persons With Histories of Both Substance Use Disorders and Criminal Justice Supervision

Individuals must feel free to exert personal control over decisions regarding research participation. We present an examination of participants' perceived personal control over, as well as reported pressures and threats from others, influencing their decision to join a study assessing the effectiveness of extended-release naltrexone in preventing opioid dependence relapse. Most participants endorsed a strong sense of control over the decision; few reported pressures or threats. Although few in number, participants' brief narrative descriptions of the pressures and threats are illuminating and provide context for their perceptions of personal control. Based on this work, we propose a useful set of tools to help ascertain participants' sense of personal control in joining research.

Assessing informed consent in an opioid relapse prevention study with adults under current or recent criminal justice supervision

Concerns persist that individuals with substance use disorders who are under community criminal justice supervision experience circumstances that might compromise their provision of valid, informed consent for research participation. These concerns include the possibilities that desire to obtain access to treatment might lead individuals to ignore important information about research participation, including information about risks, or that cognitive impairment associated with substance use might interfere with attending to important information. We report results from a consent quiz (CQ) administered in a multisite randomized clinical trial of long-acting naltrexone to prevent relapse to opioid use disorder among adults under community criminal justice supervision-a treatment option difficult to access by this population of individuals. Participants were required to answer all 11 items correctly before randomization. On average, participants answered 9.8 items correctly (89%) at baseline first attempt (n=306). At week 21 (n=212), participants scored 87% (9.5 items correct) without review. Performance was equivalent to, or better than, published results from other populations on a basic consent quiz instrument across multiple content domains. The consent quiz is an efficient method to screen for adequate knowledge of consent information as part of the informed consent process. Clinical researchers who are concerned about these issues should consider using a consent quiz with corrected feedback to enhance the informed consent process. Overall, while primarily useful as an educational tool, employing a CQ as part of the gateway to participation in research may be particularly important as the field continues to advance and tests novel experimental treatments with significant risks and uncertain potential for benefit.

Mobile technology intervention to improve care coordination between HIV and substance use treatment providers: development, training, and evaluation protocol

Background

People living with HIV (PLWH) with a substance use disorder (SUD) tend to receive inadequate medical care in part because of a siloed healthcare system in which HIV and substance use services are delivered separately. Ideal treatment requires an interdisciplinary, team-based coordinated care approach, but many structural and systemic barriers impede the integration of HIV and SUD services. The current protocol describes the development and preliminary evaluation of a care coordination intervention (CCI), consisting of a tablet-based mobile platform for HIV and SUD treatment providers, an interagency communication protocol, and a training protocol. We hypothesize that HIV and SUD treatment providers will find the CCI to be acceptable, and that after receipt of the CCI, providers will: exhibit higher retention in dual care among patients, report increased frequency and quality of communication, and report increased rates of relational coordination.

Methods/design

A three phase approach is used to refine and evaluate the CCI. Phase 1 consists of in-depth qualitative interviews with 8 key stakeholders as well as clinical audits of participating HIV and SUD treatment agencies. Phase 2 contains functionality testing of the mobile platform with frontline HIV and SUD treatment providers, followed by refinement of the CCI. Phase 3 consists of a pre-, post-test trial with 30 SUD and 30 HIV treatment providers. Data will be collected at the provider, organization, and patient levels. Providers will complete assessments at baseline, immediately post-training, and at 1-, 3-, and 6-months post-training. Organizational data will be collected at baseline, 1-, 3-, and 6-months post training, while patient data will be collected at baseline and 6-months post training.

Discussion

This study will develop and evaluate a CCI consisting of a tablet-based mobile platform for treatment providers, an interagency communication protocol, and a training protocol as a means of improving the integration of care for PLWH who have a SUD. Results have the potential to advance the field by bridging gaps in a fragmented healthcare system, and improving treatment efficiency, work flow, and communication among interdisciplinary providers from different treatment settings.

Trial Registration: NCT02906215

Informed Assent Recall Among Adolescents in Substance Use Disorder Treatment Research

Evidence suggests that vulnerable populations such as substance users, those involved in the criminal justice system, and those with cognitive deficits often fail to recall information regarding the informed assent process. This study investigated correlates of assent quiz errors (AQE) among adolescents enrolling in a substance use disorder treatment study.

METHOD

Adolescents (age 13-19) entering substance use treatment completed a standard informed consent procedure to participate in a longitudinal research study, followed by a brief 6-item assent quiz.

RESULTS

Informed assent quiz errors were lower in this study relative to those observed in the adult literature. Being male and having lower treatment resistance was associated with making an AQE. Both days of marijuana use and days spent in the criminal justice system were associated with AQE. Hyperactivity-impulsivity approached significance (p = .057) but was not a correlate of AQE.

CONCLUSION

Those collecting assent should be aware that heavily-using males involved in the criminal justice system are prone to make more errors, and should use procedures such as assent quizzes to enhance their understanding of study procedures. Future research should investigate the impact of motivation and consider using experimental designs to test adolescent recall of study procedures under various assenting conditions.

Mental Health Research in Correctional Settings: Perceptions of Risk and Vulnerabilities

With over half of individuals incarcerated having serious mental health concerns, correctional settings offer excellent opportunities for epidemiological, prevention, and intervention research. However, due to unique ethical and structural challenges, these settings create risks and vulnerabilities for participants not typically encountered in research populations. We surveyed 1,224 researchers, IRB members, and IRB prisoner representatives to assess their perceptions of risks associated with mental health research conducted in correctional settings. Highest-ranked risks were related to privacy, stigma, and confidentiality; lowest-ranked risks were related to prisoners' loss of privileges or becoming targets of violence due to having participated in research. Cognitive impairment, mental illness, lack of autonomy, and limited access to services emerged as the greatest sources of vulnerability; being male, being female, being over age of 60, being a minority, and being pregnant were the lowest-ranked sources of vulnerability. Researchers with corrections experience perceived lower risks and vulnerabilities than all other groups, raising the question whether these researchers accurately appraise risk and vulnerability based on experience, or if their lower risk and vulnerability perceptions reflect potential bias due to their vested interests. By identifying areas of particular risk and vulnerability, this study provides important information for researchers and research reviewers alike.

Exploitation of Prisoners in Clinical Research: Perceptions of Study Participants

This paper discusses findings of a study examining whether prisoners view their participation in clinical research studies as exploitative. Perspectives of seventy prisoners who were enrolled in one of six different clinical studies were analyzed. A minority of participants agreed with statements suggestive of potential exploitation. All but one participant believed that prisoners should have greater access to research. On balance, these data provide reassurance that prisoners in this sample do not view their involvement in clinical research as inappropriately exploitative.

A qualitative analysis of peer recruitment pressures in respondent driven sampling: Are risks above the ethical limit?

BACKGROUND

This paper examines peer recruitment dynamics through respondent driven sampling (RDS) with a sample of injection drug users in Hartford, CT to understand the strategies participants use to recruit peers into a study and the extent to which these strategies may introduce risks above the ethical limit despite safeguards in RDS.

METHODS

Out of 526 injection drug users who participated in a mixed-method RDS methodology evaluation study, a nested sample of 61 participants completed an in-depth semi-structured interview at a 2-month follow-up to explore their experiences with the recruitment process.

RESULTS

Findings revealed that participants used a variety of strategies to recruit peers, ranging from one-time interactions to more persistent strategies to encourage participation (e.g., selecting peers that can easily be found and contacted later, following up with peers to remind them of their appointment, accompanying peers to the study site, etc.). Some participants described the more persistent strategies as helpful, while some others experienced these strategies as minor peer pressure, creating a feeling of obligation to participate. Narratives revealed that overall, the probability of experiencing study-related risks remains relatively low for most participants; however, a disconcerting finding was that higher study-related risks (e.g., relationship conflict, loss of relationship, physical fights, violence) were seen for recruits who participated but switched coupons or for recruits who decided not to participate in the study and did not return the coupon to the recruiter.

CONCLUSIONS

Findings indicate that peer recruitment practices in RDS generally pose minimal risk, but that peer recruitment may occasionally exceed the ethical limit, and that enhanced safeguards for studies using peer recruitment methods are recommended. Suggestions for possible enhancements are described.

Measuring Voluntariness of Consent to Research

The conceptual complexity of the term voluntariness has resulted in relatively few empirical studies of the voluntariness component of consent to research. As the call for a formal assessment of voluntariness to be incorporated into the consent process intensifies, more researchers are responding to the challenge of developing a valid and reliable measure of voluntariness. The purpose of this article was to summarize and describe the empirical literature on voluntariness of consent. As part of a broader study on the voluntariness of consent to research, existing empirical studies of voluntariness of consent to research were reviewed to establish how voluntariness of consent to research has been assessed to date. Fifteen studies using different voluntariness assessment instruments were identified and included in the review. The review found that little attempt has been made to systematically collect data on the reliability and validity of voluntariness assessment instruments. No two instruments reviewed were found to be based on a shared conceptualization of voluntary consent to research.

Extended-release naltrexone to prevent relapse among opioid dependent, criminal justice system involved adults: rationale and design of a randomized controlled effectiveness trial

BACKGROUND

Extended-release naltrexone (XR-NTX, Vivitrol; Alkermes Inc.) is an injectable monthly sustained-release mu opioid receptor antagonist. XR-NTX is a potentially effective intervention for opioid use disorders and as relapse prevention among criminal justice system (CJS) populations.

METHODS

This 5-site open-label randomized controlled effectiveness trial examines whether XR-NTX reduces opioid relapse compared with treatment as usual (TAU) among community dwelling, non-incarcerated volunteers with current or recent CJS involvement. The XR-NTX arm receives 6 monthly XR-NTX injections at Medical Management visits; the TAU group receives referrals to available community treatment options. Assessments occur every 2 weeks during a 24-week treatment phase and at 12- and 18-month follow-ups. The primary outcome is a relapse event, defined as either self-report or urine toxicology evidence of ≥10 days of opioid use in a 28-day (4 week) period, with a positive or missing urine test counted as 5 days of opioid use.

RESULTS

We describe the rationale, specific aims, and design of the study. Alternative design considerations and extensive secondary aims and outcomes are discussed.

CONCLUSIONS

XR-NTX is a potentially important treatment and relapse prevention option among persons with opioid dependence and CJS involvement. ClinicalTrials.gov: NCT00781898.

Developing an index to measure the voluntariness of consent to research

The goals of the current study were to expand the content domain and further validate the Coercion Assessment Scale (CAS), a measure of perceived coercion for criminally involved substance abusers being recruited into research. Unlike the few existing measures of this construct, the CAS identifies specific external sources of pressure that may influence one's decision to participate. In Phase 1, we conducted focus groups with criminal justice clients and stakeholders to expand the instrument by identifying additional sources of pressure. In Phase 2, we evaluated the expanded measure (i.e., endorsement rates, reliability, validity) in an ongoing research trial. Results identified new sources of pressure and provided evidence supporting the CAS's utility and reliability over time as well as convergent and discriminative validity.

Review of measurement instruments in research ethics in the biomedical sciences, 2008−2012

There is an urgent need in biomedical science to understand whether regulations are being met, prerequisite to goals of subject protection and integrity in research practice. This article presents an update of a 2006 summary of measurement instruments in research ethics with psychometric information in the years 2008−2012. A review of 25 instruments identified seven used in the time period 2008−2012 and which had accumulated at least one study of its psychometric qualities beyond its developmental phase. Many of these instruments had been accumulating psychometric information over more than a decade. Two additional but still underdeveloped instruments addressing important bioethical issues − coercion and therapeutic misconception − are included because they address important issues in research ethics. Bioethicists use a wide range of methods for knowledge development and verification; each method should meet stringent standards of quality. Measurement instruments that meet these standards have the potential to greatly ease the work of institutional review boards and other regulatory bodies as well as to enhance empirical work on human research ethics.

Altruism in terminal cancer patients and rapid tissue donation program: does the theory apply?

Rapid tissue donation (RTD) is an advancing oncology research procedure for collecting tumors, metastases, and unaffected tissue 2-6 h after death. Researchers can better determine rates of progression, response to treatment, and polymorphic differences among patients. Cancer patients may inquire about posthumous body donation for research to offer a personal contribution to research; however, there are barriers to recruiting for an RTD program. Physicians must reassure the patient that their treatment options and quality of care will not be compromised due to participating in RTD. In this commentary we discuss how theories of altruism may explain cancer patients' desire to participate in an RTD program, the ethical concerns of health care professionals and patients and the use of altruism as a recruitment strategy. We offer recommendations for examining the cultural and ethical climate of the institution prior to initiating such a program such as examining the relationship of healthcare professionals and patients, identifying ethical concerns, and examining ways to promote acceptance and buy-in across professionals, patients, and families.

Naltrexone in the treatment of opioid-dependent pregnant women: the case for a considered and measured approach to research

The present paper considers naltrexone to treat opioid dependence during pregnancy. The public health problem of opioid dependence and its treatment during pregnancy is reviewed first. Next, the naltrexone and opioid dependence treatment literature is summarized, with overviews of the pre-clinical and clinical research on prenatal naltrexone exposure. Finally, considerations and recommendations for future medication research for the treatment of opioid dependence in pregnant women are provided. The efficacy of long-acting injectable naltrexone relative to placebo, its blockade of opioid agonist euphoric effects, its lack of abuse and tolerance development and its modest adverse effect profile make it a potential medication for opioid-dependent pregnant women. However, it is not without seriously concerning potential drawbacks, including the difficulty surrounding medication induction that may lead to vulnerability with regard to relapse, physical dependence re-establishment, increased risk behaviors, treatment dropout and resulting opioid overdose. Before embarking on future research with this medication, the benefits and risks for the mother-embryo/fetus/child dyad should be weighed carefully. Should future research be conducted, a multi-level commitment to proactive ethical research is needed to reach the ultimate goal of improving the lives of women and children affected by opioid dependence.

Do Research Intermediaries Reduce Perceived Coercion to Enter Research Trials Among Criminally Involved Substance Abusers?

We examined the efficacy of including a research intermediary (RI) during the consent process in reducing participants' perceptions of coercion to enroll in a research study. Eighty-four drug court clients being recruited into an ongoing study were randomized to receive a standard informed consent process alone (standard condition) or with an RI (intermediary condition). Before obtaining consent, RIs met with clients individually to discuss remaining concerns. Findings provided preliminary evidence that RIs reduced client perceptions that their participation might influence how clinical and judicial staff view them. This suggests that using RIs may improve participant autonomy in clinical studies.

Methodological, ethical, and legal considerations in drug court research

Since their inception in the late 1980s, drug courts have become the most prevalent specialty court in the United States. A large body of outcome research conducted over the past two decades has demonstrated that drug courts effectively reduce drug use and criminal recidivism, which has led to the rapid proliferation of these courts. Importantly, drug court research has flourished despite the many challenges faced by researchers when working with a vulnerable population of justice-involved substance users. In this article, we highlight the most common methodological, ethical, and legal challenges encountered in drug court research, and discuss ways in which researchers can overcome these challenges to conduct high-quality research. Drug court research exemplifies how rigorous empirical investigation can be accomplished in the criminal justice system, and it can serve as a useful model for researchers working in other parts of the judicial system.

An Empirical Ethics Agenda for Psychiatric Research Involving Prisoners

In the past 30 years, the incarcerated population in the United States has more than quadrupled to 2.3 million adults. With an alarmingly high prevalence of mental illness, substance use, and other serious health conditions compounding their curtailed autonomy, prisoners constitute perhaps the nation's most disadvantaged group. Scientifically rigorous research involving prisoners holds the potential to inform and enlighten correctional policy and to improve their treatment. At the same time, prisoner research presents significant ethical challenges to investigators and institutional review boards (IRBs) alike, by subjecting participants to conditions that potentially undermine the validity of their informed consent. In 2006, the Institute of Medicine Committee on Ethical Considerations for Revisions to the Department of Health and Human Services (DHHS) Regulations for Protection of Prisoners Involved in Research recommended both further protections and a more permissive approach to research review that would allow inmates greater access to potentially beneficial research. These recommendations have sparked renewed debate about the ethical trade-offs inherent to prisoner research. In this article, the authors review the major justifications for research with prisoner subjects and the associated ethical concerns, and argue that the field of empirical ethics has much to offer to the debate. They then propose a framework for prioritizing future empirical ethics inquiry on this understudied topic.

Ethics in Psychiatric Research: A Review of 25 Years of NIH-funded Empirical Research Projects

BACKGROUND: This paper reviews the past 25 years of empirical research funded by the National Institutes of Health (NIH) on matters of ethics in psychiatric research. METHODS: Using the NIH RePORTER and Medline databases, we identified 43 grants and 77 publications that involved the empirical study of a matter of ethics in research involving mental health service users. RESULTS: These articles provide original and useful information on important topics, most especially the capacity to consent and the voluntariness of consent. For example, participants who share a diagnosis vary widely in levels of cognitive impairment that correlate with decisional capacity, and capacity to consent can be enhanced easily using iterative consent processes. Few articles address matters of justice or benefits in research, particularly from the perspectives of participants. No articles address matters of privacy, confidentiality, or researcher professionalism. CONCLUSIONS: Despite the usefulness of data from the studies conducted to date, current research on research ethics in psychiatry does not adequately address the concerns of service users as expressed in recent publications.