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Kampi R, Okello C, Ochieng J, Mwaka ES. Informed consent in cancer clinical care: Perspectives of healthcare professionals on information disclosure at a tertiary institution in Uganda. PLoS One 2024; 19:e0301586. [PMID: 38574007 PMCID: PMC10994281 DOI: 10.1371/journal.pone.0301586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 03/19/2024] [Indexed: 04/06/2024] Open
Abstract
INTRODUCTION While there have been several studies examining the understanding and quality of informed consent in clinical trials of cancer therapies, there is limited empirical research on health practitioners' experiences on the informed consent process in cancer care, especially from low resource settings. This study explored health professionals' perspectives on information disclosure during the consenting process in cancer care. METHODS A qualitative descriptive approach was used to collect data. Face to face interviews were conducted with 10 purposively selected healthcare professionals who were actively involved in soliciting informed consent at a cancer treatment centre in Uganda. A thematic approach was used to interpret the results. RESULTS There were five key themes, and these included information disclosure to patients; assessment of patients' cancer awareness, treatment preferences and expectations; informed consent practices; barriers to optimal informed consent and information disclosure; and recommendations for improving the consenting process. All respondents appreciated the value of disclosing accurate information to patients to facilitate informed decision making. However, the informed consent process was deemed sub-optimal. Respondents asserted that patients should be the psychological wellbeing of patients should be protected by mentally preparing them before disclosing potentially distressing information. All healthcare professionals were appreciative of the central role the family plays in the consenting process. CONCLUSION Overall, informed consent practices were not ideal because of the several challenges. Inadequate time is devoted to information disclosure and patient education; there is lack of privacy; and informed consent documentation is poor. There is a need for significant improvement in informed consent practices and healthcare professional-patient communication.
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Affiliation(s)
- Rebecca Kampi
- School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Joseph Ochieng
- School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Erisa Sabakaki Mwaka
- School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
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Gupta M, Madhavan S, Teo FSY, Low JK, Shelat VG. Perceptions of Singaporeans towards informed consent: a cross-sectional survey. Singapore Med J 2024; 65:91-98. [PMID: 34717299 PMCID: PMC10942135 DOI: 10.11622/smedj.2021163] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/26/2021] [Indexed: 02/05/2023]
Abstract
INTRODUCTION In a patient-centric health system, it is essential to know patients' views about informed consent. The objective of this study was to understand the perceptions of the local population regarding informed consent. METHODS Spanning 6 weeks from January 2016 to March 2016, a cross-sectional survey of adults attending the General Surgery outpatient clinics at Tan Tock Seng Hospital was conducted. Sociodemographic data, lifestyle- and health-related information, perception and purpose of consent forms, and decision-making preferences were studied. RESULTS A total of 445 adults participated in the survey. Most participants were aged below 40 years ( n = 265, 60.1%), female ( n = 309, 70.1%) and degree holders ( n = 196, 44.4%). Also, 56.9% of participants wanted to know every possible risk, while 28.3% wanted to know the common and serious risks. On multivariate analysis, age (61-74 years: odds ratio [OR] 11.1, 95% confidence interval [CI] 2.2-56.1, P = 0.004; age >75 years: OR 22.2, 95% CI 1.8-279.1, P = 0.017) was a predictor of not wanting to know any risks. Age also predicted risk of disclosure for death (age 61-74 years: OR 13.4, 95% CI 4.2-42.6, P < 0.001; age >75 years: OR 32.0, 95% CI 4.5-228.0, P = 0.001). Most participants (48.1%) preferred making shared decisions with doctors, and an important predictor was employment status (OR 4.8, 95% CI 1.9-12.2, P = 0.001). CONCLUSION Sociodemographic factors and educational level influence decision-making, and therefore, the informed consent process should be tailored for each patient.
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Affiliation(s)
- Mehek Gupta
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Sudharsan Madhavan
- Ministry of Health Holdings, Nanyang Technological University, Singapore
| | | | - Jee Keem Low
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Vishal G. Shelat
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore
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Abstract
In this narrative medicine essay, an oncologist ruminates over a chemotherapy consent form about the goals of therapy for a young adult whose body is filled with an aggressive cancer most commonly seen in children.
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Affiliation(s)
- Vinayak Venkataraman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Maiwald CA, Rovers C, Janvier A, Sturm H, Michaelis M, Marckmann G, Ehni HJ, Poets CF, Rüdiger M, Franz AR. Parental perspectives about information and deferred versus two-stage consent in studies of neonatal asphyxia. Arch Dis Child Fetal Neonatal Ed 2023; 109:106-111. [PMID: 37648417 PMCID: PMC10804040 DOI: 10.1136/archdischild-2023-325900] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/10/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE The ALBINO Trial (NCT03162653) investigates effects of very early postnatal allopurinol on neurocognitive outcome following perinatal asphyxia where prenatal informed consent (IC) is impossible. Ethically and legally, waiver of consent and/or deferred consent (DC) is acceptable in such an emergency. Short oral/two-step consent (SOC, brief information and oral consent followed by IC) has recently been investigated. METHODS Mixed-methods analysis of parental opinions on DC versus SOC in the context of neonatal asphyxia in a survey at two German centres. Prospective parents (ProP), parents of healthy newborns (PNeo) and parents of asphyxiated infants (PAx) born between 2006 and 2016 were invited. RESULTS 108 of 422 parents participated (ProP:43; PNeo:35; PAx:30). Most parents trusted physicians, wanted preinterventional information and agreed that in emergencies interventions should begin immediately. Intergroup and intragroup variability existed for questions about DC and SOC. In the ALBINO Trial situation, 55% preferred SOC, and 26% reported DC without information might adversely affect their trust. Only 3% reported to potentially take legal action after DC. PAx were significantly more likely to support DC. PAx more frequently expressed positive emotions and appreciation for neonatal research. In open-ended questions, parents gave many constructive recommendations. CONCLUSION In this survey, parents expressed diverse opinions on consent, but the majority preferred SOC over DC. Parents who had experienced emergency admission of their asphyxiated neonates were more trusting. Obtaining parental perspectives is essential when designing studies, while being cognisant that these groups of parents may not represent the opinion of all parents.
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Affiliation(s)
- Christian A Maiwald
- Department of Neonatology, University Children's Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
- Center for Pediatric Clinical Studies (CPCS), University Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Charlotte Rovers
- Department of Neonatology, University Children's Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Annie Janvier
- Department of Pediatrics, Bureau de l'Éthique Clinique, Université de Montréal, Montreal, Québec, Canada
- Division of Neonatology, Research Center, Clinical Ethics Unit, Palliative Care Unit, Unité de recherche en éthique clinique et partenariat famille, CHU Sainte-Justine, Montreal, Québec, Canada
| | - Heidrun Sturm
- Centre for Public Health and Health Services Research, Faculty of Medicine, University Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Martina Michaelis
- Centre for Public Health and Health Services Research, Faculty of Medicine, University Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
- Institute of Occupational and Social Medicine and Health Services Research, University Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Georg Marckmann
- Institute of Ethics, History and Theory of Medicine, Ludwig Maximilians University (LMU) Munich, Munich, Bayern, Germany
| | - Hans-Joerg Ehni
- Institute for Ethics and History of Medicine, Medical Faculty, University of Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Christian F Poets
- Department of Neonatology, University Children's Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Mario Rüdiger
- Clinic for Pediatrics, Department of Neonatology and Pediatric Intensive Care, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Saxony, Germany
| | - Axel R Franz
- Department of Neonatology, University Children's Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
- Center for Pediatric Clinical Studies (CPCS), University Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
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Iijima Y. A survey of informed consent in patients with dementia in the US and Japan. Nagoya J Med Sci 2023; 85:797-806. [PMID: 38155614 PMCID: PMC10751487 DOI: 10.18999/nagjms.85.4.797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/06/2023] [Indexed: 12/30/2023]
Abstract
This study aimed to confirm the reality of family-focused medical treatment of dementia in Japan and the US. It conducted a questionnaire survey on informed consent from patients with dementia among neurologists and psychiatrists in four prefectures in the Tokai Region (Aichi, Gifu, Mie, and Shizuoka) and dementia specialists in the US. Of the responses, 120 (39.7% response rate) and 20 (5.9% response rate) were obtained, respectively. In obtaining informed consent from patients with dementia, 75 Japanese specialists (62.5%) and 16 US specialists (80.0%) regularly assessed patients' decision-making abilities. The majority of specialists in both Japan and the US used the Mini-Mental State Examination and Hierarchic Dementia Scale-Revised, which are widely used for cognitive function assessment. In the survey, 27 Japanese specialists (22.5%) and 10 US specialists (50.0%) had different considerations when obtaining informed consent for participation in research, compared to their medical practice. The majority of Japanese and US specialists obtained informed consent from both the patient and their family.
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Affiliation(s)
- Yoshihiko Iijima
- Department of Bioethics, Fujita Health University, Toyoake, Japan
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Portley M, Sherer C, Wu T, Farren J, Danielian LE, Scholz SW, Traynor BJ, Ward ME, Haselhuhn T, Snyder A, Kwan JY. Cognitive determinants of decisional capacity in neurodegenerative disorders. Ann Clin Transl Neurol 2023; 10:1816-1823. [PMID: 37545108 PMCID: PMC10578892 DOI: 10.1002/acn3.51871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 08/08/2023] Open
Abstract
OBJECTIVE Cognitive contributions to decisional capacity are complex and not well understood. Capacity to consent for research has been linked to executive function, but executive function assessment tools are imperfect. In this study, we examine the relationship between decisional capacity and a newly developed executive function composite score and determine whether cognitive performance can predict impaired decisional capacity. METHODS This is a cross sectional study of participants at the National Institutes of Health with frontotemporal dementia-amyotrophic lateral sclerosis spectrum disorders enrolled between 2017 and 2022. A structured interview tool was used to ascertain research decisional capacity. Study participant Uniform Data Set (v3.0) executive function (UDS3-EF) composite score, Clinical Dementia Rating Scale©, and Neuropsychiatric Inventory was determined. RESULTS A decrease in UDS3-EF composite score significantly increased the odds of impaired decisional capacity (OR = 2.92, 95% CI [1.66-5.13], p = 0.0002). Executive function was most impaired in frontotemporal dementia (-2.86, SD = 1.26) and least impaired in amyotrophic lateral sclerosis (-0.52, SD = 1.25) participants. The UDS3-EF composite score was also strongly correlated to the Clinical Dementia Rating Scale©. INTERPRETATION Decisional capacity is intrinsically related to executive function in neurodegenerative disorders, and executive dysfunction may predict a lack of decisional capacity alerting investigators of the need for additional scrutiny during the informed consent process.
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Affiliation(s)
- Makayla Portley
- National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMarylandUSA
| | - Carolyn Sherer
- National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMarylandUSA
| | - Tianxia Wu
- National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMarylandUSA
| | - Jennifer Farren
- National Heart, Lung, and Blood InstituteNational Institutes of HealthBethesdaMarylandUSA
| | - Laura E. Danielian
- National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMarylandUSA
| | - Sonja W. Scholz
- National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMarylandUSA
| | - Bryan J. Traynor
- National Institute on AgingNational Institutes of HealthBethesdaMarylandUSA
| | - Michael E. Ward
- National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMarylandUSA
| | - Taryn Haselhuhn
- National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMarylandUSA
| | - Allison Snyder
- National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMarylandUSA
| | - Justin Y. Kwan
- National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMarylandUSA
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Hallquist MLG, Borensztein MJ, Coughlin CR, Buchanan AH, Andrew Faucett W, Peay HL, Smith ME, Tricou EP, Uhlmann WR, Wain KE, Ormond KE. Defining critical educational components of informed consent for genetic testing: views of US-based genetic counselors and medical geneticists. Eur J Hum Genet 2023; 31:1165-1174. [PMID: 37308598 PMCID: PMC10545703 DOI: 10.1038/s41431-023-01401-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/22/2023] [Accepted: 05/23/2023] [Indexed: 06/14/2023] Open
Abstract
The Clinical Genome Resource (ClinGen) Consent and Disclosure Recommendation (CADRe) framework proposes that key components of informed consent for genetic testing can be covered with a targeted discussion for many conditions rather than a time-intensive traditional genetic counseling approach. We surveyed US genetics professionals (medical geneticists and genetic counselors) on their response to scenarios that proposed core informed consent concepts for clinical genetic testing developed in a prior expert consensus process. The anonymous online survey included responses to 3 (of 6 possible) different clinical scenarios that summarized the application of the core concepts. There was a binary (yes/no) question asking respondents whether they agreed the scenarios included the minimum necessary and critical educational concepts to allow an informed decision. Respondents then provided open-ended feedback on what concepts were missing or could be removed. At least one scenario was completed by 238 respondents. For all but one scenario, over 65% of respondents agreed that the identified concepts portrayed were sufficient for an informed decision; the exome scenario had the lowest agreement (58%). Qualitative analysis of the open-ended comments showed no consistently mentioned concepts to add or remove. The level of agreement with the example scenarios suggests that the minimum critical educational components for pre-test informed consent proposed in our prior work is a reasonable starting place for targeted pre-test discussions. This may be helpful in providing consistency to the clinical practice of both genetics and non-genetics providers, meeting patients' informational needs, tailoring consent for psychosocial support, and in future guideline development.
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Affiliation(s)
| | - Maia J Borensztein
- Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA
| | - Curtis R Coughlin
- Department of Pediatrics and Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | | | - Holly L Peay
- RTI International, Genomics, Bioinformatics, and Translational Research Center, Raleigh, NC, USA
| | - Maureen E Smith
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Evanston, IL, USA
| | - Eric P Tricou
- Geisinger, Danville, PA, USA
- Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA
| | - Wendy R Uhlmann
- Division of Genetic Medicine, Department of Internal Medicine; Department of Human Genetics; Center for Bioethics & Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Kelly E Ormond
- Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA, USA
- Health Ethics and Policy Lab, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
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Whyte S, Bray L, Brumpton M, Chan HF, Peltz TS, Tamar M, Dulleck U, Hutmacher DW. Factors impacting informed consent in cosmetic breast augmentation. Breast 2023; 68:225-232. [PMID: 36868139 PMCID: PMC9996440 DOI: 10.1016/j.breast.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 01/17/2023] [Accepted: 02/14/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND For women who undergo cosmetic breast augmentation, their post-operative risk assessment may not match their pre-operative understanding of the involved risks and likelihood of revision surgeries. This may be due to the potential issues surrounding whether patients are being fully informed about all possible risks and related financial implications during the consent phases of patient/doctor consultation. METHODS To explore comprehension, risk preference, and perceptions of breast augmentation procedure, we conducted a recorded online experiment with 178 women (18-40 years) who received varying amounts of risk-related information from two experienced breast surgeons in a hypothetical first consultation scenario. RESULTS We find patient's age, self-rated health, income, education level, and openness to experience to be significant factors impacting initial breast augmentation risk preferences (before receiving any risk information). Further, more emotionally stable patients perceived greater breast augmentation risks, were less likely to recommend breast augmentation, and were more likely to acknowledge the likelihood for future revision surgery. After providing women with risk-related information we find increases in risk assessment in all treatment conditions, and that increased amounts of risk information do decrease women's willingness to recommend breast augmentation. But that increased risk information does not appear to increase women's assessment of the likelihood of future revision surgery. Finally, we find some participant individual differences (such as education level, having children, conscientiousness and emotional stability) appear to impact risk assessment post receiving risk information. CONCLUSION Continuous improvement of the informed consent consultation process is vital to optimising patient outcomes efficiently and cost-effectively. Greater acknowledgement and emphasis on disclosure of related risks and financial burden when complications arise is also important. As such, future behavioural research is warranted into the factors impacting women's understanding both prior to and across the BA informed consent process.
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Affiliation(s)
- Stephen Whyte
- School of Economics and Finance, Queensland University of Technology (QUT), 2 George St, Brisbane, QLD, 4001, Australia; Centre for Behavioural Economics, Society & Technology (BEST), Queensland University of Technology (QUT), Brisbane, QLD, 4001, Australia; Centre in Regenerative Medicine, Institute of Health and Biomedical Innovation, Queensland University of Technology (QUT), 60 Musk Avenue, Kelvin Grove, QLD, 4059, Australia; ARC Training Centre for Cell and Tissue Engineering Technologies, Queensland University of Technology (QUT), Brisbane, QLD, 4059, Australia.
| | - Laura Bray
- Centre for Behavioural Economics, Society & Technology (BEST), Queensland University of Technology (QUT), Brisbane, QLD, 4001, Australia; ARC Training Centre for Cell and Tissue Engineering Technologies, Queensland University of Technology (QUT), Brisbane, QLD, 4059, Australia; School of Mechanical, Medical and Process Engineering, Science and Engineering Faculty, Queensland University of Technology (QUT), 2 George St, Brisbane, QLD, 4001, Australia
| | - Martin Brumpton
- Centre for Behavioural Economics, Society & Technology (BEST), Queensland University of Technology (QUT), Brisbane, QLD, 4001, Australia; Behavioural Economics Team of the Australian Government (BETA), Department of Prime Minister & Cabinet, Canberra, Australia
| | - Ho Fai Chan
- School of Economics and Finance, Queensland University of Technology (QUT), 2 George St, Brisbane, QLD, 4001, Australia; Centre for Behavioural Economics, Society & Technology (BEST), Queensland University of Technology (QUT), Brisbane, QLD, 4001, Australia
| | - Tim S Peltz
- Surgical and Orthopaedic Research Laboratories, Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Manisha Tamar
- Centre for Behavioural Economics, Society & Technology (BEST), Queensland University of Technology (QUT), Brisbane, QLD, 4001, Australia; Queensland University of Technology (QUT), 2 George St, Brisbane, QLD 4001, Australia
| | - Uwe Dulleck
- School of Economics and Finance, Queensland University of Technology (QUT), 2 George St, Brisbane, QLD, 4001, Australia; Centre for Behavioural Economics, Society & Technology (BEST), Queensland University of Technology (QUT), Brisbane, QLD, 4001, Australia; ARC Training Centre for Cell and Tissue Engineering Technologies, Queensland University of Technology (QUT), Brisbane, QLD, 4059, Australia
| | - Dietmar W Hutmacher
- Centre for Behavioural Economics, Society & Technology (BEST), Queensland University of Technology (QUT), Brisbane, QLD, 4001, Australia; ARC Training Centre in Additive Biomanufacturing, Queensland University of Technology, Brisbane, QLD, 4059, Australia; ARC Training Centre for Multiscale 3D Imaging, Modelling and Manufacturing, Queensland University of Technology, Brisbane, QLD, 4059, Australia
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Cancino Jiménez DC, Cancino Jiménez JI. [Ethical aspects in the assent of adolescents to participate in research]. Andes Pediatr 2023; 94:104-111. [PMID: 37906877 DOI: 10.32641/andespediatr.v94i1.4516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/07/2022] [Indexed: 11/02/2023]
Abstract
OBJECTIVE to describe the ethical aspects to be considered in the consent of adolescents to participate in research. MATERIAL AND METHOD A narrative review was conducted in the scientific databases PUBMED and BVS, between 2010-2021, the search was conducted in English, and MeSH and DeCS descriptors were used, obtaining a total sample of 12 articles selected for analysis. RESULTS Age was commonly used instead of directly assessing the ability to understand the issues and make an informed decision about participating in research. This ability is influenced by age, context, and development. Adolescent decision-making is substantially different in the presence of peers. A balance is needed between recognizing the emerging autonomy in adolescents, their differential developmental rhythms, and their not yet fully mature response to personal risk. CONCLUSIONS It is necessary to generate responses and strategies that safeguard both safety and respect for adolescents, focusing on the characteristics of both the age group and the individual, unifying valid mechanisms for determining the capacity to consent, integrating criteria from the sciences regarding cognition, maturation and development, psychology and ethics.
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Abstract
According to a standard account of patient decision-making capacity (DMC), patients can provide ethically valid consent or refusal only if they are able to understand and appreciate their medical condition and can comparatively evaluate all offered treatment options. We argue instead that some patient refusals can be capacitated, and therefore ethically authoritative, without meeting the strict criteria of this standard account-what we call comparative DMC. We describe how patients may possess burdens-based DMC for refusal if they have an overriding objection to at least one burden associated with each treatment option or goals-based DMC for refusal if they have an overriding goal that is inconsistent with treatment. The overridingness of a patient's objections to burdens, or of their commitment to a goal, can justify the moral authority of their refusal, even when a patient lacks some of the cognitive capacities that standard accounts of DMC involve.
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Affiliation(s)
- Mark Christopher Navin
- Oakland University
- Beaumont Hospital - Royal Oak
- Oakland University William Beaumont School of Medicine
| | - Abram L Brummett
- Beaumont Hospital - Royal Oak
- Oakland University William Beaumont School of Medicine
| | - Jason Adam Wasserman
- Beaumont Hospital - Royal Oak
- Oakland University William Beaumont School of Medicine
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Mackie TI, Schaefer AJ, Palatucci JS, Leslie LK, Crystal S, Gusmano M, Karpman HE. The Role of Formal Policy to Promote Informed Consent of Psychotropic Medications for Youth in Child Welfare Custody: A National Examination. Adm Policy Ment Health 2022; 49:986-1003. [PMID: 35932357 PMCID: PMC9616785 DOI: 10.1007/s10488-022-01212-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 01/25/2023]
Abstract
Active participation of youth and surrogate decision-makers in providing informed consent and assent for mental health treatment is critical. However, the procedural elements of an informed consent process, particularly for youth in child welfare custody, are not well defined. Given calls for psychotropic medication oversight for youth in child welfare custody, this study proposes a taxonomy for the procedural elements of informed consent policies based upon formal and informal child welfare policies and then examines whether enacted state formal policies across the United States endorsed these elements. A sequential multi-method study design included: (1) semi-structured interviews with key informants (n = 58) primarily from state child welfare agencies to identify a taxonomy of procedural elements for informed consent of psychotropic medications and then (2) a legislative review of the 50 states and D.C. to characterize whether formal policies endorsed each procedural element through February 2022. Key informants reported five procedural elements in policy, including how to: (1) gather social and medical history, (2) prescribe the medication, (3) authorize its use through consent and youth assent, (4) notify relevant stakeholders, and (5) routinely review the consenting decision. Twenty-three states endorsed relevant legislation; however, only two states specified all five procedural elements. Additionally, the content of a procedural element, when included, varied substantively across policies. Further research and expert consensus are needed to set best practices and guide policymakers in setting policies to advance transparency and accountability for informed consent of mental health treatment among youth in child welfare custody.
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Affiliation(s)
- Thomas I Mackie
- Department of Health Policy and Management, SUNY Downstate Health Sciences University School of Public Health, 450 Clarkson Ave, Brooklyn, NY, 11203, USA.
| | - Ana J Schaefer
- Department of Health Policy and Management, SUNY Downstate Health Sciences University School of Public Health, 450 Clarkson Ave, Brooklyn, NY, 11203, USA
| | - John S Palatucci
- Rutgers School of Public Health, 683 Hoes Lane W, Piscataway, NJ, 08854, USA
| | - Laurel K Leslie
- American Board of Pediatrics, Chapel Hill, NC, USA
- Tufts University School of Medicine, 136 Harrison Ave, Boston, MA, 02111, USA
| | - Stephen Crystal
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, 112 Paterson Street, New Brunswick, NJ, 08901, USA
| | - Michael Gusmano
- College of Health, Lehigh University, 27 Memorial Drive, Bethlehem, PA, 18015, USA
| | - Hannah E Karpman
- Smith College, North Hampton, MA, 01062, USA
- University of Massachusetts Chan Medical School, Shiver Center, 55 N Lake Ave, Worcester, 01655, USA
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Shepherd V. (Re)Conceptualising 'good' proxy decision-making for research: the implications for proxy consent decision quality. BMC Med Ethics 2022; 23:75. [PMID: 35850682 PMCID: PMC9294776 DOI: 10.1186/s12910-022-00809-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 07/06/2022] [Indexed: 11/18/2022] Open
Abstract
People who are unable to make decisions about participating in research rely on proxies to make a decision based on their wishes and preferences. However, patients rarely discuss their preferences about research and proxies find it challenging to determine what their wishes would be. While the process of informed consent has traditionally been the focus of research to improve consent decisions, the more conceptually complex area of what constitutes 'good' proxy decision-making for research has remained unexplored. Interventions are needed to improve and support proxy decision-making for research but are hampered by a lack of understanding about what constitutes decision quality in this context. A global increase in conditions associated with cognitive impairment such as dementia has led to an urgent need for more research into these conditions. The COVID-19 pandemic and subsequent necessity to conduct research with large numbers of critically ill patients has made this need even more pressing. Much of the empirical research centres on the desire to improve decision accuracy, despite growing evidence that authenticity is more reflective of the aim of proxy decisions and concerns about the methodological flaws in authenticity-focused studies. Such studies also fail to take account of the impact of decision-making on proxies, or the considerable body of research on improving the quality of healthcare decisions. This paper reports a concept synthesis of the literature that was conducted to develop the first conceptualisation of 'good' proxy decisions about research participation. Elements of decision quality were identified across three stages of decision-making: proxy preparedness for decision-making which includes knowledge and understanding, and values clarification and preference elicitation; the role of uncertainty, decisional conflict, satisfaction and regret in the decision-making process; and preference linked outcomes and their effect. This conceptualisation provides an essential first step towards the future development of interventions to enhance the quality of proxy decision-making and ensure proxy decisions represent patients' values and preferences.
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Affiliation(s)
- Victoria Shepherd
- Centre for Trials Research, Cardiff University, 4th Floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 0GB, UK.
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Jones LA, Nelder JR, Fryer JM, Alsop PH, Geary MR, Prince M, Cardinal RN. Public opinion on sharing data from health services for clinical and research purposes without explicit consent: an anonymous online survey in the UK. BMJ Open 2022; 12:e057579. [PMID: 35477868 PMCID: PMC9058801 DOI: 10.1136/bmjopen-2021-057579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES UK National Health Service/Health and Social Care (NHS/HSC) data are variably shared between healthcare organisations for direct care, and increasingly de-identified for research. Few large-scale studies have examined public opinion on sharing, including of mental health (MH) versus physical health (PH) data. We measured data sharing preferences. DESIGN/SETTING/INTERVENTIONS/OUTCOMES Pre-registered anonymous online survey, measuring expressed preferences, recruiting February to September 2020. Participants were randomised to one of three framing statements regarding MH versus PH data. PARTICIPANTS Open to all UK residents. Participants numbered 29 275; 40% had experienced an MH condition. RESULTS Most (76%) supported identifiable data sharing for direct clinical care without explicit consent, but 20% opposed this. Preference for clinical/identifiable sharing decreased with geographical distance and was slightly less for MH than PH data, with small framing effects. Preference for research/de-identified data sharing without explicit consent showed the same small PH/MH and framing effects, plus greater preference for sharing structured data than de-identified free text. There was net support for research sharing to the NHS, academic institutions, and national research charities, net ambivalence about sharing to profit-making companies researching treatments, and net opposition to sharing to other companies (similar to sharing publicly). De-identified linkage to non-health data was generally supported, except to data held by private companies. We report demographic influences on preference. A majority (89%) supported a single NHS mechanism to choose uses of their data. Support for data sharing increased during COVID-19. CONCLUSIONS Support for healthcare data sharing for direct care without explicit consent is broad but not universal. There is net support for the sharing of de-identified data for research to the NHS, academia, and the charitable sector, but not the commercial sector. A single national NHS-hosted system for patients to control the use of their NHS data for clinical purposes and for research would have broad support. TRIAL REGISTRATION NUMBER ISRCTN37444142.
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Affiliation(s)
- Linda A Jones
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Jenny R Nelder
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Joseph M Fryer
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | | | | | | | - Rudolf N Cardinal
- Department of Psychiatry, University of Cambridge, Cambridge, UK
- Liaison Psychiatry Service, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
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Schupmann W, Li X, Wendler D. Do the Potential Medical Benefits of Phase 1 Pediatric Oncology Trials Justify the Risks? Views of the United States Public. J Pediatr 2021; 238:249-258.e3. [PMID: 34144034 PMCID: PMC8551010 DOI: 10.1016/j.jpeds.2021.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 06/03/2021] [Accepted: 06/09/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To assess the US public's views on whether the potential medical benefits of phase 1 pediatric oncology trials justify the risks. STUDY DESIGN Online survey of a nationally representative sample of US adults. Participants were presented with a hypothetical scenario in which they have a 10-year-old child with advanced cancer. They were then offered the option of giving their child supportive care or trying one more potential treatment, in the research or clinical care setting, which has the same risks and potential medical benefits as the average phase 1 pediatric oncology trial. We assessed what percentage of respondents thought the potential medical benefits justify the risks. RESULTS In total, 1658 of the 2508 individuals who were sent the survey participated (response rate = 66.1%). Of those who passed all 3 test questions indicating understanding, 67.1% in the research scenario and 58.5% in the clinical care scenario regarded the potential medical benefits of an average phase 1 pediatric oncology trial as equal to or greater than the risks. In addition, 53.4% of respondents in the research scenario thought it was appropriate for researchers to conduct a study in children with these risks and potential medical benefits, and 46.9% stated they would enroll their own child in such a trial. CONCLUSIONS A majority of the US public regards the potential medical benefits of average phase 1 pediatric oncology trials as justifying the risks. This finding suggests that these trials are ethically appropriate and approvable in patients who have no more effective treatment options. At the same time, a significant minority thought the potential medical benefits do not justify the risks, suggesting these trials should be approved only when they have significant social value. Moreover, approximately one-half of respondents regarded the trials as inappropriate and would not enroll their own child, underscoring the need for a rigorous informed consent process that accurately educates parents regarding the risks, potential medical benefits, and alternatives, so they can decide whether to enroll their child based on their own preferences and goals.
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Affiliation(s)
- Will Schupmann
- Department of Bioethics, NIH Clinical Center, Bethesda, MD
| | - Xiaobai Li
- Biostatistics and Clinical Epidemiology Service, NIH Clinical Center, Bethesda, MD
| | - David Wendler
- Department of Bioethics, NIH Clinical Center, Bethesda, MD.
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Lapid MI, Clarke BL, Ho JB, Ouellette Y, Armbrust TL, Wright RS. Research Involving Participants With Impaired Consent Capacity: An Examination of Methods to Determine Capacity to Consent. Mayo Clin Proc 2021; 96:2806-2822. [PMID: 34736608 DOI: 10.1016/j.mayocp.2021.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 03/24/2021] [Accepted: 04/29/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To examine methods of assessing consent capacity in research protocols involving participants with impaired consent capacity, and examine instruments used to evaluate research consent capacity. METHODS A retrospective review of 330 active research protocols involving participants lacking capacity to consent over a 10-year period (January 1, 2009, through March 1, 2019) was conducted to collect protocol characteristics (medical specialty, level of risk and type of study, consent and assent procedures, and type of vulnerable or protected population). Methods to assess consent capacity are described, and instruments to assess consent capacity are summarized. RESULTS The specialties most frequently involving participants with impaired consent capacity in research were Neurology (27.3%), Critical Care (16.7%), and Surgery (10%). Type of studies are observational (43.9%), clinical trials (33%), chart review (11.5%), biobank (6.1%), and biomarker (5.5%). Minimal risk (53.3%) outnumbered greater than minimal risk (46.7%) studies. Most obtained written informed consent (77%) and assent (40.9%). The most common method to assess consent capacity was direct assessment by investigators (32.7%). Only 86 (26%) studies used instruments to assess consent capacity. Of the 13 instruments used, the most common was the Evaluation of Decision-Making Capacity for Consent to Act as a Research Subject, and is the only instrument that assesses all four components of decisional capacity: understanding, appreciation, reasoning, and choice. CONCLUSION Generally, there was lack of uniformity in determining capacity to consent to research participation. Very few studies used instruments to assess consent capacity. Institutional review boards can provide greater guidance for research consent capacity determination.
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Affiliation(s)
- Maria I Lapid
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN; Mayo Clinic Institutional Review Board and Office of Human Research Protection Program, Mayo Clinic, Rochester, MN.
| | - Bart L Clarke
- Department of Internal Medicine, Division of Endocrinology, Mayo Clinic, Rochester, MN; Mayo Clinic Institutional Review Board and Office of Human Research Protection Program, Mayo Clinic, Rochester, MN
| | - Jacqueline B Ho
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN; Mayo Clinic Undergraduate Research Employment Program, Mayo Clinic, Rochester, MN
| | - Yves Ouellette
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN; Mayo Clinic Institutional Review Board and Office of Human Research Protection Program, Mayo Clinic, Rochester, MN
| | - Tamyra L Armbrust
- Mayo Clinic Institutional Review Board and Office of Human Research Protection Program, Mayo Clinic, Rochester, MN
| | - R Scott Wright
- Department of Cardiology, Mayo Clinic, Rochester, MN; Mayo Clinic Institutional Review Board and Office of Human Research Protection Program, Mayo Clinic, Rochester, MN
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Affiliation(s)
- Sonia Saxena
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Helen Skirrow
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Helen Bedford
- Department of Population Policy and Practice, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Kate Wighton
- Communications and Public Affairs, Imperial College London, London, UK
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Metwally AM, Amer HA, Salama HI, Abd El Hady SI, Alam RR, Aboulghate A, Mohamed HA, Badran HM, Saadallah AA, El-Sonbaty MM, Eltahlawy E, Saad W, Mohsen A, Abdel-Latif GA, Fathy AM, Hassanain AI, Eldali A. Egyptian patients'/guardians' experiences and perception about clinical informed consent and its purpose: Cross sectional study. PLoS One 2021; 16:e0252996. [PMID: 34125842 PMCID: PMC8202917 DOI: 10.1371/journal.pone.0252996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 05/27/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Informed consent (IC) is a healthcare standard emphasizing the meaning of human dignity as clarified in the Universal Declaration of Human Rights. Data about IC practices in Egypt is insufficient. This study aimed to assess the Egyptian patients'/guardians' experiences about IC and their expectations about its practices' purposes in general and according to the type of the healthcare facility. METHODS Self-administered questionnaire was carried out for 1092 participants who had undergone or were scheduled to a procedure requiring an IC at three studied types for Egyptian health care facilities. Ten statements were ranked twice by the participants to reflect their perception of IC purpose as per what is currently practiced and what they believe should be practiced. RESULTS IC implementation varies significantly (p<0.05) across the health care facilities in Egypt. The percentage of its implementation at the non-governmental facilities, governmental facilities, and university hospital was 85.9%, 77.8%, and 63.8 respectively. The first three ranked purposes of the current IC practices were: "Helping patient/guardian decide (64.9%)", "Documenting patient's/guardian's decision (59.3%)", and "Having shared decision (57.3%)". The perceived purposes of IC to be practiced were: "Informing the patient/guardian (68.4%)", "Making sure patient/guardian understand (65.3%)" and "Documenting patients/guardians decisions (65.1%)". "Being a meaningless routine" was reported by the majority to be ranked as a low purpose for IC current and preferred practices. CONCLUSION The practice of IC is common within the Egyptian medical community. Participants believe that information disclosure "Making sure patients understand" has to help in IC decision making and its main purpose. However, unfortunately, this is not perceived as a current purpose of IC. There was consensus agreement that documenting the patient's/guardian's decision and informing the patient/guardian are perceived as both important current and preferred purposes for IC practices.
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Affiliation(s)
- Ammal M. Metwally
- Medical Research Division, Community Medicine Research Department, National Research Centre, Dokki, Cairo, Egypt
| | - Hala A. Amer
- Medical Research Division, Community Medicine Research Department, National Research Centre, Dokki, Cairo, Egypt
- Department of Infection Control, King Saud Medical City, Riyadh, KSA
| | - Hend I. Salama
- National Blood Transfusion Services Mansoura Region, Ministry of Health and Population, Egypt
| | | | - Raefa R. Alam
- Faculty of Nursing, Mansoura University, Mansoura, Egypt
- Egyptian Liver Research Institute And Hospital (ELRIAH), Mansoura, Egypt
| | - Ahmed Aboulghate
- Medical Research Division, Community Medicine Research Department, National Research Centre, Dokki, Cairo, Egypt
| | - Hanan A. Mohamed
- Faculty of Nursing, Mansoura University, Mansoura, Egypt
- Egyptian Liver Research Institute And Hospital (ELRIAH), Mansoura, Egypt
| | - Hanan M. Badran
- Faculty of Nursing, Mansoura University, Mansoura, Egypt
- Egyptian Liver Research Institute And Hospital (ELRIAH), Mansoura, Egypt
| | - Amal A. Saadallah
- King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Marwa M. El-Sonbaty
- Medical Research Division, Child Health Department, National Research Centre, Cairo, Egypt
- Department of Pediatrics, College of Medicine, Taibah University, Madinah, K.S.A
| | - Eman Eltahlawy
- Environmental Research Division, Environmental Health and Occupational Medicine, National Research Centre, Egypt
| | - Walaa Saad
- Department of biological anthropology, National Research Centre, Egypt, Cairo, Egypt
| | - Amira Mohsen
- Medical Research Division, Community Medicine Research Department, National Research Centre, Dokki, Cairo, Egypt
| | - Ghada A. Abdel-Latif
- Medical Research Division, Community Medicine Research Department, National Research Centre, Dokki, Cairo, Egypt
| | - Asmaa M. Fathy
- Medical Research Division, Community Medicine Research Department, National Research Centre, Dokki, Cairo, Egypt
| | - Amal I. Hassanain
- Medical Research Division, Child Health Department, National Research Centre, Cairo, Egypt
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Affiliation(s)
- Gregory W Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
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Maher DI, Serpell JW, Ayton D, Lee JC. Patient Reported Experience on Consenting for Surgery - Elective Versus Emergency Patients. J Surg Res 2021; 265:114-121. [PMID: 33901840 DOI: 10.1016/j.jss.2021.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/05/2021] [Accepted: 03/16/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Informed consent for surgery is a medical and legal requirement, but completing these does not necessarily translate to high patient satisfaction. This patient-reported experience study aimed to examine the surgical consent process, comparing the patients' experience in elective and emergency settings. METHODS Over a 6-mo period, postoperative patients at The Alfred Hospital Breast and Endocrine Surgical Unit were invited to participate in a survey on the surgical consent process - including perceived priorities, information provided and overall experience. Standard statistical techniques were used, with a significant P-value of < 0.05. RESULTS A total of 412 patients were invited, with 130 (32%) responses. More patients underwent elective surgery (N= 90, 69%) than emergency surgery (N = 40, 31%). Emergency patients were more likely to sign the consent form regardless of its contents (93% versus 39%, P < 0.001) and more likely to be influenced by external pressures (63% versus 1%, P < 0.001). Elective patients were more likely to want to discuss their surgery with a senior surgeon (74% versus 23%, P < 0.001) and more likely to seek advice from external sources (83% versus 10%, P < 0.001). Both groups highly valued the opportunity to ask questions (67% versus 63%, P = 0.65). CONCLUSION This study shows patients have a range of different priorities in preparation for surgery. Therefore, each consent process should be patient-specific, and focus on providing the patient with quality resources that inform decision-making.
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Affiliation(s)
- Dominic I Maher
- Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jonathan W Serpell
- Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Darshini Ayton
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - James C Lee
- Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, Monash University, Melbourne, Victoria, Australia.
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Machin H, Sutton G, Baird PN. Should Donors Consent to Export Their Corneas? Examination of Eye Tissue and Eye Care Sector Opinion. Cornea 2021; 40:398-403. [PMID: 33252381 DOI: 10.1097/ico.0000000000002559] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/23/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Corneal tissue international activity is only possible because of the willingness of export populations to donate their corneas on their death. Current predonation public education campaigns and at-the-point-of-donation consent practice generally includes consent for transplantation, research, and/or training. It is unclear whether a consent-for-export step is universally included in the consent process or, indeed, whether it should. We interviewed eye tissue and eye care professionals from around the world, who exported, imported, or did neither to understand current consent-for-export awareness and determine opinion on future practice. METHOD During wider qualitative grounded-theory semistructured interviews with sector experts, to determine whether Australia should export, we captured sector opinion on consent-for-export. We used saturation and sentiment methods to determine opinion and χ2 correlation coefficients to examine association, using an α of P = 0.05. RESULTS We interviewed 92 individuals, 83 of whom discussed consent-for-export. Of those, 51% (42/83) demonstrated some awareness of the practice; however, there were contradictions between interviewees from the same location. Regardless of current awareness, 57% (41/72) believed donors should be informed or consented for export. Their approval did not extend to donor-directed decisions, which would allow donors to decide which nation their donation should be sent, with 62.5% (45/72) opposing that notion. CONCLUSIONS Our research indicates that the consent-for-export practice is not universally applied by exporting nations and that eye tissue and eye care professionals have limited awareness of the practice. Universally implementing a consent-for-export step within general consent practice would improve awareness, reduce confusion, and support donor wishes.
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Affiliation(s)
- Heather Machin
- Lions Eye Donation Service, Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
- Department of Surgery, Ophthalmology, University of Melbourne, Melbourne, Victoria, Australia
| | - Gerard Sutton
- The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia; and
- The University of Technology Sydney, Graduate School of Health, Sydney, New South Wales, Australia
| | - Paul N Baird
- Department of Surgery, Ophthalmology, University of Melbourne, Melbourne, Victoria, Australia
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Spinsanti S. [Imagine a new relationship of trust in medicine.]. Recenti Prog Med 2021; 112:13-14. [PMID: 33512352 DOI: 10.1701/3525.35117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Informed consent for CoViD-19 vaccines can be considered a step that can help us focus on an increasingly burdensome problem for contemporary medicine: the difficult relationship of trust between citizens and academic medicine. Filling out forms full of useless information cannot replace the rebuilding of trust based on shared essential ethical principles. Trust needs to be protected by a transparent accountability, which can also decrease the threatening looming of lawsuits. Medicine must be safe, first and foremost, for the practitioner. He cannot practice it if he feels constantly in check, if the outcome of the treatment does not correspond to the wishes of those who request it.
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Wagner L, Frisch M, Turner-Brown L, Andrews S, Edwards A, Moultrie R, Alvarez Rivas A, Wheeler A, Raspa M. Preferences for the research use of electronic health records among young adults with fragile X syndrome or autism spectrum disorder. Disabil Health J 2020; 13:100927. [PMID: 32360031 PMCID: PMC7541430 DOI: 10.1016/j.dhjo.2020.100927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 03/03/2020] [Accepted: 03/25/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Health researchers are increasingly using electronic health records (EHRs) to study the health care needs of people with neurodevelopmental disorders (NDDs). However, little is known about the preferences of people with NDDs for sharing EHRs for research. OBJECTIVE To explore preferences for sharing EHRs for research among young adults ages 18-40 who make their own legal decisions and who have autism spectrum disorder (ASD), fragile X syndrome (FXS), or no NDDs. METHODS We conducted a qualitative study with seven focus groups: 2 ASD groups, 3 FXS groups, and 2 no-NDD groups. We asked participants about factors that could affect their willingness to share their EHRs for research: type of organization, type of information, study purpose, duration, contact frequency, return of results, benefits, and risks. We analyzed the qualitative data using directed content analysis. RESULTS Participants with NDDs valued personally relevant and directly beneficial EHR research. Participants with NDDs expressed willingness to share sensitive data if the study was personally relevant. Most participants wanted to receive results, but only participants with FXS indicated it would affect their willingness to participate. Participants were concerned about privacy risks, discrimination, researcher misconduct, and financial conflicts of interest. CONCLUSION This study provides initial evidence suggesting that young adults with NDDs prefer EHR research that is personally relevant, benefits themselves and their communities, and is conducted in the context of trusting, reciprocal participant-researcher relationships. The findings point to the need for researchers to improve the informed consent process and to better engage individuals with NDDs in research.
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Affiliation(s)
- Laura Wagner
- RTI International, Research Triangle Park, NC, United States.
| | - MaryKate Frisch
- University of North Carolina TEACCH Autism Program, Chapel Hill, NC, United States.
| | - Lauren Turner-Brown
- University of North Carolina TEACCH Autism Program, Chapel Hill, NC, United States.
| | - Sara Andrews
- RTI International, Research Triangle Park, NC, United States.
| | - Anne Edwards
- RTI International, Research Triangle Park, NC, United States.
| | | | - Alexandra Alvarez Rivas
- University of North Carolina, Carolina Institute for Developmental Disabilities, Chapel Hill, NC, United States.
| | - Anne Wheeler
- RTI International, Research Triangle Park, NC, United States.
| | - Melissa Raspa
- RTI International, Research Triangle Park, NC, United States.
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Furlong A. Consenting and Assenting to Psychoanalytic Work. J Am Psychoanal Assoc 2020; 68:583-613. [PMID: 32927986 DOI: 10.1177/0003065120954353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The moment is opportune for a renewed look at what we understand about patient consent to treatment. Until recently, little reference to informed consent could be found in the literature, as though it has never been a preoccupation for psychoanalytic practitioners. Yet several post-Freudian authors offer reasons to suppose the risk of misunderstandings about consent. In fact, the very discovery of transference, replete with unrequited infantile wishes, implies that at some level, at some moment, in every psychoanalytic treatment there will be moments when "consent" will to some extent vacillate. A distinction, justifiable on etymological and intersubjective grounds, is made between patients' consent as a cognitive, somewhat passive, acceptance and patients' assent as an arduous, conflicted, partial disagreement with the symbolically limiting details of analytic work. It is in the discovery and working through of unexpected unconscious responses to aspects of the analytic setting and to the analyst that patients become "informed" of the unique risks to their psychic equilibrium the process poses, as well as its benefits. Instead of a static and unitary contractual event, informed consent in psychoanalysis is more properly conceived as a multilayered, repetitively posed, and necessarily ambivalent process of good-enough assenting over time.
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Kraft SA, Porter KM, Duenas DM, Sullivan E, Rowland M, Saelens BE, Wilfond BS, Shah SK. Assessing Parent Decisions About Child Participation in a Behavioral Health Intervention Study and Utility of Informed Consent Forms. JAMA Netw Open 2020; 3:e209296. [PMID: 32735337 PMCID: PMC7395235 DOI: 10.1001/jamanetworkopen.2020.9296] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Obtaining informed consent is an important ethical obligation for clinical research participation that is imperfectly implemented. Research on improving consent processes often focuses on consent forms, but little is known about consent forms' influence on decision-making compared with other types of engagement. OBJECTIVE To evaluate whether parents decide whether to enroll their children in research before or after they receive the consent form. DESIGN, SETTING, AND PARTICIPANTS An online survey of 88 parents who enrolled or declined to enroll their child in a weight management intervention study between January 2, 2018, and June 24, 2019, was conducted; surveys were completed between February 2, 2018, and July 9, 2019. A 31-item survey asked about impressions of the study throughout the enrollment process, timing of enrollment decisions, and decision-making factors. Responses were summarized descriptively and subgroups were compared using the Fisher exact test or χ2 test. MAIN OUTCOMES AND MEASURES Self-reported timing of enrollment decision. RESULTS A total of 106 parents were approached and gave permission for their contact information to be shared with the study team; 22 additional parents declined to allow their information to be shared, and 24 lost contact with the partner study before they could be asked for permission. A total of 88 parents (67 enrollees, 21 decliners) completed the survey (83% participation rate); 79 of 88 reporting gender (instead of sex, as biological sex was not relevant to survey) information were women (91%), 66 participants (75%) were non-Hispanic White, and 63 participants (72%) had annual household incomes greater than or equal to $70 000. No significant differences in respondent characteristics between enrollees and decliners were identified. Fifty-nine parents (67%) responded that they decided whether to enroll in the weight management study before receiving the consent form. Only 17 of 69 parents (25%) who remembered receiving the consent form responded that it taught them new information. CONCLUSIONS AND RELEVANCE The findings of this study suggest that interventions to improve informed consent forms may have limited influence on decision-making because many research decisions occur before review of the consent form. It appears that regulatory review and interventions to improve decision-making should focus more on early engagement (eg, recruitment materials). Future studies should test timing of decisions in other types of research with different populations and clinical settings.
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Affiliation(s)
- Stephanie A. Kraft
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, Washington
- University of Washington School of Medicine, Department of Pediatrics, Seattle
| | - Kathryn M. Porter
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, Washington
| | - Devan M. Duenas
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, Washington
| | - Erin Sullivan
- Seattle Children’s Core for Biomedical Statistics, Seattle Children’s Research Institute, Seattle, Washington
| | - Maya Rowland
- Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, Washington
| | - Brian E. Saelens
- University of Washington School of Medicine, Department of Pediatrics, Seattle
- Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, Washington
| | - Benjamin S. Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, Washington
- University of Washington School of Medicine, Department of Pediatrics, Seattle
| | - Seema K. Shah
- Mary Ann & J. Milburn Smith Child Health Research, Outreach, and Advocacy Center; Stanley Manne Children’s Research Institute; Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Bak MAR, Ploem MC, Ateşyürek H, Blom MT, Tan HL, Willems DL. Stakeholders' perspectives on the post-mortem use of genetic and health-related data for research: a systematic review. Eur J Hum Genet 2020; 28:403-416. [PMID: 31527854 PMCID: PMC7080773 DOI: 10.1038/s41431-019-0503-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 08/07/2019] [Accepted: 08/27/2019] [Indexed: 01/20/2023] Open
Abstract
The majority of biobank policies and consent forms do not address post-mortem use of data for medical research, thus causing uncertainty after research participants' death. This systematic review identifies studies examining stakeholders' perspectives on this issue. We conducted a search in MEDLINE, CINAHL, EMBASE and Web of Science. Findings were categorised in two themes: (1) views on the use of data for medical research after participants' death, and (2) perspectives regarding the post-mortem return of individual genetic research results. An important subtheme was the appropriate authority and degree of control over posthumous use of data. The sixteen included studies all focused on genetic data and used quantitative and qualitative methods to survey perspectives of research participants, family members, researchers and Institutional Review Board members. Acceptability of post-mortem use of data for medical research was high among research participants and their relatives. Most stakeholders thought participants should be informed about post-mortem research uses during initial consent. Between lay persons and professionals, disagreement exists about whether relatives should receive actionable genetic findings, and whether the deceased's previous preferences can be overridden. We conclude that regulations and ethical guidance should leave room for post-mortem use of personal data for research, provided that informed consent procedures are transparent on this issue, including the return of individual research findings to relatives. Future research is needed to explore underlying causes for differences in views, as well as ethical and legal issues on the appropriate level of control by deceased research participants (while alive) and their relatives.
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Affiliation(s)
- Marieke A R Bak
- Section of Medical Ethics, Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - M Corrette Ploem
- Section of Health Law, Department of Social Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Hakan Ateşyürek
- Faculty of Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marieke T Blom
- Department of Cardiology, Heart Center, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Hanno L Tan
- Department of Cardiology, Heart Center, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Dick L Willems
- Section of Medical Ethics, Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Birkeland S. The oral communication principle and coming up to informed decision requirements in national screening programs. Public Health 2020; 182:51-52. [PMID: 32171090 DOI: 10.1016/j.puhe.2020.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 01/08/2020] [Accepted: 01/27/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Informed consent (IC) principles are often overlooked aspects in debates about national screening programs. This short communication examines the Danish approach to IC in decision-making about screening participation. STUDY DESIGN A descriptive approach is adopted in linking present screening practices with Danish regulation about IC and international ethical principles. METHODS To ascertain the extent to which screening procedures come up to IC requirements, the article adopts a review approach by examining relevant Danish national legislation including ministerial orders as well as international ethical codes. RESULTS The article finds that, although Danish legislation as well as international IC principles generally stipulates a decision-making process requiring oral communication, current procedures largely rely on one-way communication through written information available from leaflets, web sites, etc. Screening programs seem to have established no general formula to qualify healthcare users' understanding of data underlying their choice whether to be screened. CONCLUSION The deviance from common IC principles may reduce healthcare quality, pose a safety problem, and challenge healthcare users' ability to exercise autonomy.
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Affiliation(s)
- S Birkeland
- OPEN, Department of Clinical Medicine, University of Southern Denmark, J P Winsløws Vej 9 5000 Odense, Denmark.
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27
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Kong C, Efrem M, Campbell M. Education versus screening: the use of capacity to consent tools in psychiatric genomics. J Med Ethics 2020; 46:137-143. [PMID: 31563871 DOI: 10.1136/medethics-2019-105396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 07/30/2019] [Accepted: 08/01/2019] [Indexed: 06/10/2023]
Abstract
Informed consent procedures for participation in psychiatric genomics research among individuals with mental disorder and intellectual disability can often be unclear, particularly because the underlying ethos guiding consent tools reflects a core ethical tension between safeguarding and inclusion. This tension reflects important debates around the function of consent tools, as well as the contested legitimacy of decision-making capacity thresholds to screen potentially vulnerable participants. Drawing on human rights, person-centred psychiatry and supported decision-making, this paper problematises the use of consent procedures as screening tools in psychiatric genomics studies, particularly as increasing normative emphasis has shifted towards the empowerment and participation of those with mental disorder and intellectual disabilities. We expound on core aspects of supported decision-making, such as relational autonomy and hermeneutic competence, to orient consent procedures towards a more educative, participatory framework that is better aligned with developments in disability studies. The paper concludes with an acknowledgement of the pragmatic and substantive challenges in adopting this framework in psychiatric genomics studies if this participatory ethos towards persons with mental disorder and intellectual disability is to be fully realised.
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Affiliation(s)
- Camillia Kong
- School of Law, Birkbeck University of London Institute for Criminal Policy Research, School of Law, London, UK
| | - Mehret Efrem
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Megan Campbell
- Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Anderson ML, Riker T, Hakulin S, Meehan J, Gagne K, Higgins T, Stout E, Pici-D’Ottavio E, Cappetta K, Wolf Craig KS. Deaf ACCESS: Adapting Consent Through Community Engagement and State-of-the-Art Simulation. J Deaf Stud Deaf Educ 2020; 25:115-125. [PMID: 31782774 PMCID: PMC6951030 DOI: 10.1093/deafed/enz035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/31/2019] [Accepted: 07/31/2019] [Indexed: 06/10/2023]
Abstract
One of the most understudied health disparity populations in the United States is the Deaf community, a sociolinguistic minority group of more than 500,000 individuals who communicate via American Sign Language. Research on Deaf health disparities is lacking due to inaccessible recruitment, sampling, and data collection procedures, as well as the fundamental disconnect between medical and cultural views of Deaf people. A potential starting place for addressing inaccessible research methods and mistrust of the biomedical research community is the careful reconsideration of the traditional informed consent process, often a Deaf individual's first point of contact with the research world. Yet, most Deaf individuals experience obstacles to engaging in informed consent due to differences in language and development compared to hearing individuals. In response to these issues, our team led a three-phase, formative, community-engaged approach to adapt the informed consent process and train research staff in the updated method so that all required components are properly communicated and understood. The goals of our work were to promote Deaf engagement in research about the Deaf community, increase the number of Deaf individuals who participate in general population biomedical research, and generalize our findings to improve research accessibility for the general population.
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Affiliation(s)
| | | | | | | | - Kurt Gagne
- University of Massachusetts Medical School
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Deshpande SN, Mishra NN, Bhatia T, Jakhar K, Goyal S, Sharma S, Sachdeva A, Choudhary M, Shah GD, Lewis-Fernandez R, Jadhav S. Informed consent in psychiatry outpatients. Indian J Med Res 2020; 151:35-41. [PMID: 32134012 PMCID: PMC7055165 DOI: 10.4103/ijmr.ijmr_1036_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Indexed: 01/13/2023] Open
Abstract
Background & objectives Comprehension and process of consent are important for persons with mental illness as they may not be impaired in considering research participation. The American Psychiatric Association developed a detailed Cultural Formulation Interview (CFI). The present study was a part of field testing of CFI, aimed to standardize cultural information affecting the patients' management in India. This paper describes the process and conclusions from the consent-seeking process of this study. Methods The purpose and procedures about field trial of the CFI were introduced and the patient and caregiver were requested for participation. Consent process was carried out step by step, by reading out the consent form to the first new patient of the day in the psychiatry outpatients department of a tertiary care hospital in north India, inviting questions followed by the 'comprehension' questions. The entire process was audiotaped without any personal identifiers. The process was repeated if not comprehended. Results A total of 67 patients consented, 11 refused and majority were educated more than secondary school. Some concerns shown by the patients and caregivers included risk of participation, loss or benefits of participation, privacy, etc. All types of mentally ill patients participated in the study. Interpretation & conclusions Translations of consent forms used simple words, consonant with understanding of the potential participants. Patients' belief that participating in this long process would improve their care, and serve humanity, influenced their decision to participate. Except for intoxication and severe psychosis, patients could understand and comprehend issues around consent. Main issues were confidentiality and culture. Our experience in the psychiatry OPD refutes the commonly held belief that mentally ill persons lack comprehension and ability to consent.
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Affiliation(s)
- Smita N. Deshpande
- Department of Psychiatry, Centre of Excellence in Mental Health, Atal Bihari Vajpayee Institute of Medical Sciences, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | | | - Triptish Bhatia
- Department of Psychiatry, Centre of Excellence in Mental Health, Atal Bihari Vajpayee Institute of Medical Sciences, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Kiran Jakhar
- Department of Psychiatry, Government Institute of Medical Sciences, Noida, Uttar Pradesh, India
| | - Satnam Goyal
- Cambridgeshire & Peterborough NHS Foundation Trust, Fulbourn, London, UK
| | | | - Ankur Sachdeva
- Department of Psychiatry, ESIC Medical College & Hospital, Faridabad, Haryana, India
| | | | - Gyan Deep Shah
- Department of Psychiatry, Centre of Excellence in Mental Health, Atal Bihari Vajpayee Institute of Medical Sciences, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Roberto Lewis-Fernandez
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, USA
| | - Sushrut Jadhav
- Division of Psychiatry, University College London, London, UK
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Woudstra AJ, Smets EMA, Galenkamp H, Fransen MP. Validation of health literacy domains for informed decision making about colorectal cancer screening using classical test theory and item response theory. Patient Educ Couns 2019; 102:2335-2343. [PMID: 31561933 DOI: 10.1016/j.pec.2019.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 08/14/2019] [Accepted: 09/14/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To construct and validate a computer-based and performance-based instrument to assess health literacy skills for informed decision making in colorectal cancer screening among screening invitees. METHODS An instrument was constructed based on a conceptual framework of health literacy skills in colorectal cancer screening and findings from an expert survey. The instrument was field-tested among individuals with low health literacy (n = 28). Its validity and reliability was assessed using classical test theory and item response theory approaches in an online panel of colorectal cancer screening invitees (n = 696). RESULTS Confirmatory factor analysis confirmed four separate factors: Comprehension, Application, Numeracy and Communication. A fifth domain (Appraisal) demonstrated poor reliability and validity and was omitted in further analyses. Internal consistency (Cronbach's alpha > 0.6 for the four scales) was acceptable and test-retest reliability was moderate. The four factors were measurement invariant for age, sex and educational level. CONCLUSION The computer-based measures were acceptable for self-administration. The constructed multidimensional health literacy instrument showed acceptable measurement properties. PRACTICE IMPLICATIONS Our findings imply that the computer-based instrument can be used for the development of interventions to support informed decision making about colorectal cancer screening among individuals with varying health literacy levels. Further research is needed for optimizing performance-based measurement of the Appraisal and Communication domains.
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Affiliation(s)
- Anke J Woudstra
- Amsterdam UMC, University of Amsterdam, Department of Public Health, Amsterdam Public Health Research Institute, Meibergdreef 9, Amsterdam, the Netherlands.
| | - Ellen M A Smets
- Amsterdam UMC, University of Amsterdam, Department of Medical Psychology, Amsterdam Public Health Research Institute, Meibergdreef 9, Amsterdam, the Netherlands.
| | - Henrike Galenkamp
- Amsterdam UMC, University of Amsterdam, Department of Public Health, Amsterdam Public Health Research Institute, Meibergdreef 9, Amsterdam, the Netherlands.
| | - Mirjam P Fransen
- Amsterdam UMC, University of Amsterdam, Department of Public Health, Amsterdam Public Health Research Institute, Meibergdreef 9, Amsterdam, the Netherlands.
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Koch P. The Paradox of Consent for Capacity Assessments. J Law Med Ethics 2019; 47:751-757. [PMID: 31957575 DOI: 10.1177/1073110519897752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The use of decision-making capacity assessments (DMCA) in clinical medicine is an underdeveloped yet quickly growing practice. Despite the ethical and clinical importance of these assessments as a means of protecting patient autonomy, clinicians, philosophers, and ethicists have identified a number of practical and theoretical hurdles which remain unresolved.2 One ethically important yet largely unaddressed issue is whether, and to what extent physicians ought to inform and obtain consent from patients prior to initiating a capacity assessment. In what follows, I address the following question: Must, or should, physicians obtain consent for capacity assessments? I argue that physicians have an ethical obligation to obtain express patient consent for capacity assessments, and in doing so, I challenge the predominant view which requires physicians to merely inform patients without obtaining consent. I then identify an underlying philosophical paradox that complicates the clinician's duty to obtain consent: in short, consent is needed for an assessment of one's ability to consent. Finally, I recommend a practical solution to this paradox of consent for capacity assessments by proposing a model of double consent from both the patient and health care representative.
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Affiliation(s)
- Peter Koch
- Peter Koch, Ph.D., is an assistant professor of philosophy at Villanova University. His research interests include clinical and biomedical ethics, philosophy of law, and philosophy of medicine. Along with experience as a clinical ethics consultant, Peter has published on a range of topics, including patient welfare, the metaphysics of brain death, medical professionalism, and harm in medicine
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Mandarelli G, Parmigiani G, Carabellese F, Codella S, Roma P, Brancadoro D, Ferretti A, Alessandro L, Pinto G, Ferracuti S. Decisional capacity to consent to treatment and anaesthesia in patients over the age of 60 undergoing major orthopaedic surgery. Med Sci Law 2019; 59:247-254. [PMID: 31366276 DOI: 10.1177/0025802419865854] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Despite growing attention to the ability of patients to provide informed consent to treatment in different medical settings, few studies have dealt with the issue of informed consent to major orthopaedic surgery in those over the age of 60. This population is at risk of impaired decision-making capacity (DMC) because older age is often associated with a decline in cognitive function, and they often present with anxiety and depressive symptoms, which could also affect their capacity to consent to treatment. Consent to major orthopaedic surgery requires the patient to understand, retain and reason about complex procedures. This study was undertaken to extend the literature on decisional capacity to consent to surgery and anaesthesia of patients over the age of 60 undergoing major orthopaedic surgery. Recruited patients ( N=83) were evaluated using the Aid to Capacity Evaluation, the Beck Depression Inventory, the State–Trait Anxiety Inventory Y, the Mini-Mental State Examination and a visual analogue scale for measuring pain symptomatology. Impairment of medical DMC was common in the overall sample, with about 50% of the recruited patients showing a doubtful ability, or overt inability, to provide informed consent. Poor cognitive functioning was associated with reduced medical DMC, although no association was found between decisional capacity and depressive, anxiety and pain symptoms. These findings underline the need of an in-depth assessment of capacity in older patients undergoing major orthopaedic surgery.
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Affiliation(s)
| | | | - Felice Carabellese
- Section of Criminology and Forensic Psychiatry, Department of Interdisciplinary Medicine, University of Bari, Italy
| | - Silvia Codella
- Anesthesiology Department, Sant'Andrea Hospital, 'Sapienza' University of Rome, Italy
| | - Paolo Roma
- Department of Human Neurosciences, 'Sapienza' University of Rome, Italy
| | - Domitilla Brancadoro
- Anesthesiology Department, Sant'Andrea Hospital, 'Sapienza' University of Rome, Italy
| | - Andrea Ferretti
- Orthopaedic Unit, Sant'Andrea Hospital, 'Sapienza' University of Rome, Italy
| | | | - Giovanni Pinto
- Anesthesiology Department, Sant'Andrea Hospital, 'Sapienza' University of Rome, Italy
| | - Stefano Ferracuti
- Department of Human Neurosciences, 'Sapienza' University of Rome, Italy
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Abstract
This essay indicates that Confucian family-based ethics is by no means a stumbling block to organ donation in China. We contend that China should not change to an opt-out consent system in order to enhance donation because a "hard" opt-out system is unethical, and a "soft" opt-out system is unhelpful. We argue that the recently-introduced familist model of motivation for organ donation in mainland China can provide a proper incentive for donation. This model, and the family priority right that this model supports, is ethically justifiable in terms of Confucian family-based ethics.
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Affiliation(s)
- Ruiping Fan
- City University of Hong Kong, Hong Kong, PRC
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Abstract
Medical decision-making capacity, the patient's ability to exercise autonomy reasonably, is an essential component of both informed consent and informed refusal. The assessment of medical decision-making capacity is thus fundamental to the ethical practice of medicine. Medical decision-making capacity is not all or nothing but rather exists on a continuum and should be assessed on a decision-by-decision basis. Alzheimer disease and other neurocognitive disorders can affect a patient's medical decision-making capacity and may pose special challenges to capacity assessment. To illustrate some of these challenges, this article presents a case of a patient with Alzheimer disease who refused a recommended operation and discusses the components of capacity, a useful mnemonic and tools, the variability of state laws, and the roles neurologists and psychiatrists play in the assessment of capacity.
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Abstract
IMPORTANCE Patients increasingly demand transparency in and control of how their medical records and biospecimens are shared for research. How much they are willing to share and what factors influence their sharing preferences remain understudied in real settings. OBJECTIVES To examine whether and how various presentations of consent forms are associated with differences in electronic health record and biospecimen sharing rates and whether these rates vary according to user interface design, data recipients, data and biospecimen items, and patient characteristics. DESIGN, SETTING, AND PARTICIPANTS For this survey study, a data and biospecimen sharing preference survey was conducted at 2 academic hospitals from May 1, 2017, to September 31, 2018, after simple randomization of patients to 1 of 4 options with different layout and formats of indicating sharing preferences: opt-in simple, opt-in detailed, opt-out simple, and opt-out detailed. INTERVENTIONS All participants were presented with a list of data and biospecimen items that could be shared for research within the same health care organization or with other nonprofit or for-profit institutions. Participating patients were randomly asked to select the items that they would share (opt-in) or were asked to select items they would not share (opt-out). Patients in these 2 groups were further randomized to select only among 18 categories vs 59 detailed items (simple vs detailed form layout). MAIN OUTCOMES AND MEASURES The primary end points were the percentages of patients willing to share data and biospecimen categories or items. RESULTS Among 1800 eligible participants, 1246 (69.2%) who completed their data sharing survey were included in the analysis, and 850 of these patients (mean [SD] age, 51.1 [16.7] years; 507 [59.6%] female; 677 [79.6%] white) responded to the satisfaction survey. A total of 46 participants (3.7%) declined sharing with the home institution, 352 (28.3%) with nonprofit institutions, and 590 (47.4%) with for-profit institutions. A total of 836 (67.1%) indicated that they would share all items with researchers from the home institution. When comparing opt-out with opt-in interfaces, all 59 sharing choice variables (100%) were associated with the sharing decision. When comparing simple with detailed forms, only 14 variables (23.7%) were associated with the sharing decision. CONCLUSIONS AND RELEVANCE The findings suggest that most patients are willing to share their data and biospecimens for research. Allowing patients to decide with whom they want to share certain types of data may affect research that involves secondary use of electronic health records and/or biosamples for research.
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Affiliation(s)
- Jihoon Kim
- Department of Biomedical Informatics, UC San Diego Health, University of California, San Diego, La Jolla
| | - Hyeoneui Kim
- School of Nursing, Duke University, Durham, North Carolina
| | - Elizabeth Bell
- Office of Graduate Studies and Research, California State University, San Marcos
| | - Tyler Bath
- Department of Biomedical Informatics, UC San Diego Health, University of California, San Diego, La Jolla
| | - Paulina Paul
- Department of Biomedical Informatics, UC San Diego Health, University of California, San Diego, La Jolla
| | - Anh Pham
- Department of Biomedical Informatics, UC San Diego Health, University of California, San Diego, La Jolla
| | - Xiaoqian Jiang
- School of Biomedical Informatics, University of Texas Health Science Center, Houston
| | - Kai Zheng
- Department of Informatics, University of California, Irvine
| | - Lucila Ohno-Machado
- Department of Biomedical Informatics, UC San Diego Health, University of California, San Diego, La Jolla
- Division of Health Services Research and Development, Veterans Affairs San Diego Healthcare System, La Jolla, California
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Dickert NW, Wendler D, Devireddy CM, Goldkind SF, Ko YA, Speight CD, Kim SYH. Consent for Pragmatic Trials in Acute Myocardial Infarction. J Am Coll Cardiol 2019; 71:1051-1053. [PMID: 29495987 DOI: 10.1016/j.jacc.2017.12.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 12/05/2017] [Accepted: 12/11/2017] [Indexed: 11/19/2022]
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Feldman WB, Hey SP, Franklin JM, Kesselheim AS. Public Approval of Exception From Informed Consent in Emergency Clinical Trials: A Systematic Review of Community Consultation Surveys. JAMA Netw Open 2019; 2:e197591. [PMID: 31339546 PMCID: PMC6659147 DOI: 10.1001/jamanetworkopen.2019.7591] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
IMPORTANCE The US Food and Drug Administration (FDA) created the exception from informed consent (EFIC) pathway in 1996 to allow some emergency trials to enroll patients without informed consent. To protect individual autonomy and preserve public trust, the FDA requires that EFIC trial investigators consult with community members before a trial may begin. OBJECTIVES To analyze data from surveys conducted as part of community consultation ahead of EFIC trials and assess levels of public approval. DATA SOURCES All trials granted an EFIC must submit documentation of compliance with EFIC regulations to a publicly available docket at the FDA. Submissions between November 1, 1996, and October 23, 2017, were reviewed. STUDY SELECTION Trials with survey data were included. DATA EXTRACTION AND SYNTHESIS Data were extracted between January 2018 and June 2018 and were analyzed between June 2018 and August 2018. The quality and validity of data were assessed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A random-effects metaregression was used to assess the association of demographic characteristics with EFIC approval. MAIN OUTCOMES AND MEASURES The primary study outcome was EFIC approval. RESULTS The FDA docket contained 15 958 pages of material with survey data for 42 448 individuals submitted by 27 trials. Public approval of EFIC varied by question type, with more people willing to approve initiation of EFIC trials in their community (86.5%) than personal enrollment (73.0%), enrollment of a family member (68.6%), or the principle of enrollment without consent (58.4%) (P < .001 for all comparisons). In the United States, African American individuals made up 29.3% of those enrolled in EFIC trials that reported data on race (5064 of 17 302) but only 16.7% of those surveyed as part of community consultation. In the United States and Canada, men made up 42.9% of the surveyed population but 65.6% of those eventually enrolled in EFIC trials (29 961 of 45 694). Groups surveyed with higher proportions of African American and male respondents had lower rates of EFIC approval. CONCLUSIONS AND RELEVANCE Public approval of EFIC trials varied by question type and by the respondents' reported race and sex. The demographic characteristics of those surveyed did not match the demographic characteristics of EFIC enrollees. The FDA could strengthen community consultation by standardizing survey instruments and reporting, requiring broader inclusion of African American and male respondents, clarifying the function of surveys in the development and modification of trial protocols, and building more public consensus around the acceptable use of EFIC.
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Affiliation(s)
- William B. Feldman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Spencer P. Hey
- Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Harvard Medical School Center for Bioethics, Boston, Massachusetts
| | - Jessica M. Franklin
- Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aaron S. Kesselheim
- Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Harvard Medical School Center for Bioethics, Boston, Massachusetts
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McCarthy KN, Ryan NC, O'Shea DT, Doran K, Greene R, Livingstone V, Ryan CA, Boylan GB, Dempsey EM. Parental opinion of consent in neonatal research. Arch Dis Child Fetal Neonatal Ed 2019; 104:F409-F414. [PMID: 30266759 DOI: 10.1136/archdischild-2018-315289] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 08/28/2018] [Accepted: 08/28/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Neonatal research, particularly neonatal emergency research is a challenging area, notably in relation to obtaining valid prospective informed consent. The aim of this study is to determine parental perceptions of the consent process involved in performing research in newborn care, to explore methods used to obtain consent and their acceptability to parents. METHODS A parental questionnaire was developed that examined attitudes towards research and hypothetical research studies, in which the acceptability of various methods of consent was examined (informed, waived, deferred). These research scenarios were of varying time sensitivity and perceived risk level. The study setting was an Irish maternity hospital. RESULTS There were 600 responses to the questionnaire. In 93% of cases, parents felt that their involvement in the consent process was essential. In emergency situations, 52% felt full prospective informed consent was necessary; however, almost 28% of parents would feel pressure to consent. Most (75%) parents would prefer to be approached to discuss neonatal research studies antenatally, irrespective of study type and 40% of parents felt that neonates involved in research studies received overall better care. Acceptability of deferred consent was greater than waived, and was highest for the more emergency-based scenarios presented. DISCUSSION Parents feel that they should play a central role in research involving their children. There were differences in the acceptability of various consent methods with strongest agreement for informed consent and lowest agreement for waived consent. Parents were more willing to accede to deferred consent in the cardiopulmonary resuscitation scenario study. These findings provide useful insights to consent strategies in future newborn research studies.
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Affiliation(s)
- Karen Nora McCarthy
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, Cork University Maternity Hospital, Cork, Ireland
| | - Niamh C Ryan
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, Cork University Maternity Hospital, Cork, Ireland
| | - Darragh T O'Shea
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, Cork University Maternity Hospital, Cork, Ireland
| | - Kieran Doran
- School of Medicine and Health, University College Cork, Cork, Ireland
| | - Richard Greene
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
| | - Vicki Livingstone
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, Cork University Maternity Hospital, Cork, Ireland
| | - C Anthony Ryan
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, Cork University Maternity Hospital, Cork, Ireland
| | - Geraldine B Boylan
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, Cork University Maternity Hospital, Cork, Ireland
| | - Eugene M Dempsey
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, Cork University Maternity Hospital, Cork, Ireland
- INFANT, Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
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Abstract
The paper argues that the idea of gift-giving and its associated imagery, which has been founding the ethics of organ transplants since the time of the first successful transplants, should be abandoned because it cannot effectively block arguments for (regulated) markets in human body parts. The imagery suggests that human bodies or their parts are transferable objects which belong to individuals. Such imagery is, however, neither a self-evident nor anthropologically unproblematic construal of the relation between a human being and their body. The paper proposes an alternative conceptualization of that relation, the identity view according to which a human being is identical with their living body. This view, which offers a new ethical perspective on some central concepts of transplant medicine and its ethical and legal standards and institutions, supports widely shared intuitive ethical judgments. On this proposal, an act of selling a human body or one of its parts is an act of trade in human beings, not in owned objects. Transfers of human body parts for treatment purposes are to be seen as sharing in another human being's misfortune rather than as giving owned objects. From the perspective of policy-making, the proposal requires, first, that informed consent for removal of transplant material be obtained from the potential benefactor. Secondly, explicit consent by the prospective benefactor is obligatory in the case of removal of transplant material from a living benefactor. Thirdly, in the case of posthumous retrieval, informed consent by the potential benefactor during their life is not ethically indispensable. Additionally, while refusal of posthumous retrieval expressed by a potential benefactor during their life must be respected, such a refusal needs ethical justification and explanation.
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Affiliation(s)
- Paweł Łuków
- Instytut Filozofii, Uniwersytet Warszawski, Krakowskie Przedmieście 3, 00-927, Warsaw, Poland.
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40
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Halpern J, Paolo D, Huang A. Informed consent for early-phase clinical trials: therapeutic misestimation, unrealistic optimism and appreciation. J Med Ethics 2019; 45:384-387. [PMID: 31189726 DOI: 10.1136/medethics-2018-105226] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 03/29/2019] [Accepted: 04/16/2019] [Indexed: 05/24/2023]
Abstract
Unrealistic therapeutic beliefs are very common-the majority of patient-subjects (up to 94%) enrol in phase 1 trials seeking and expecting significant medical benefit, even though the likelihood of such benefit has historically proven very low. The high prevalence of therapeutic misestimation and unrealistic optimism in particular has stimulated debate about whether unrealistic therapeutic beliefs in early-phase clinical trials preclude adequate informed consent. We seek here to help resolve this controversy by showing that a crucial determination of when such therapeutic beliefs are ethically problematic turns on whether they are causally linked and instrumental to the motivation to participate in the trial. Thus, in practice, it is ethically incumbent on researchers to determine which understanding and beliefs lead to the participant's primary motivation for enrolling, not to simply assess understanding, beliefs and motivations independently. We further contend that assessing patient-subjects' appreciation as a component of informed consent-it is already an established component of decision-making capacity assessments-can help elucidate the link between understanding-beliefs and motivation; appreciation refers to an individual's understanding of the personal significance of both the medical facts and the experience of trial participation. Therefore, we recommend that: (1) in addition to the usual question, 'Why do you want to participate in this trial?', all potential participants should be asked the question: 'What are you giving up by participating in this trial?' and (2) researchers should consider the settings in which it may be possible and practical to obtain 'two-point consent'.
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Affiliation(s)
- Jodi Halpern
- School of Public Health, University of California Berkeley, Berkeley, California, USA
| | - David Paolo
- School of Public Health, University of California Berkeley, Berkeley, California, USA
| | - Andrew Huang
- Department of Neurology, University of Rochester, Rochester, New York, USA
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41
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Abstract
Data documenting poor understanding among research participants and real-time efforts to assess comprehension in large-scale studies are focusing new attention on informed consent comprehension. Within the context of biobanking consent, we previously convened a multidisciplinary panel to reach consensus about what information must be understood for a prospective participant's consent to be considered valid. Subsequently, we presented them with data from another study showing that many U.S. adults would fail to comprehend the information the panel had deemed essential. When asked to evaluate the importance of the information again, panelists' opinions shifted dramatically in the direction of requiring that less information be understood. Follow-up interviews indicated significant uncertainty about defining a threshold of understanding and what should happen when prospective participants are unable to grasp key information. These findings have important implications for urgently needed discussion of whether consent comprehension is an ethical requirement or an ethical aspiration.
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Affiliation(s)
- Laura M. Beskow
- Center for Biomedical Ethics and Society and Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN USA
| | - Kevin P. Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC USA
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42
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Wada K, Charland LC, Bellingham G. Can women in labor give informed consent to epidural analgesia? Bioethics 2019; 33:475-486. [PMID: 30358905 DOI: 10.1111/bioe.12517] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 06/20/2018] [Accepted: 07/27/2018] [Indexed: 06/08/2023]
Abstract
There are reasons to believe that decision-making capacity (mental competence) of women in labor may be compromised in relation to giving informed consent to epidural analgesia. Not only severe labor pain, but also stress, anxiety, and premedication of analgesics such as opioids, may influence women's decisional capacity. Decision-making capacity is a complex construct involving cognitive and emotional components which cannot be reduced to 'understanding' alone. A systematic literature search identified a total of 20 empirical studies focused on women's decision-making about epidural analgesia for labor pain. Our review of these studies suggests that empirical evidence to date is insufficient to determine whether women undergoing labor are capable of consenting to epidural analgesia. Given such uncertainties, sufficient information about pain management should be provided as part of prenatal education and the consent process must be carefully conducted to enhance women's autonomy. To fill in the significant gap in clinical knowledge about laboring women's decision-making capacity, well-designed prospective and retrospective studies may be required.
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Affiliation(s)
- Kyoko Wada
- Centre for Clinical Ethics, St. Joseph's Health Centre Toronto, Toronto, Canada
| | - Louis C Charland
- Philosophy and Psychiatry & School of Health Studies, Western University, London, Canada
| | - Geoff Bellingham
- Anesthesia & Perioperative Medicine, London Health Sciences Centre University Hospital, London, Canada
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43
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Bruni T, Graham M, Norton L, Gofton T, Owen AM, Weijer C. Informed consent for functional MRI research on comatose patients following severe brain injury: balancing the social benefits of research against patient autonomy. J Med Ethics 2019; 45:299-303. [PMID: 30803985 PMCID: PMC6582739 DOI: 10.1136/medethics-2018-104867] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 12/01/2018] [Accepted: 12/12/2018] [Indexed: 05/29/2023]
Abstract
Functional MRI shows promise as a candidate prognostication method in acutely comatose patients following severe brain injury. However, further research is needed before this technique becomes appropriate for clinical practice. Drawing on a clinical case, we investigate the process of obtaining informed consent for this kind of research and identify four ethical issues. After describing each issue, we propose potential solutions which would make a patient's participation in research compatible with her rights and interests. First, we defend the need for traditional proxy consent against two alternative approaches. Second, we examine the impact of the intensive care unit environment on the informed consent process. Third, we discuss the therapeutic misconception and its potential influence on informed consent. Finally, we deal with issues of timing in recruiting participants and related factors which may affect the risks of participation.
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Affiliation(s)
- Tommaso Bruni
- Medizinhistorisches Institut, Universitätsklinikum Bonn, Bonn, Germany
| | - Mackenzie Graham
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Loretta Norton
- Brain and Mind Institute, Western University, London, Ontario, Canada
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada
| | - Teneille Gofton
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada
| | - Adrian M Owen
- Brain and Mind Institute, Western University, London, Ontario, Canada
- Rotman Institute of Philosophy, Western University, London, Ontario, Canada
| | - Charles Weijer
- Brain and Mind Institute, Western University, London, Ontario, Canada
- Rotman Institute of Philosophy, Western University, London, Ontario, Canada
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Craigie J, Davies A. Problems of Control: Alcohol Dependence, Anorexia Nervosa, and the Flexible Interpretation of Mental Incapacity Tests. Med Law Rev 2019; 27:215-241. [PMID: 30053254 PMCID: PMC6536256 DOI: 10.1093/medlaw/fwy022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
This article investigates the ability of mental incapacity tests to account for problems of control, through a study of the approach to alcohol dependence and a comparison with the approach to anorexia nervosa, in England and Wales. The focus is on two areas of law where questions of legal and mental capacity arise for people who are alcohol dependent: decisions about treatment for alcohol dependence and diminished responsibility for a killing. The mental incapacity tests used in these legal contexts are importantly different-one involves a 'cognitive' test, while the other includes an explicit impaired-control limb-and the comparison provides insight into a longstanding debate about the virtues of one type of test over the other. It is shown that both kinds of test can take control problems into account, but also that both can be interpreted in narrow and wide ways that significantly influence the outcome of the assessment. It is therefore argued that to a large extent, it is not the kind of mental incapacity test that matters, but how the test is interpreted. It is further proposed that value judgements are playing an unrecognised and inappropriate role in shaping this interpretation. This raises concerns about the current approach to assessing the impact of alcohol dependency on the capacity to make decisions about alcohol use or treatment, as well as broader concerns about flexibility within incapacity tests.
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Affiliation(s)
- Jillian Craigie
- Centre of Medical Law and Ethics, Dickson Poon School of Law, King’s College London, Strand, London, UK
| | - Ailsa Davies
- Fitness to Practise, Nursing and Midwifery Council, London, UK
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45
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Noyes J, McLaughlin L, Morgan K, Walton P, Curtis R, Madden S, Roberts A, Stephens M. Short-term impact of introducing a soft opt-out organ donation system in Wales: before and after study. BMJ Open 2019; 9:e025159. [PMID: 30948578 PMCID: PMC6500329 DOI: 10.1136/bmjopen-2018-025159] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 02/18/2019] [Accepted: 02/21/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To determine the short-term impact of a soft opt-out organ donation system on consent rates and donor numbers. DESIGN Before and after observational study using bespoke routinely collected data. SETTING National Health Service Blood and Transplant. PARTICIPANTS 205 potential organ donor cases in Wales. INTERVENTIONS The Act and implementation strategy. PRIMARY AND SECONDARY OUTCOMES Consent rates at 18 months post implementation compared with 3 previous years, and organ donor numbers 21 months before and after implementation. Changes in organ donor register activity post implementation for 18 months. RESULTS The consent rate for all modes of consent was 61.0% (125/205), showing a recovery from the dip to 45.8% in 2014/2015. 22.4% (46/205) were deemed consented donors: consent rate 60.8% (28/46). Compared with the 3 years before the switch there was a significant difference in Welsh consent rates (χ2 p value=0.009). Over the same time period, rest of the UK consent rates also significantly increased from 58.6% (5256/8969) to 63.1% (2913/4614) (χ2 p value<0.0001), therefore the Wales increase cannot be attributed to the Welsh legislation change. Deceased donors did not increase: 101 compared with 104. Organ donation registration increased from 34% to 38% with 6% registering to opt-out. CONCLUSION This is the first rigorous initial evaluation with bespoke data collected on all cases. The longer-term impact on consent rates and donor numbers is unclear. Concerns about a potential backlash and mass opting out were not realised. The move to a soft opt-out system has not resulted in a step change in organ donation behaviour, but can be seen as the first step of a longer journey. Policymakers should not assume that soft opt-out systems by themselves simply need more time to have a meaningful effect. Ongoing interventions to further enhance implementation and the public's understanding of organ donation are needed to reach the 2020 target of 80% consent rates. Further longitudinal monitoring is required.
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Affiliation(s)
- Jane Noyes
- School of Social Sciences, Bangor University, Bangor, UK
| | | | - Karen Morgan
- Major Health Conditions Policy Team, Welsh Government, Cardiff, UK
| | - Philip Walton
- Organ Donation Department, NHS Blood and Transplant, Cardiff, UK
| | - Rebecca Curtis
- Statistics and Clinical Studies, NHS Blood and Transplant Organ Donation and Transplantation Directorate, Bristol, UK
| | - Susanna Madden
- Statistics and Clinical Studies, NHS Blood and Transplant Organ Donation and Transplantation Directorate, Bristol, UK
| | - Abigail Roberts
- Organ Donation Department, NHS Blood and Transplant, Speke, UK
| | - Michael Stephens
- Department of Nephrology and Transplantation, Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK
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46
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Pervola J, Myers MF, McGowan ML, Prows CA. Giving adolescents a voice: the types of genetic information adolescents choose to learn and why. Genet Med 2019; 21:965-971. [PMID: 30369597 PMCID: PMC10445294 DOI: 10.1038/s41436-018-0320-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 09/14/2018] [Indexed: 12/26/2022] Open
Abstract
PURPOSE The American College of Medical Genetics and Genomics supports parents' opting in or out of secondary analysis of 59 genes when their child has clinical exome/genome sequencing. We explored the reasons adolescents choose to learn certain types of results and the reasons they want to involve or not involve parents in decision-making. METHODS Adolescents recruited without clinical indication were offered independent, followed by joint choices with a parent to learn genomic results. After making independent choices, adolescent/parent dyads were interviewed to explore the reasons for their choices. Interviews were audio-recorded and transcribed. The constant comparative method was used to analyze 64 purposefully selected transcripts that included 31 from adolescents who excluded some or all potential results. RESULTS Three major themes informed adolescents' choices: (1) actionability of information, (2) knowledge seeking, and (3) psychological impact. Of adolescents who independently excluded some conditions (n=31), 58% changed their initial choices during the joint interview due to parental influence or improved understanding. Nearly all adolescents (98%) wanted to be involved in the decision-making process, and 53% wanted to make choices independently. CONCLUSIONS Our findings contribute empirical evidence to support the refinement of professional guidelines for adolescents' engagement and preferences in genetic testing decisions.
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Affiliation(s)
- Josie Pervola
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Melanie F Myers
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Michelle L McGowan
- Ethics Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics & Women's, Gender & Sexuality Studies, University of Cincinnati, Cincinnati, OH, USA
| | - Cynthia A Prows
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- Patient Services, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, OH, USA.
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47
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Sullivan WF, Heng J, McNeil K, Bach M, Henze M, Perry A, Vogt J. Promoting health care decision-making capabilities of adults with intellectual and developmental disabilities. Can Fam Physician 2019; 65:S27-S29. [PMID: 31023776 PMCID: PMC6501714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- William F Sullivan
- Associate Professor in the Department of Family and Community Medicine at the University of Toronto in Ontario, a staff physician in Medical Services at Surrey Place and the Academic Family Health Team at St Michael's Hospital, and Clinical Lead of the Developmental Disabilities Primary Care Program, Surrey Place
| | - John Heng
- Teaches in the Department of Philosophy and the Department of Interdisciplinary Programs at King's University College at the University of Western Ontario in London
| | - Karen McNeil
- Assistant Professor in the Department of Family Medicine at Dalhousie University in Halifax, NS
| | - Michael Bach
- Managing Director of the Institutes for Research and Development on Inclusion and Society in Toronto
| | - Megan Henze
- Transition Facilitator for the Developmental Disabilities Primary Care Program, Surrey Place in Toronto
| | - Andrea Perry
- Transition Facilitator for the Developmental Disabilities Primary Care Program, Surrey Place in Toronto
| | - Janet Vogt
- Manager and Senior Research Associate at Surrey Place
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48
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Abstract
Although Chinese law imposes informed consent for medical treatments, the Chinese understanding of this requirement is very different from the European one, mostly due to the influence of Confucianism. Chinese doctors and relatives are primarily interested in protecting the patient, even from the truth; thus, patients are commonly uninformed of their medical conditions, often at the family's request. The family plays an important role in health care decisions, even substituting their decisions for the patient's. Accordingly, instead of personal informed consent, what actually exists is 'family informed consent'. From a Western perspective, these features of Chinese law and Chinese culture might seem strange, contradicting our understanding of doctor-patient relationship and even the very essence of self-determination and fundamental rights. However, we cannot forget the huge influence of cultural factors in these domains, and that 'Western' informed consent is grounded on the individualistic nature of Western culture. This article will underline the differences between the Western and the Chinese perspectives, clarifying how each of them must be understood in its own cultural environment. But, while still respecting Chinese particularities, this paper advocates that China adopt patient individual informed consent because this is the only solution compatible with human dignity and human rights.
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Affiliation(s)
- Vera Lúcia Raposo
- Faculty of Law, University of Macau, Room 2043, E32, Avenida da Universidade, Taipa, Macau, China.
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49
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Webster RK, Weinman J, Rubin GJ. Explaining all without causing unnecessary harm: Is there scope for positively framing medical risk information? Patient Educ Couns 2019; 102:602-603. [PMID: 30243771 DOI: 10.1016/j.pec.2018.09.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 08/20/2018] [Accepted: 09/14/2018] [Indexed: 06/08/2023]
Abstract
Clinicians in the United Kingdom are now legally obliged to tell patients about every risk involved in prescribed medical treatments. Although important for informed consent, warning patients of risks such as side-effects can increase the incidence of these very side-effects, through the nocebo effect. Positively framing risk information could be a potential solution to this dilemma, and preliminary data has shown it is effective in healthy volunteers receiving a sham drug. Future research is needed to test its effectiveness in a clinical population.
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Affiliation(s)
- R K Webster
- Department of Psychological Medicine, King's College London, London, UK; NIHR Health Protection Research Unit in Emergency Preparedness and Response, King's College London, London, UK.
| | - J Weinman
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK; NIHR Health Protection Research Unit in Emergency Preparedness and Response, King's College London, London, UK
| | - G J Rubin
- Department of Psychological Medicine, King's College London, London, UK; NIHR Health Protection Research Unit in Emergency Preparedness and Response, King's College London, London, UK
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50
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Bjorå IKH, Jorem J, Tveito M. Tvangsbehandling av somatisk sykdom ved psykisk lidelse. Tidsskr Nor Laegeforen 2019; 139:18-0553. [PMID: 30754946 DOI: 10.4045/tidsskr.18.0553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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