The Rationalization of Unethical Research: Revisionist Accounts of the Tuskegee Syphilis Study and the New Zealand "Unfortunate Experiment"

The Syphilis Pandemic Prior to Penicillin: Origin, Health Issues, Cultural Representation and Ethical Challenges

Syphilis is currently a treatable disease, with a low incidence in most developed countries, although the prevalence has increased recently, especially among men-who-have-sex-with-men. In many of the least developed countries, however, syphilis is still a major health problem, although the problem is not comparable to the desperate situation worldwide less than 80 years ago. At that time, and for many centuries previously, syphilis dramatically affected the lives and health of individuals and threatened the well-being of many societies. This review examines the aetiology, transmission, and many manifestations of syphilis from a historical perspective, emphasizing morbidity, treatment, psychosocial and cultural manifestations, as well as ethical issues uncovered in the clinical search for knowledge about the manifestations of the disease.

Controlled Human Infection Challenge Studies with RSV

Despite considerable momentum in the development of RSV vaccines and therapeutics, there remain substantial barriers to the development and licensing of effective agents, particularly in high-risk populations. The unique immunobiology of RSV and lack of clear protective immunological correlates has held back RSV vaccine development, which, therefore, depends on large and costly clinical trials to demonstrate efficacy. Studies involving the deliberate infection of human volunteers offer an intermediate step between pre-clinical and large-scale studies of natural infection. Human challenge has been used to demonstrate the potential efficacy of vaccines and antivirals while improving our understanding of the protective immunity against RSV infection. Early RSV human infection challenge studies determined the role of routes of administration and size of inoculum on the disease. However, inherent limitations, the use of highly attenuated/laboratory-adapted RSV strains and the continued evolutionary adaptation of RSV limits extrapolation of results to present-day vaccine testing. With advances in technology, it is now possible to perform more detailed investigations of human mucosal immunity against RSV in experimentally infected adults and, more recently, older adults to optimise the design of vaccines and novel therapies. These studies identified defects in RSV-induced humoral and CD8+ T cell immunity that may partly explain susceptibility to recurrent RSV infection. We discuss the insights from human infection challenge models, ethical and logistical considerations, potential benefits, and role in streamlining and accelerating novel antivirals and vaccines against RSV. Finally, we consider how human challenges might be extended to include relevant at-risk populations.

Evaluating ethnically diverse patients' perspectives of considering participation in renal clinical research

BACKGROUND

Clinical trial cohorts do not often reflect target patient populations because minority ethnic groups are underrepresented in clinical trials.

AIM

To increase minority ethnic groups' opportunities to participate in clinical trials, by evaluating ethnically diverse patients' perspectives of considering participation in renal clinical research.

DISCUSSION

The authors gave patients participating in at least one research study the opportunity to take part in a structured survey. The survey explored preferences, barriers and opportunities that patients considered when deciding whether to take part in a clinical trial. The authors included participants from multiple ethnic groups so they could compare data for different ethnicities.

CONCLUSION

Participation was a positive experience for most patients, mostly because of the research team's flexibility and professionalism. Researchers' gender and ethnicity did not affect the participants' decision to participate. Cultural preferences were not obvious from the data as 80% of the participants were white.

IMPLICATIONS FOR PRACTICE

Patients preferred a face-to-face approach and the expertise of the research team affected participation more than any other characteristics did. However, respondents were already research-engaged and conducting a similar study with those who have declined to participate in research may show different results.

Racial Disparities in Psychiatric Decisional Capacity Consultations

OBJECTIVE

In this study, the authors examined potential disparities and biases in the placement and outcomes of decisional capacity evaluations across races, controlling for patient characteristics.

METHODS

The authors reviewed 181 patient decisional capacity consultations requested for the consultation-liaison psychiatry service at a tertiary care medical center from 2018 to 2019. The racial distribution of patients in these consultations was compared with the racial distribution of hospital inpatient admissions from 2018 to 2019. The authors analyzed patient outcomes by using logistic regression that controlled for race, gender, age, education, primary insurance, type of capacity assessment, and psychiatric diagnosis.

RESULTS

Decisional capacity consultations were placed disproportionately for Black (43% of consultations vs. 18% of total admissions) and Hispanic patients (26% of consultations vs. 21% of admissions) compared with White and Asian patients. Among 130 patients with a capacity determination, 95 (53% of total sample) were determined not to have capacity, an outcome that did not differ by race but was more likely to occur among patients diagnosed as having delirium. Sixty-seven patients with no capacity (37% of total sample) experienced a change in treatment, an outcome that was less likely to occur among Hispanic patients in the univariable analysis.

CONCLUSIONS

Significant racial disparities were observed during the placement of a decisional capacity consultation. These findings reveal the potential biases introduced with both the initial challenge to a patient's capacity and the subsequent outcomes of the consultation. As such, the balance of risk versus benefit or utility of these consultations in certain populations must be carefully considered.

What Matters to Whom: Patient and Public Involvement in Research

We outline a call to action for reproductive health researchers to include patient and public involvement (PPI) in research. PPI prioritizes the patient perspective from study design through dissemination of results which centers the people research intends to serve. PPI highlights the patient as an expert in their own condition. PPI that includes groups harmed by health care disparities can draw attention to these harms and generate novel approaches to address them. Numerous frameworks exist for the use of PPI in research. Because obstetrics and gynecology conditions can be particularly sensitive, PPI is crucial in our field.

The weight of harm: A Response to “Editor’s Note: Societal changes and expression of concern about Rekers and Lovaas’ (1974) Behavioral Treatment of Deviant Sex-Role Behaviors in a Male Child”

In 1974, Rekers and Lovaas published an article in the Journal of Applied Behavior Analysis (JABA) wherein the authors coached a 4-year-old child’s parents to ignore and physically abuse him when he engaged in behaviors that were identified by the authors as inappropriate for a child whose sex assigned at birth was male. In October 2020, a Statement of Concern regarding Rekers and Lovaas (1974) was published in JABA (SEAB & LeBlanc, 2020), which described concerns regarding the paper and then provided justification for the journal’s decision to not retract this paper. In this current response, I provide a counterpoint to the Statement of Concern, arguing that (a) the available evidence strongly suggests that the original study was unethical and misaligned with the principles of Applied Behavior Analysis (ABA), and (b) the evidence presented to support its contemporaneous ethicality is insufficient. I end with an argument that Rekers and Lovaas (1974) should be retracted and discuss the critical role of ethics and social significance for the field of ABA.

Diversity in modern heart failure trials: Where are we, and where are we going

Over the last three decades, increased attention has been given to the representation of historically underrepresented groups within the landscape of pivotal clinical trials. However, recent events (i.e., coronavirus pandemic) have laid bare the potential continuation of historic inequities in available clinical trials and studies aimed at the care of broad patient populations. Anecdotally, cardiovascular disease (CVD) has not been immune to these disparities. Within this review, we examine and discuss recent landmark CVD trials, with a specific focus on the representation of Blacks within several critically foundational heart failure clinical trials tied to contemporary treatment strategies and drug approvals. We also discuss solutions for inequities within the landscape of cardiovascular trials. Building a more diverse clinical trial workforce coupled with intentional efforts to increase clinical trial diversity will advance equity in cardiovascular care.

The role of race and scientific trust on support for COVID-19 social distancing measures in the United States

Pundits and academics across disciplines note that the human toll brought forth by the novel coronavirus (COVID-19) pandemic in the United States (U.S.) is fundamentally unequal for communities of color. Standing literature on public health posits that one of the chief predictors of racial disparity in health outcomes is a lack of institutional trust among minority communities. Furthermore, in our own county-level analysis from the U.S., we find that counties with higher percentages of Black and Hispanic residents have had vastly higher cumulative deaths from COVID-19. In light of this standing literature and our own analysis, it is critical to better understand how to mitigate or prevent these unequal outcomes for any future pandemic or public health emergency. Therefore, we assess the claim that raising institutional trust, primarily scientific trust, is key to mitigating these racial inequities. Leveraging a new, pre-pandemic measure of scientific trust, we find that trust in science, unlike trust in politicians or the media, significantly raises support for COVID-19 social distancing policies across racial lines. Our findings suggest that increasing scientific trust is essential to garnering support for public health policies that lessen the severity of the current, and potentially a future, pandemic.

Informed Consent in Biomedical Research: Scopes and Challenges

Medical science is evolving constantly and this evolution cannot happen without biomedical research involving human participant. Owing to a tumultuous history, importance of ethical research cannot be over emphasized in today's world and the concept of informed consent becomes the guardian of ethics, not only to improve the bonding between the participant and researcher aiding a wholehearted involvement but also ensuring safety for the participants from research related injury/loss. Subject information sheet (SIF) and Informed consent form (ICF) are the fundamental elements of informed consent document. Process of obtaining them from illiterate and vulnerable populations involves the legally authorized representative (LAR) and impartial witness. Audiovisual recording becomes important in case of clinical trials. Process of obtaining informed consent becomes challenging for vulnerable populations as well as during pandemic situations. A comprehensive informed consent is essential for a credible and ethical research.

The Role of Emotion in Understanding Whiteness

This paper argues that stoicism as a central element of whiteness shapes, controls, and ultimately limits the experience and expression of emotion in public space. I explore how this may play out in particular medical settings like hospitals in Aotearoa New Zealand. I argue that working in conjunction with other values of whiteness identified by Myser (2003)-hyper-individualism, a contractual view of relationships, and an emphasis on personal control and autonomy-this makes hospitals emotionally unsafe spaces for Māori and other groups who place high importance in the collective sharing of emotion. Using death and bereavement as an example, I suggest that challenging and addressing stoicism in the structure and performance of whiteness in hospital settings may provide an important point of entry for anti-racism measures and health equity.

Informed Consent for Scholarly Articles during the COVID-19 Pandemic

The coronavirus disease 2019 pandemic has caused a breakdown in the healthcare system worldwide. The need to rapidly update guidelines in order to control the transmission in the population and for evidenced-based healthcare care has led to the need for timely, voluminous and valid research. Amid the quest for a vaccine and better therapies, researchers clamouring for information has led to a wide variety of ethical issues due to the unique situation. This paper aims to examine the positive and negative aspects of recent changes in the process of obtaining informed consent. The article outlines the various aspects, from history, previously described exemptions to consenting as well as those implemented during the pandemic and the current impact of virtual methods. Further, the authors make recommendations based on the outcome of suggested adjustments described in the literature. This article looks into increasing the awareness of physicians and researchers about ethical issues that need to be addressed to provide optimal care for patients while assuring their integrity and confidentiality.

Pandemic ethics: the case for risky research

There is too much that we do not know about COVID-19. The longer we take to find it out, the more lives will be lost. In this paper, we will defend a principle of risk parity: if it is permissible to expose some members of society (e.g. health workers or the economically vulnerable) to a certain level of ex ante risk in order to minimize overall harm from the virus, then it is permissible to expose fully informed volunteers to a comparable level of risk in the context of promising research into the virus. We apply this principle to three examples of risky research: skipping animal trials for promising treatments, human challenge trials to speed up vaccine development, and low-dose controlled infection or “variolation.” We conclude that if volunteers, fully informed about the risks, are willing to help fight the pandemic by aiding promising research, there are strong moral reasons to gratefully accept their help. To refuse it would implicitly subject others to still graver risks.

AAN position statement: Ethical issues in clinical research in neurology

This update to the American Academy of Neurology's 1998 position statement endeavors to provide guidance for the consistent ethical conduct and review of neurologic research involving human participants. It does so by outlining a widely used ethical framework of 7 principles derived from the foundational documents of modern bioethics, including the Nuremberg Code, the World Medical Association's Declaration of Helsinki, the Belmont Report, and the US Department of Health and Human Service's Common Rule. The position statement then applies this principle-based framework to analyze and produce recommendations for the management of common and important ethical issues encountered in neurologic clinical research. These include institutional review board oversight, equitable research participant inclusion, cognitive impairment in research participants, international studies, the replication crisis, and genetic testing and modification.

Disturbing the Doxa of Patient Safety Comment on "False Dawns and New Horizons in Patient Safety Research and Practice"

In a recent edition of this journal, Mannion and Braithwaite provide a succinct analysis of the emergence, and ultimately limited impact, of what they term the current ‘Safety I’ movement in healthcare. They describe the arc of this field from denial, through engagement via mechanisms and approaches imported from other industries, to the current situation where, despite ‘best efforts,’ error rates remain stubbornly recalcitrant. In examining the failure of system-wide efforts to produce sustained reductions in errors and adverse events, that article exposes the doxa, or what Bourdieu calls ‘the taken for granted’ which is central to this latest wave of patient safety movement. In this commentary, I would like to take focus on two key elements of Mannion and Braithwaite’s argument: that harm is caused by misguided but otherwise well-intentioned actions and the ‘embracing’ of patient safety. I then conclude by briefly considering the implications of these for Safety II, particularly as envisaged by the authors as an evolutionary, and therefore linear progression, from Safety I.

Balancing the Rights to Protection and Participation: A Call for Expanded Access to Ethically Conducted Correctional Health Research

Incarcerated individuals, over 95% of whom are eventually released, experience high burdens of chronic disease and behavioral health and social risk factors. Understanding the health needs of this population is critical to ensuring that general medicine physicians in prisons and in the community are adequately prepared to meet those needs. However, people in prison are significantly underrepresented in health research. In response to historical exploitation of prisoners in medical experimentation, federal guidelines appropriately require additional oversight for, and limit the scope of, research in prisons. Yet, according to a 2006 Institute of Medicine report, these requirements have produced inconsistent local regulations that often limit opportunities for incarcerated individuals to participate in research, and can slow the development of innovative medical interventions to improve their health. In this article, we describe the historical context surrounding regulations on research involving individuals in prison, the harms that can arise from excessive limitations to research in such settings, and the benefits of greater access to ethically conducted research in prison. We conclude with recommended actions that can be taken by general medicine researchers, correctional leaders, and policymakers to achieve consistent access to health research for incarcerated populations.

The Acceptability of Biobehavioral Research With Latino Youth in the United States

In this study, we explored Latinx adolescents’ knowledge and perceptions of biobehavioral research and their willingness to participate in such studies. We conducted four focus groups in the summer of 2014 with Latinx adolescents in Texas between the ages of 12 and 17 years ( n = 17; 53% male; M age = 14.6 years [ SD = 1.66]) who were recruited from a community-based clinic. Five themes emerged from our content analysis: (a) protection of human subjects is important to participants, (b) comfort with providing different types of biological data varies depending on different factors, (c) engagement in biobehavioral research should be grounded in a cultural lens, (d) providing bilingual research staff is essential, and (e) adolescents have various motivations for participating. Findings highlighted how various factors could serve as both barriers and facilitators to participation. Our study provides insight into strategies for conducting biobehavioral research with Latinxs, who are the fastest growing group of adolescents in the United States and experience disparities in health-risk behaviors that can be better understood through research approaches that integrate biological and psychological measures. Without considering the perspectives of historically marginalized or understudied populations, we jeopardize the quality and validity of research findings, and risk harming participants.

Transitioning from learning healthcare systems to learning health care communities

The learning healthcare system (LHS) model framework has three core, foundational components. These include an infrastructure for health-related data capture, care improvement targets and a supportive policy environment. Despite progress in advancing and implementing LHS approaches, low levels of participation from patients and the public have hampered the transformational potential of the LHS model. An enhanced vision of a community-engaged LHS redesign would focus on the provision of health care from the patient and community perspective to complement the healthcare system as the entity that provides the environment for care. Addressing the LHS framework implementation challenges and utilizing community levers are requisite components of a learning health care community model, version two of the LHS archetype.