A paradigm for understanding trust and mistrust in medical research: The Community VOICES study

BACKGROUND

To promote justice in research practice and rectify health disparities, greater diversity in research participation is needed. Lack of trust in medical research is one of the most significant obstacles to research participation. Multiple variables have been identified as factors associated with research participant trust/mistrust. A conceptual model that provides meaningful insight into the interplay of factors impacting trust may promote more ethical research practice and provide an enhanced, actionable understanding of participant mistrust.

METHODS

A structured survey was developed to capture attitudes toward research conducted in emergency situations; this article focuses on items designed to assess respondents' level of trust or mistrust in medical research in general. Community-based interviews were conducted in English or Spanish with 355 New York City residents (white 42%, African American 29%, Latino 22%).

RESULTS

Generally favorable attitudes toward research were expressed by a majority (85.3%), but many respondents expressed mistrust. Factor analysis yielded four specific domains of trust/mistrust, each of which was associated with different demographic variables: general trustworthiness (older age, not disabled); perceptions of discrimination (African American, Latino, Spanish language preference); perceptions of deception (prior research experience, African American); and perceptions of exploitation (less education).

CONCLUSIONS

The four domains identified in the analysis provide a framework for understanding specific areas of research trust/mistrust among disparate study populations. This model offers a conceptual basis for the design of tailored interventions that target specific groups to promote trust of individual researchers and research institutions as well as to facilitate broader research participation.

Adsorbent 2D and 3D carbon matrices with protected magnetic iron nanoparticles

We report on the synthesis of two and three dimensional carbonaceous sponges produced directly from graphene oxide (GO) into which functionalized iron nanoparticles can be introduced to render it magnetic. This simple, low cost procedure, wherein an iron polymeric resin precursor is introduced into the carbon framework, results in carbon-based materials with specific surface areas of the order of 93 and 66 m(2) g(-1), compared to approx. 4 m(2) g(-1) for graphite, decorated with ferromagnetic iron nanoparticles giving coercivity fields postulated to be 216 and 98 Oe, values typical for ferrite magnets, for 3.2 and 13.5 wt% Fe respectively. The strongly magnetic iron nanoparticles are robustly anchored to the GO sheets by a layer of residual graphite, on the order of 5 nm, formed during the pyrolysis of the precursor material. The applicability of the carbon sponges is demonstrated in their ability to absorb, store and subsequently elute an organic dye, Rhodamine B, from water as required. It is possible to regenerate the carbon-iron hybrid material after adsorption by eluting the dye with a solvent to which it has a high affinity, such as ethanol. The use of a carbon framework opens the hybrid materials to further chemical functionalization, for enhanced chemical uptake of contaminants, or co-decoration with, for example, silver nanoparticles for bactericidal properties. Such analytical properties, combined with the material's magnetic character, offer solutions for environmental decontamination at land and sea, wastewater purification, solvent extraction, and for the concentration of dilute species.

Kinetic Energy Release in Metastable Transitions. I

A method is described for detecting metastable transitions which take place with the release of kinetic energy in the field-free region between the source and electrostatic analyser of a doublefocusing mass spectrometer, and a procedure is given for evaluating the kinetic energy release. Values are given for a number of transitions and are in agreement with those obtained by other methods where comparison is possible. The variation of peak shape with accelerating voltage is ascribed to the varying efficiency with which product ions are collected.

Whistleblowing in academic medicine

Although medical centres have established boards, special committees, and offices for the review and redress of breaches in ethical behaviour, these mechanisms repeatedly prove themselves ineffective in addressing research misconduct within the institutions of academic medicine. As the authors see it, institutional design: (1) systematically ignores serious ethical problems, (2) makes whistleblowers into institutional enemies and punishes them, and (3) thereby fails to provide an ethical environment. The authors present and discuss cases of academic medicine failing to address unethical behaviour in academic science and, thereby, illustrate the scope and seriousness of the problem. The Olivieri/Apotex affair is just another instance of academic medicine's dereliction in a case of scientific fraud and misconduct. Instead of vigorously supporting their faculty member in her efforts to honestly communicate her findings and to protect patients from the risks associated with the use of the study drug, the University of Toronto collaborated with the Apotex company's "stalling tactics," closed down Dr Olivieri's laboratory, harassed her, and ultimately dismissed her. The authors argue that the incentives for addressing problematic behaviour have to be revised in order to effect a change in the current pattern of response that occurs in academic medicine. An externally imposed realignment of incentives could convert the perception of the whistleblower, from their present caste as the enemy within, into a new position, as valued friend of the institution. The authors explain how such a correction could encourage appropriate reactions to scientific misconduct from academic medicine.

Basolateral Cl- transport is stimulated by terbutaline in adult rat alveolar epithelial cells

Stimulation of adult rat alveolar epithelial cells with terbutaline was previously shown to activate Cl- channels in the apical membrane. In this study, we show that terbutaline stimulates net transepithelial (apical-to-basolateral) Cl- absorption from 0.19 +/- 0.13 to 1.43 +/- 0.31 mmol x cm-2 x hr-1. Terbutaline also increases net Cl- efflux across the basolateral membrane under conditions where an outward [K+] gradient exists and the membrane voltage is clamped at zero mV. When the [K+] gradient is eliminated, the effect of terbutaline on net Cl- efflux is inhibited to the extent that no significant Cl- efflux can be detected across the basolateral membrane. RT-PCR experiments detected mRNA for three KCl cotransport isoforms (KCC1, KCC3 and KCC4) in monolayer cultures of alveolar epithelial cells. Western blot analysis using antibodies to the four cloned isoforms of KCl cotransporters revealed the presence of KCC1 and KCC4 isoforms in monolayer cultures of these cells. These results provide evidence suggesting a role for KCl cotransport in terbutaline-stimulated transepithelial Cl- absorption.

Cultural collisions at the bedside: social expectations and value triage in medical practice

As early as 1981 Gorlin and Zucker produced a film, A Complicating Factor: Doctors' Feelings as a Factor in Medical Care and in a 1983 paper on the subject they described one of the important epiphenomena of the encounter between doctor and patient—namely, the reaction of the physician to the patient and how this affects both the physician and the quality of the relationship. At that time they were concerned with the physicians' ability to reckon with their own reactions to patients who presented with problems or personality traits that complicated the doctor-patient relationship. Some patients were hateful or unlikable, some denied their disease state, some became unusually dependent on the physician, some were intimidating to the doctor. Their behavior evoked responses that tended to complicate the doctor-patient relationship with distancing, unusual identification, or hostility. That publication recognized and explained the problem and went on to suggest a process of achieving emotional awareness and mastery to help physicians maintain their appropriate role.

Ethical issues in selecting embryos

People involved in assisted reproduction frequently make decisions about which of several embryos to implant or which of several embryos to reduce from a multiple pregnancy. Yet, others have raised questions about the ethical acceptability of using sex or genetic characteristics as selection criteria. This paper reviews arguments for rejecting embryo selection and discusses the subject of choosing offspring in terms of the centrality of liberty and autonomous choice in ethics. It also presents a position on the acceptable scope of embryo selection and the professional responsibilities of those who practice reproductive medicine.

Prescriber profiles

Within a two-week period, two sales representatives from competing pharmaceutical companies visited the office of an orthopaedic group practice. One representative was elated that the group had been steadily prescribing his company's new arthritis medication. The physicians assumed that the representative was speaking about the number of sample packs used by their office. Several days later, a competing drug representative visited the office and complained that several physicians in the group were "not thinking of my company's medication first." The physicians were perplexed and asked him how he had come by that information. After multiple attempts at evading the question, the representative explained that pharmaceutical companies pay the drugstores for such data. Although unwilling to disclose the details of the arrangement, he did inform the physicians that the pharmaceutical companies know exactly which physicians are writing which prescriptions. He assured the physicians that patients' names are not disclosed. The physicians spoke to several pharmacists and other pharmaceutical representatives, who confirmed the practice.

Acceptable sex selection

John Robertson presents a persuasive argument against government prohibition of preconception sex selection (PSS) as long as there is no actual evidence of significant social harm from allowing the technology to be freely available. I am convinced by what he says about PSS and have argued along similar lines in my own work (Rhodes 1995). In these comments, I will press Robertson's conclusion in several directions to show what more he might have said in its defense.

Understanding the trusted doctor and constructing a theory of bioethics

This paper offers a constructivist account of bioethics as an alternative to previous discussions that explained the ethics of medicine by an extrapolation of principles or virtues from ordinary morality. Taking medicine as a higher and special calling, I argue that the practice of medicine would be impossible without the trust of patients. Because trust is a necessary condition for medical practice, the ethics of the profession must provide the principles for guiding physician behavior and the profession toward promoting trust and being trustworthy. In a phrase, that principle is "seek trust and deserve it." I sketch out how the concept of trust provides a different justification for common sense principles of bioethics and explain how the concept of trust provides reasonable guidance for resolving moral conflicts within medicine. The trust-seeking approach provides a new and unexpected ordering of some traditional medical values, it reveals the weightiness of previously undervalued bioethical precepts, and illuminates the centrality of some largely ignored obligations of medicine. It also has the power to guide clinical practice and to inform the profession about standards for medical institutions.

Ethical considerations in orthopaedic surgery

Because our actions as physicians have far-reaching consequences, and because society allows us to do things to others that no one else is free to do, physicians' professional activities fall under the domain of ethical evaluation. We are charged with the obligation to use specialized scientific knowledge, to work in concert with others, and to act for the good of our patients. In fact, acting for the good of our patients is the central tenet of ethical medical behavior. What constitutes the good of the patient, however, is not always clear. In general, we act to limit disease, restore function, alleviate suffering, and prolong life. We understand fully, however, that these goals may conflict with one another. Judgment about what is right for a particular patient leads us to another crucial consideration of ethical behavior, namely, respect for patient autonomy. We recognize that individuals have the right to control their own destiny. Patients have a right, therefore, to make choices about their medical care. As physicians, we must respect those rights. As such, certain ethical behavior is expected of us. We must be honest with our patients. We must provide them with accurate information on which to base their decisions. We must convey to them information about their diagnosis, prognosis, and treatment, even when it is unpleasant to do so. We must be open about our expertise and level of training for a particular procedure. We must respect their privacy and their right to withhold information even from family and friends. In short, we must respect their choices, even if we may disagree with those choices. To truly respect patient autonomy is to understand that, ultimately, the final decision lies with the patient.

Residency training

R. C. is an orthopaedic resident in a teaching program. At the orthopaedic clinic, he examines an elderly, otherwise healthy patient who requires a total hip replacement. He presents the patient to his covering attending physician, who agrees to supervise the joint replacement surgery. The resident discusses the surgery with the patient. The procedure, risks, goals, benefits, and alternatives are presented. The patient agrees to proceed with the surgery. The resident performs the surgical procedure with the attending physician's assistance. The surgery lasts forty minutes longer than the attending physician's usual surgical time, and the blood loss is 300 milliliters greater. Postoperative radiographs demonstrate a well positioned press-fit acetabular component and a cemented femoral component in 6 degrees of varus.

Paternalism

J. S. is a sixty-five-year-old man who was treated at another hospital with arthroscopic debridement of an infection at the site of a right total knee replacement and was placed on long-term intravenous antibiotics. He signed out of that hospital against medical advice. One month later, he presented at our hospital with recurrent sepsis of his knee. Knee aspiration yielded frank pus with a white blood-cell count of 80,000 cells per cubic millimeter. Gram-staining demonstrated gram-positive cocci. The patient was placed on intravenous antibiotics. The patient appeared cachectic, reporting a sixty-pound (27.2-kilogram) weight loss over the past year. A metastatic workup, including a chest radiograph, an abdominal sonogram, prostate-specific antigen, a complete blood-cell count, erythrocyte sedimentation rate, and a purified-protein-derivative skin test, was negative; however, an occult neoplasm could not be excluded. The patient displayed episodes of confusion, disorientation, and argumentative behavior. Medical and psychiatric consults did not determine whether this behavior was due to previous substance abuse or a primary psychiatric disorder. Nevertheless, psychiatrists at our institution determined that the patient lacked decisional capacity. Attempts were made to salvage the knee replacement, and the patient underwent an extensive surgical debridement of the knee with insertion of drains. He was placed on intravenous antibiotics. The plan was for the patient to be managed with long-term oral suppressive antibiotics. After treatment, the patient was transferred to a skilled-nursing facility. Psychiatrists at the nursing facility deemed the patient to have decisional capacity, and the patient was permitted to leave the facility. He was discharged without antibiotics. Several weeks later, he presented at our hospital with a grossly purulent knee. The orthopaedic options were reviewed with the patient and his brother. Removal of the components was recommended. The patient did not want to "lose" his knee replacement, and he refused surgical intervention. We did not believe that the infection could be either controlled or eradicated with the components in place.

Ethics in practice

H. K. is a ninety-two-year-old woman with Alzheimer's disease and mild hypertension. She resides at a nursing home, where she transfers from bed to chair with maximal assistance. She presents to our emergency department with a painful right hip. Physical examination demonstrates a confused, elderly patient with significant right hip pain and shortening and external rotation of the lower extremity. Radiographs demonstrate a displaced intertrochanteric hip fracture. The patient lacks the capacity for informed consent. Her family is contacted to obtain consent for insertion of a compression screw. The family refuses to give consent, stating that the patient is too old and the surgery is too dangerous.

Trust and transforming medical institutions

Medicine needs our trust. We need to be able to rely on individual clinicians and researchers, and we need to be able to have confidence in hospitals and clinics. Yet the organization of our healthcare institutions is not designed to promote that trust. In fact, the structure of our medical institutions seems to undermine our faith.

Abortion and assent

Volumes have been written arguing the morality of abortion. A crucial premise in many of these arguments concerns the status of the fetus; specifically, that the fetus has or does not have a right to life. Opponents of abortion typically argue that fetuses are persons and hence have an inviolable right to life. Advocates of the right to abortion typically maintain that fetuses are not persons and hence have no right to life.

The relaxin-like factor is a hormone

The relaxin-like factor (RLF) circulates in the bloodstream of humans, interacts with a membrane protein with all the characteristics of ligand-receptor binding, and must therefore be considered a hormone by definition. The polyclonal antibody raised against synthetic human RLF showed no crossreactivity to other structurally related hormones, like insulin and relaxin. The sensitivity of this assay (ED50 at 100 pM) allowed the direct measurement of RLF concentrations in serum. The highest levels were detected in the serum of postpuberty males (190 pM), whereas in females and children, the RLF concentration was one order of magnitude lower.

Curriculum Revision: Reaching Faculty Consensus Through the Nominal Group Technique

A fundamental concept to initiate change in the curriculum revision process is to overcome resistance to change and the boundaries of self-interest. Curriculum change cannot occur without an "unfreezing" of faculty values and interests. The Nominal Group Technique (NGT) was used to facilitate faculty identification of areas needing change in the undergraduate nursing curriculum. The process led to the generation of numerous independent ideas in which all faculty participated. The revised curriculum which resulted from the NGT process has had full and enthusiastic support of the faculty.

Ethical considerations for residents

To help residents understand the moral obligations they have undertaken by becoming doctors, the author presents an overview of the ethical landscape of medical practice. She begins by stating that doctors' primary obligation is to use the knowledge of science in working together with others for the good of their patients. This involves (1) relying on the scientific method (and thus eschewing nonscientific alternatives) and supporting or conducting scientific research; (2) embracing the cooperative model (i.e., when appropriate, working cooperatively with other physicians and other health care providers); and (3) working for the good of the patient to preserve life, cure disease, restore or preserve function, educate, and alleviate suffering. In order to fulfill this complex obligation physicians must be professionally competent, they must respect their colleagues and patients, and they must genuinely care about their patients' well-being. The author then discusses the moral complexity of common encounters in medical practice. She explains the ethical conflicts that underlie issues of paternalism, justice, the use of patients for teaching, and end-of-life care. Since new moral problems are introduced with new technology and since medicine is confronting an increasing demand for services in the face of shrinking resources, she maintains that, more than ever, physicians must be aware of the ethical dimensions of their work and be able to organize their understanding of the issues. To meet the complex and demanding commitments of medical practice and to successfully navigate the ethical challenges that they will encounter, physicians must mold themselves not only to be knowledge and skilled professionals but also to be respectful and compassionate human beings.

Putting universal healthcare on the religious agenda

In modern industrial society the issue of access to healthcare is inseparable from the question of whether there is a right to healthcare and whether government has the correlative duty to assure a minimum level of care to all citizens. While discussion in terms of rights and duties tends to direct our attention to broader, more theoretical ethical issues, discussion in terms of ‘access’ invites consideration of more practical concerns. The news media rarely report in terms of whether a citizen's right to healthcare has been abridged or disregarded, but rather offers tales of people being denied access. Advocacy groups for specific illnesses do not necessarily argue for universal health insurance, but rather press that certain conditions, such as renal failure requiring dialysis, receive unlimited insurance coverage and that people with the condition be given automatic access to care.

Genetic links, family ties, and social bonds: rights and responsibilities in the face of genetic knowledge

Currently, some of the most significant moral issues involving genetic links relate to genetic knowledge. In this paper, instead of looking at the frequently addressed issues of responsibilities professionals or institutions have to individuals, I take up the question of what responsibilities individuals have to one another with respect to genetic knowledge. I address the questions of whether individuals have a moral right to pursue their own goals without contributing to society's knowledge of population genetics, without adding to their family's knowledge of its genetic history, and without discovering genetic information about themselves and their offspring. These questions lead to an examination of the presumed right to genetic ignorance and an exploration of a variety of social bonds. Analyzing cases in light of these considerations leads to a surprising conclusion about a widely accepted precept of genetic counseling, to some ethical insights into typical problems, and to some further unanswered questions about personal responsibility in the face of genetic knowledge.