Counterfactual Consent and the Use of Deception in Research

The use of deception for the purposes of research is a widespread practice within many areas of study. If we want to avoid either absolute acceptance or absolute rejection of this practice then we require some method of distinguishing between those uses of deception which are morally acceptable and those which are not. In this article I discuss the concept of counterfactual consent, and propose a related distinction between counterfactual-defeating deception and counterfactual-compatible deception. The aim is to show that this proposed distinction will be useful in furthering the debate regarding the use of deception for the purposes of research.

Testing the waters: Ethical considerations for including PrEP in a phase IIb HIV vaccine efficacy trial

BACKGROUND

The field of HIV prevention research has recently experienced some mixed results in efficacy trials of pre-exposure prophylaxis, vaginal microbicides, and HIV vaccines. While there have been positive trial results in some studies, in the near term, no single method will be sufficient to quell the epidemic. Improved HIV prevention methods, choices among methods, and coverage for all at-risk populations will be needed. The emergence of partially effective prevention methods that are not uniformly available raises complex ethical and scientific questions regarding the design of ongoing prevention trials.

METHODS

We present here an ethical analysis regarding inclusion of pre-exposure prophylaxis in an ongoing phase IIb vaccine efficacy trial, HVTN 505. This is the first large vaccine efficacy trial to address the issue of pre-exposure prophylaxis, and the decisions made by the protocol team were informed by extensive stakeholder consultations. The key ethical concerns are analyzed here, and the process of stakeholder engagement and decision-making described.

DISCUSSION

This discussion and analysis will be useful as current and future research teams grapple with ethical and scientific study design questions emerging with the rapidly expanding evidence base for HIV prevention.

Is pharmacologic research on pregnant women with psychoses ethically permissible?

There is a consistent view in the literature that research on pregnant woman with psychoses is ethically questionable or impermissible. This paper provides a critical appraisal of these views by asking whether pharmacologic research on pregnant women with psychosis for maternal, fetal, and newborn benefit is ethically permissible. We examine separately the documented clinical benefits and risks to the pregnant patient, the fetal patient, and the neonatal and pediatric patient. The outcomes reported in the pertinent literature do not support the conclusion that pharmacologic management of psychosis during pregnancy results in documented, unacceptable risk to the pregnant, fetal, or neonatal patient and is therefore ethically ruled out. Claims that research on the pharmacologic management of psychosis during pregnancy is ethically impermissible because of unacceptable risk of harm to pregnant, fetal, neonatal, or pediatric patients cannot therefore be supported. Having shown that such research is permissible, we then ask what ethical considerations should guide study design. We show that Phase I studies are appropriate and can meet the requirements of the Common Rule, which are more specific than international guidance. As a matter of professionally responsible obstetric practice, pregnant women with psychoses should be included, and not be neglected, in research for both maternal and fetal benefit.

Understanding, interests and informed consent: a reply to Sreenivasan

It is widely agreed that the view of informed consent found in the regulations and guidelines struggles to keep pace with the ever-advancing enterprise of human subjects research. Over the last 10 years, there have been serious attempts to rethink informed consent so that it conforms to our considered judgments about cases where we are confident valid consent has been given. These arguments are influenced by an argument from Gopal Sreenivasan, which apparently shows that a potential participant's consent to research participation can be perfectly valid even if she fails to understand the risk-benefit profile of the study. I argue that Sreenivasan's argument fails. The set of clinical trials that is supposed to be ethical in the face of this kind of ignorance is empty. However, I argue that his argument is nonetheless instructive in allowing us to identify three important but neglected areas for future conceptual research on informed consent. I close by arguing that research on these identified questions promises to yield a defensible view of consent, lessen the burden of ambiguity on researchers attempting to obtain consent to research participation, and facilitate socially valuable research.

Examining the ethics of clinical use of unproven interventions outside of clinical trials during the Ebola epidemic

The recent Ebola outbreak in West Africa began in the spring of 2014 and has since caused the deaths of over 6,000 people. Since there are no approved treatments or prevention modalities specifically targeted at Ebola Virus Disease (EVD), debate has focused on whether unproven interventions should be offered to Ebola patients outside of clinical trials. Those engaged in the debate have responded rapidly to a complex and evolving crisis, however, and this debate has not provided much opportunity for in-depth analysis. Additionally, the existing literature on access to unproven therapies has focused on contexts like HIV/AIDS and oncology, which are very different than the Ebola epidemic. In this paper, we examine the ethical issues surrounding access to unproven therapies in the context of the recent Ebola outbreak to yield new insights about this controversial and unsettled issue. We argue first that, in this context, the interests of patients in obtaining access to unproven therapies are not fully aligned with the interests of their providers and drug developers. Second, we focus on the resource constraints facing providers, funders, and patients and conclude that they often counsel against the use of unproven interventions against EVD.

Selecting the right tool for the job

There are competing ethical concerns when it comes to designing any clinical research study. Clinical trials of possible treatments for Ebola virus are no exception. If anything, the competing ethical concerns are exacerbated in trying to find answers to a deadly, rapidly spreading, infectious disease. The primary goal of current research is to identify experimental therapies that can cure Ebola or cure it with reasonable probability in infected individuals. Pursuit of that goal must be methodologically sound, practical and consistent with prevailing norms governing human subjects research. Some maintain that only randomized controlled trials (RCTs) with a placebo or standard-of-care arm can meet these conditions. We maintain that there are alternative trial designs that can do so as well and that sometimes these are preferable to RCTs.