Taking the principle of the primacy of the human being seriously

This paper targets an orphan topic in research ethics, namely the so called principle of the primacy of the human being, which states that the interests of the human subject should always take precedence over the interests of science and society. Although the principle occupies the central position in the majority of international ethical and legal standards for biomedical research, it has been commented in the literature mainly in passing. With a few notable exceptions, there is little in-depth discussion about the meaning and role of the principle. Several authors note that the principle is vogue, ambiguous and apparently conflicting with the accepted practice of conducting non-beneficial research on individuals unable to give consent. There are opinions that it is just "a vacuous figure of speech" and should be abandoned. This paper argues that the primacy principle is far from being "a vacuous figure of speech", rather it should be seen as a threefold concept: a fundamental interpretative rule, a procedural rule, and a substantive rule aimed at protecting research subjects from instrumental treatment and unacceptable risks. This interpretation tracks back to the principle regulatory and normative origins in the Declaration of Helsinki of 1975, but also acknowledges changes in research ethics and practice, which took place at the turn on the twentieth and twenty-first centuries. Thus, the proposed reading of the principle is not only original, but also historically grounded and normatively fruitful. It provides a fresh and ethically rich perspective on extensively debated, but still controversial problem of an upper limit of permissible risks in non-beneficial studies.

[Cognitive, ethical, social and political aspects in risk assessment: regarding vaccines against SARS-CoV-2]

Risk is a concept that is usually evaluated by scientists and public health experts by comparing probabilities. However, this ethical utilitarian perspective, which considers that the best decision is the one that has less probability of harm than of benefit, does not consider normative aspects based on other ethical perspectives. Interpreting the origin of public controversies arising from people's reactions to the small risks of attenuated SARS-CoV-2 vaccines and evaluating the responses of public institutions requires an understanding of both the cognitive aspects that introduce systematic biases in the assessment of probabilities and the sociological, ethical, and political framework that contextualizes risk management in modern societies.

Induced Earthquakes from Long-Term Gas Extraction in Groningen, the Netherlands: Statistical Analysis and Prognosis for Acceptable-Risk Regulation

Recently, growing earthquake activity in the northeastern Netherlands has aroused considerable concern among the 600,000 provincial inhabitants. There, at 3 km deep, the rich Groningen gas field extends over 900 km² and still contains about 600 of the original 2,800 billion cubic meters (bcm). Particularly after 2001, earthquakes have increased in number, magnitude (M, on the logarithmic Richter scale), and damage to numerous buildings. The man-made nature of extraction-induced earthquakes challenges static notions of risk, complicates formal risk assessment, and questions familiar conceptions of acceptable risk. Here, a 26-year set of 294 earthquakes with M ≥ 1.5 is statistically analyzed in relation to increasing cumulative gas extraction since 1963. Extrapolations from a fast-rising trend over 2001-2013 indicate that-under "business as usual"-around 2021 some 35 earthquakes with M ≥ 1.5 might occur annually, including four with M ≥ 2.5 (ten-fold stronger), and one with M ≥ 3.5 every 2.5 years. Given this uneasy prospect, annual gas extraction has been reduced from 54 bcm in 2013 to 24 bcm in 2017. This has significantly reduced earthquake activity, so far. However, when extraction is stabilized at 24 bcm per year for 2017-2021 (or 21.6 bcm, as judicially established in Nov. 2017), the annual number of earthquakes would gradually increase again, with an expected all-time maximum M ≈ 4.5. Further safety management may best follow distinct stages of seismic risk generation, with moderation of gas extraction and massive (but late and slow) building reinforcement as outstanding strategies. Officially, "acceptable risk" is mainly approached by quantification of risk (e.g., of fatal building collapse) for testing against national safety standards, but actual (local) risk estimation remains problematic. Additionally important are societal cost-benefit analysis, equity considerations, and precautionary restraint. Socially and psychologically, deliberate attempts are made to improve risk communication, reduce public anxiety, and restore people's confidence in responsible experts and policymakers.

A simple procedure for estimating pseudo risk ratios from exposure to non-carcinogenic chemical mixtures

Non-cancer risk assessment traditionally assumes a threshold of effect, below which there is a negligible risk of an adverse effect. The Agency for Toxic Substances and Disease Registry derives health-based guidance values known as Minimal Risk Levels (MRLs) as estimates of the toxicity threshold for non-carcinogens. Although the definition of an MRL, as well as EPA reference dose values (RfD and RfC), is a level that corresponds to "negligible risk," they represent daily exposure doses or concentrations, not risks. We present a new approach to calculate the risk at exposure to specific doses for chemical mixtures, the assumption in this approach is to assign de minimis risk at the MRL. The assigned risk enables the estimation of parameters in an exponential model, providing a complete dose-response curve for each compound from the chosen point of departure to zero. We estimated parameters for 27 chemicals. The value of k, which determines the shape of the dose-response curve, was moderately insensitive to the choice of the risk at the MRL. The approach presented here allows for the calculation of a risk from a single substance or the combined risk from multiple chemical exposures in a community. The methodology is applicable from point of departure data derived from quantal data, such as data from benchmark dose analyses or from data that can be transformed into probabilities, such as lowest-observed-adverse-effect level. The individual risks are used to calculate risk ratios that can facilitate comparison and cost-benefit analyses of environmental contamination control strategies.

EPA underestimates, oversimplifies, miscommunicates, and mismanages cancer risks by ignoring human susceptibility

If exposed to an identical concentration of a carcinogen, every human being would face a different level of risk, determined by his or her genetic, environmental, medical, and other uniquely individual characteristics. Various lines of evidence indicate that this susceptibility variable is distributed rather broadly in the human population, with perhaps a factor of 25- to 50-fold between the center of this distribution and either of its tails, but cancer risk assessment at the EPA and elsewhere has always treated every (adult) human as identically susceptible. The National Academy of Sciences "Silver Book" concluded that EPA and the other agencies should fundamentally correct their mis-computation of carcinogenic risk in two ways: (1) adjust individual risk estimates upward to provide information about the upper tail; and (2) adjust population risk estimates upward (by about sevenfold) to correct an underestimation due to a mathematical property of the interindividual distribution of human susceptibility, in which the susceptibility averaged over the entire (right-skewed) population exceeds the median value for the typical human. In this issue of Risk Analysis, Kenneth Bogen disputes the second adjustment and endorses the first, though he also relegates the problem of underestimated individual risks to the realm of "equity concerns" that he says should have little if any bearing on risk management policy. In this article, I show why the basis for the population risk adjustment that the NAS recommended is correct-that current population cancer risk estimates, whether they are derived from animal bioassays or from human epidemiologic studies, likely provide estimates of the median with respect to human variation, which in turn must be an underestimate of the mean. If cancer risk estimates have larger "conservative" biases embedded in them, a premise I have disputed in many previous writings, such a defect would not excuse ignoring this additional bias in the direction of underestimation. I also demonstrate that sensible, legally appropriate, and ethical risk policy must not only inform the public when the tail of the individual risk distribution extends into the "high-risk" range, but must alter benefit-cost balancing to account for the need to try to reduce these tail risks preferentially.

Patient preferences and acceptable risk for computed tomography in trauma

BACKGROUND

Rising use of computed tomography (CT) to evaluate patients with trauma has increased both patient costs and risk of cancer from ionizing radiation, without demonstrable improvements in outcome. Patient-centred care mandates disclosure of the potential risks, costs and benefits of diagnostic testing whenever possible.

OBJECTIVE

We sought to determine (1) patient preferences regarding emergency department (ED) real-time discussions of risks and costs of CT during their trauma evaluations; and (2) whether varying levels of odds of detection of life-threatening injury (LTI) were associated with changes in patient preferences for CT.

METHODS

Excluding patients already receiving CT and patients with altered mental status, we surveyed adult, English-speaking patients at four Level I verified trauma centres. After informing subjects of cancer risks associated with chest CT, we used hypothetical scenarios with varying LTIs to assess patients' preferences regarding CT.

RESULTS

Of 941 patients enrolled, 50% were male and their mean age was 42 years. Most patients stated they would prefer to discuss CT radiation risks (73.5%, 95% CI [66.1-80.8]) and costs (53.2%, 95% CI [46.1-60.4]) with physicians. As the odds of detecting LTI decreased, preferences for receiving CT decreased accordingly: LTI 25% (desire 91.2%, 95% CI [89.4-93.1]), LTI 10% (desire 79.3%, 95% CI [76.7-81.9]), LTI 5% (desire 69.1%, 95% CI [66.1-72.1]) and LTI <2% (desire 53.8%, 95% CI [50.6-57.0]). If the LTI was <2% and subjects were required to pay $1000 out-of-pocket, only 34.5% (95% CI 31.4-37.5) would opt for CT.

CONCLUSION

Most non-critically injured patients prefer to discuss radiation risks and costs of CT prior to receiving imaging. As the odds of detecting LTI decrease, fewer patients prefer to have CT; at an LTI threshold of 2%, approximately half of patients would prefer to forego CT. Adding out-of-pocket costs reduced this proportion to one-third of patients.