Exclusion of Women from Phase I Trials: Perspectives from Investigators and Research Oversight Officials

Over the past 30 years, progress has been made in increasing women's representation in clinical research. However, women continue to be underrepresented in phase I clinical trials-those trials that test the safety and tolerability of investigational drugs, often on healthy individuals. As sex-based differences in adverse drug reactions are often linked to drug dose, pivotal safety information in phase I trials is often insufficiently-and inequitably-captured for females. Yet there has been little attention to how clinical investigators and those charged with overseeing the ethical conduct of these trials perceive the barriers to women's inclusion in phase I trials. To address this gap, we report on 22 interviews with U.S. phase I investigators and institutional review board (IRB) members. Our findings indicate that although these investigators and IRB members acknowledged the importance of including women in clinical trials, they justified women's exclusion from phase I trials by citing the need to manage their reproductive potential. In particular, we identified four key themes that informants used to warrant women's exclusion from phase I trials: the structure of the drug-development system itself, fears about risks to potential fetuses, distrust of women to prevent pregnancy, and concerns about risks and burdens to institutions from resulting pregnancies. We argue that these rationales reflect structural and cultural barriers to women's inclusion in clinical research that ultimately fail to respect female research participants as persons, highlighting the need for broad-based solutions.

Learning Health Systems, Informed Consent, and Respect for Persons

Several pieces in the Hastings Center Report's May-June 2022 issue concern research ethics issues that arise in learning health care systems. In the lead article, Stephanie Morain and colleagues propose a new ethical framework for pragmatic clinical trials (PCTs), which are trials embedded in clinical care. Their framework consists of eight dimensions of demonstrating respect for patients enrolled in PCTs. In the second article, Robert Steel argues that patients being treated in a learning health care system can be required to participate in a clinical trial even if the risk to them is more than minimal. If they wish to refuse, they must either forgo treatment in the system or seek it elsewhere. Three commentaries explore various dimensions of Steel's argument. A third article in the issue turns in a different direction, to assumptions in bioethics about the quality of lives lived with disability. The authors, Debjani Mukherjee, Preya Tarsney, and Kristi Kirschner, find much that needs to change and offer recommendations for improvements at multiple levels.

Respect for persons and the allocation of lifesaving healthcare resources

Many ethicists argue that we should respect persons when we distribute resources. Yet it is unclear what this means in practice. For some, the idea of respect for persons is synonymous with the idea of respect for autonomy. Yet a principle of respect for autonomy provides limited guidance for how we should distribute scarce medical interventions. In this article, however, I sketch an alternative conception of respect for persons-one that is based on an ethic of mutual accountability. I draw in particular upon Stephen Darwall's writings on respect and the second-person standpoint. I consider the implications of this conception of respect for the distribution of scarce, lifesaving healthcare resources. A second-personal account of respect rules out aggregative approaches to distribution, and instead requires that we give individual consideration to the claims that persons in need make on the resources in our control. The principles that we use to govern our allocation of resources, furthermore, should be principles that are acceptable to all reasonable agents. Building on this insight, the final section of this paper considers how a principle of need can be used as a means to make decisions about the allocation of lifesaving resources.

Should Participants in Clinical Trials Be Able to Withdraw from Passive Follow-Up?

A research participant's right to withdraw from all research procedures is widely accepted, but there can be justifiable limits to a participant's exercise of autonomy to withdraw from some procedures. Clinical outcomes trials depend on complete subject follow-up for accurate assessment of the safety and efficacy of investigational therapies. Subjects' refusal to complete follow-up, even through passive medical record review, can cause failure to detect safety signals, inaccurate estimation of efficacy, or lack of acceptance of trial results, which alters the study's benefit-risk ratio. Allowing participant refusal of follow-up data collection therefore creates tension between respect for persons and beneficence. With minimal risk study procedures that can help preserve trial benefit, such as passive data collection, we argue that the importance of upholding the principle of beneficence outweighs individual autonomy concerns. Furthermore, a consent process that prospectively informs participants of mandatory passive follow-up is ethically justified and optimizes the balance between autonomy and beneficence.

Human Biospecimens Come from People

Contrary to the revised Common Rule, and contrary to the views of many bioethicists and researchers, we argue that broad consent should be sought for anticipated later research uses of deidentified biospecimens and health information collected during medical care. Individuals differ in the kinds of risk they find concerning and in their willingness to permit use of their biospecimens for future research. For this reason, asking their permission for unspecified research uses is a fundamental expression of respect for them as persons and should be done absent some compelling moral consideration to the contrary. We examine three moral considerations and argue that each of them fails: that there is a duty of easy rescue binding on all, that seeking consent creates a selection bias that undermines the validity of biospecimen research, and that seeking and documenting consent will be prohibitively expensive.

Privacy and confidentiality in pragmatic clinical trials

With pragmatic clinical trials, an opportunity exists to answer important questions about the relative risks, burdens, and benefits of therapeutic interventions. However, concerns about protecting the privacy of this information are significant and must be balanced with the imperative to learn from the data gathered in routine clinical practice. Traditional privacy protections for research uses of identifiable information rely disproportionately on informed consent or authorizations, based on a presumption that this is necessary to fulfill ethical principles of respect for persons. But frequently, the ideal of informed consent is not realized in its implementation. Moreover, the principle of respect for persons—which encompasses their interests in health information privacy—can be honored through other mechanisms. Data anonymization also plays a role in protecting privacy but is not suitable for all research, particularly pragmatic clinical trials. In this article, we explore both the ethical foundation and regulatory framework intended to protect privacy in pragmatic clinical trials. We then review examples of novel approaches to respecting persons in research that may have the added benefit of honoring patient privacy considerations.

What does 'respect' mean? Exploring the moral obligation of health professionals to respect patients

Respect is frequently invoked as an integral aspect of ethics and professionalism in medicine, yet it is often unclear what respect means in this setting. While we recognize that there are many reasonable ways to think about and use the term 'respect', in this paper, we develop a conception of respect that imposes a distinct moral duty on physicians. We are concerned mainly with the idea of respect for persons, or more specifically, respect for patients as persons. We develop an account of respect as recognition of the unconditional value of patients as persons. Such respect involves respecting the autonomy of patients, but we challenge the idea that respect for autonomy is a complete or self-sufficient expression of respect for persons. Furthermore, we suggest that the type of respect that physicians owe to patients is independent of a patient's personal characteristics, and therefore, ought to be accorded equally to all. Finally, the respect that we promote has both a cognitive dimension (believing that patients have value) and a behavioral dimension (acting in accordance with this belief).