Bias from industry trial funding? A framework, a suggested approach, and a negative result

Bias from funding sources of trials would threaten their validity. Meta-analyses of high quality acute pain and migraine trials were used to explore the hypothesis that industry funding of clinical trials produced more favourable results than non-profit sponsorship. Analyses were planned to evaluate whether industry-sponsored trials had different results from trials funded by academic or other non-profit sources, but of 176 trials, only two were supported by non-profit sources, while 31 provided no statement of support. An alternative method is proposed within industry-sponsored trials, looking at conflicting industry interests for the same drug, used either as test or comparator treatment. Fifty-three trials used an analgesic as test and 90 as comparator, allowing comparisons to be made for aspirin 600/650 mg, ibuprofen 400 mg, paracetamol (acetaminophen) 1000 mg, rofecoxib 50 mg and sumatriptan 50 and 100 mg. Only for sumatriptan 50 and 100 mg, with the outcome of headache response at 2 h, was there any significant difference between the drug used as a test or as a comparator. The direction was for higher (worse) NNTs with sumatriptan as comparator. Investigating potential industry bias through the funding source of trials is unlikely to be adequate because of a dearth of trials funded by non-profit organisations. We propose a method based on potential conflict of interest within industry-sponsored trials. Using this method, established clinical trial results in acute pain and migraine appear to be unbiased.

Towards the development of ethical practices in paediatric clinical trials: the special position of the terminally ill child

This article examines the emotive and vexing issue of the involvement of terminally children in paediatric clinical trials. Particular emphasis is placed on the participation of such children in Phase I clinical studies, as such studies do not yield any benefit to the individual child. It provides an historical overview of medical research involving children and examines the moral arguments surrounding the participation of children in clinical trials. The article examines the conflict between doctor-as-researcher and doctor-as-treater as well as the problems presented by proxy consent providers. The role played by the human research ethics committee in this area is examined, as is the regulatory framework established by the National Health and Medical Research Council. The article argues that the participation of terminally ill children in Phase I clinical trials is not morally repugnant provided that there is a total commitment to the protection of the child participant's well-being during the dying process. It is argued that the moral justification for such position derives from the utilitarian notion that participation in such studies aims to benefit future generations of ill children.

Conflict over conflicts of interest: an analysis of the new NIH rules

Increasing reports of financial entanglements involving scientist and industry have led some to question the neutrality of research results. In December 2003, a story in the Los Angeles Times shocked readers by exposing several cases of NIH scientists embroiled in serious financial conflicts of interest.1 It was revealed, for example, that senior NIH official Stephen Katz was a paid consultant to Schering AG, a German pharmaceutical company with which he was involved in conducting clinical trials. In a similar case, John Gallin, director of the NIH's Clinical Center, was discovered to have co-authored an article on a company's gene-transfer technology, while being paid as a consultant to a subsidiary of the same company. Jeffrey Schlom, director of the National Cancer Institute's Laboratory of Tumor Immunology and Biology, helped direct NIH-funded studies examining wider use for a particular cancer drug while serving as a consultant whose highest-paying client was looking to genetically engineer that drug.

Attorneys' requests for complete tax records from opposing expert witnesses: some approaches to the problem

As part of an impeachment attempt on cross-examination of opposing expert witnesses in trial or deposition, the cross-examining attorney may request the complete tax records of the expert. It is widely believed that expert witnesses may be expected to express opinions that favor the parties who engage them and who pay their fees. Theoretically, the purpose of this request is an attempt to paint the expert as a "hired gun" whose major source of income is forensic work. The different issues, statutes, and case law citations that bear on requests for tax records are reviewed, and the strategies for coping with this tactic are suggested.

Advisory committees at FDA: the Hinchey Amendment and "conflict of interest" waivers

In approving the Food and Drug Administration's (FDA) Fiscal Year 2007 budget, the House approved an amendment that would prevent the agency from using appropriated funds to waive certain conflicts of interest identified by members of its advisory committees. The amendment, introduced by Representative Hinchey and known as the Hinchey Amendment, provides that no funds may be used to: waive a conflict of interest under Section 505(n)(4) of the Federal Food, Drug, and Cosmetic Act (FDCA) for any voting member of an FDA advisory committee or panel; or make a certification under Section 208(b)(3) of Title 18 of the U.S. Code for any such voting member. This creates a problem, as ties to industry create the very expertise that FDA values in its outside advisors-under the Hinchey Amendment, these very ties would prevent them from serving as advisors to FDA during the drug approval process. The author opposes this change in the law and argues that the Hinchey Amendment would undermine congressional efforts in 1962 and 1989 to carefully balance the goals of attracting qualified experts and protecting agency decisionmaking. Further, the author argues, this change is unnecessary at FDA, because experts on FDA advisory committees divulge their connections to the industry, because the committees offer only advice and do not make agency decisions, and because the agency is under the watchful eye of Congress, the public, and public interest groups. The Article concludes that although FDA's advisory committee conflict-of-interest process can be improved, congressional action is unnecessary, and a change in the law through amendment to an appropriations bill that does not go through the ordinary legislative process (as an amendment to the FDCA or Title 18 would) is inappropriate. Instead, recommendations from organizations studying FDA practice, such as the OIG, GAO, and IOM, should be used to carefully and reflectively amend the process at the agency level, within the existing statutory framework.

Financial conflicts of interest in biomedical human subject research

The purpose of this paper is to examine the past, present and future of financial conflict of interest regulation in biomedical human subject testing. Part I will briefly review the forces giving rise to the current controversy. Part II will examine the more influential ethical codes on human subject testing and argue that they are inconclusive on the subject of financial conflicts of interest. Part III will examine the various regulations now in place and identify their serious flaws. Part IV will critique the leading proposals for reform. The Conclusion will synthesize the best features of the various proposals for reform and suggest improvements left unaddressed by these proposals.

Conflict of interest: Legal and ethical aspects

Conflicts of interest arise when those who owe conscientious duties to others appear to have personal interests that might tempt them to subordinate those duties to their self-interest. Conflicts of interest are distinguishable from conflicts of commitment, which arise when individuals bear two or more mutually exclusive duties to others. If persons in conflicts of interest favor their self-interest, they may violate binding legal duties such as fiduciary duties. Conflicts arise when, for instance, medical practitioners refer their patients to other practitioners in exchange for payments (fee splitting), and when they gain secondary incomes such as from testing patients' samples in laboratories in which they hold ownership or investment interests. Financial dealings with commercial sponsors may place researchers in apparent conflicts of interest with research subjects. When conflicts of interest are unavoidable, they may be resolved by appropriate disclosure.

[Criminal implication of sponsoring in medicine: legal ramifactions and recommendations]

As a consequence of the so-called "Heart-Valve-Affair" in 1994, the German public became aware of the potential criminal significance of industrial sponsoring and third-party financial support in medicine. Since 1997, when the German Anti-Corruption Law came into effect, the penal regulations regarding bribery and benefits for public officers were tightened. Due to the lack of explicit and generally accepted guidelines in combination with regional differences of jurisdiction, there is a lingering uncertainty regarding the criminal aspects of third-party funding and industrial sponsoring. The aim of this review is to summarize the penal and professional implications of third-party funding and sponsoring in medicine including recent aspects of jurisdiction. The currently available recommendations on this issue are introduced.

Medicare program; competitive acquisition of outpatient drugs and biologicals under Part B. Interim final rule with comment period

This interim final rule with comment period implements provisions of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 that require the implementation of a competitive acquisition program for certain Medicare Part B drugs not paid on a cost or prospective payment system basis. Beginning January 1, 2006, physicians will generally be given a choice between obtaining these drugs from vendors selected through a competitive bidding process or directly purchasing these drugs and being paid under the average sales price system.

Legal liabilities in research: early lessons from North America

The legal risks associated with health research involving human subjects have been highlighted recently by a number of lawsuits launched against those involved in conducting and evaluating the research. Some of these cases have been fully addressed by the legal system, resulting in judgments that provide some guidance. The vast majority of cases have either settled before going to trial, or have not yet been addressed by the courts, leaving us to wonder what might have been and what guidance future cases may bring. What is striking about the lawsuits that have been commenced is the broad range of individuals/institutions that are named as defendants and the broad range of allegations that are made. The research community should take this early experience as a warning and should reflect carefully on practices where research involving human subjects is concerned.

Tobacco control implications of the first European product liability suit

OBJECTIVE

To examine tobacco control implication of the first European product liability suit in Finland.

METHODS

Systematic search of internal tobacco industry documents available on the internet and at the British American Tobacco Guildford Depository.

RESULTS

Despite legal loss, the litigation contributed to subsequent tobacco control legislation in Finland. The proceedings revealed that the industry had concealed the health hazards of its products and, despite indisputable evidence, continued to deny them. The positions taken by the industry rocked its reliability as a social actor and thus weakened its chances of influencing tobacco policy. Despite fierce opposition from the tobacco industry, tobacco products were included in the product liability legislation, tobacco was entered on the Finnish list of carcinogens, and an extensive Tobacco Act was passed in Parliament.

CONCLUSIONS

Tobacco litigation might not stand alone as a tool for public health policymaking but it may well stimulate national debate over the role of smoking in society and influence the policy agenda.