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van der Zande ISE, van der Graaf R, Oudijk MA, van Delden JJM. A qualitative study on acceptable levels of risk for pregnant women in clinical research. BMC Med Ethics 2017; 18:35. [PMID: 28506267 PMCID: PMC5432995 DOI: 10.1186/s12910-017-0194-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 04/27/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is ambiguity with regard to what counts as an acceptable level of risk in clinical research in pregnant women and there is no input from stakeholders relative to such research risks. The aim of our paper was to explore what stakeholders who are actively involved in the conduct of clinical research in pregnant women deem an acceptable level of risk for pregnant women in clinical research. Accordingly, we used the APOSTEL VI study, a low-risk obstetrical randomised controlled trial, as a case-study. METHODS We conducted a prospective qualitative study using 35 in-depth semi-structured interviews and one focus group. We interviewed healthcare professionals, Research Ethics Committee members (RECs) and regulators who are actively involved in the conduct of clinical research in pregnant women, in addition to pregnant women recruited for the APOSTEL VI case-study in the Netherlands. RESULTS Three themes characterise the way stakeholders view risks in clinical research in pregnant women in general. Additionally, one theme characterises the way healthcare professionals and pregnant women view risks with respect to the case-study specifically. First, ideas on what constitutes an acceptable level of risk in general ranged from a preference for zero risk for the foetus up to minimal risk. Second, the desirability of clinical research in pregnant women in general was questioned altogether. Third, stakeholders proposed to establish an upper limit of risk in potentially beneficial clinical research in pregnant women in order to protect the foetus and the pregnant woman from harm. Fourth and finally, the case-study illustrates that healthcare professionals' individual perception of risk may influence recruitment. CONCLUSIONS Healthcare professionals, RECs, regulators and pregnant women are all risk adverse in practice, possibly explaining the continuing underrepresentation of pregnant women in clinical research. Determining the acceptable levels of risk on a universal level alone is insufficient, because the individual perception of risk also influences behaviour towards pregnant women in clinical research. Therefore, bioethicists and researchers might be interested in changing the perception of risk, which could be achieved by education and awareness about the actual benefits and harms of inclusion and exclusion of pregnant women.
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van Delden JJM, van der Graaf R. Revised CIOMS International Ethical Guidelines for Health-Related Research Involving Humans. JAMA 2017; 317:135-136. [PMID: 27923072 DOI: 10.1001/jama.2016.18977] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Verberne LM, Kars MC, Schouten-van Meeteren AYN, Bosman DK, Colenbrander DA, Grootenhuis MA, van Delden JJM. Aims and tasks in parental caregiving for children receiving palliative care at home: a qualitative study. Eur J Pediatr 2017; 176:343-354. [PMID: 28078429 PMCID: PMC5321698 DOI: 10.1007/s00431-016-2842-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 12/06/2016] [Accepted: 12/23/2016] [Indexed: 11/18/2022]
Abstract
UNLABELLED In paediatric palliative care (PPC), parents are confronted with increasing caregiving demands. More children are cared for at home, and the need for PPC of children is lengthened due to technical and medical improvements. Therefore, a clear understanding of the content of parental caregiving in PPC becomes increasingly important. The objective is to gain insight into parental caregiving based on the lived experience of parents with a child with a life-limiting disease. An interpretative qualitative study using thematic analysis was performed. Single or repeated interviews were undertaken with 42 parents of 24 children with a malignant or non-malignant disease, receiving PPC. Based on their ambition to be a 'good parent', parents caring for a child with a life-limiting disease strived for three aims: controlled symptoms and controlled disease, a life worth living for their ill child and family balance. These aims resulted in four tasks that parents performed: providing basic and complex care, organising good quality care and treatment, making sound decisions while managing risks and organising a good family life. CONCLUSION Parents need early explanation from professionals about balancing between their aims and the related tasks to get a grip on their situation and to prevent becoming overburdened. What is Known: • In paediatric palliative care, parents are confronted with increasing caregiving demands. • Parenting is often approached from the perspective of stress. What is New: • Parents strive for three aims: controlled symptoms and controlled disease, a life worth living for their child and family balance. • Parents perform four tasks: providing basic and complex care, organising good quality care, making decisions while managing risks and organising a good family life. • Professionals need insight into the parents' aims and tasks from the parental perspective to strengthen parents' resilience.
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Vos S, van Delden JJM, van Diest PJ, Bredenoord AL. Moral Duties of Genomics Researchers: Why Personalized Medicine Requires a Collective Approach. Trends Genet 2016; 33:118-128. [PMID: 28017398 DOI: 10.1016/j.tig.2016.11.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 11/21/2016] [Accepted: 11/28/2016] [Indexed: 12/30/2022]
Abstract
Advances in genome sequencing together with the introduction of personalized medicine offer promising new avenues for research and precision treatment, particularly in the field of oncology. At the same time, the convergence of genomics, bioinformatics, and the collection of human tissues and patient data creates novel moral duties for researchers. After all, unprecedented amounts of potentially sensitive information are being generated. Over time, traditional research ethics principles aimed at protecting individual participants have become supplemented with social obligations related to the interests of society and the research enterprise at large, illustrating that genomic medicine is also a social endeavor. In this review we provide a comprehensive assembly of moral duties that have been attributed to genomics researchers and offer suggestions for responsible advancement of personalized genomic cancer care.
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van den Broek WES, Scheele F, Ten Cate O, van Delden JJM. A Health Professions Education Research-Specific Ethical Review Board. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2016; 91:1590-1591. [PMID: 29408845 DOI: 10.1097/acm.0000000000001430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Habets MGJL, van Delden JJM, Bredenoord AL. The unique status of first-in-human studies: strengthening the social value requirement. Drug Discov Today 2016; 22:471-475. [PMID: 27894931 DOI: 10.1016/j.drudis.2016.11.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 11/12/2016] [Accepted: 11/17/2016] [Indexed: 12/14/2022]
Abstract
For clinical research to be ethical, risks need to be balanced by anticipated benefits. This is challenging for first-in-human (FIH) studies as participants are not expected to benefit directly, and risks are potentially high. We argue that this differentiates FIH studies from other clinical trials to the extent that they should be given unique status in international research ethics guidelines. As there is a general positive attitude regarding the benefits of science, it is important to establish a more systematic method to assess anticipated social value to safeguard participants not only from enrolling in risky, but also in futile trials. Here, we provide some of necessary steps needed to assess the anticipated social value of the intervention.
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Giesbertz NAA, Melham K, Kaye J, van Delden JJM, Bredenoord AL. Personalized assent for pediatric biobanks. BMC Med Ethics 2016; 17:59. [PMID: 27733160 PMCID: PMC5062866 DOI: 10.1186/s12910-016-0142-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 09/29/2016] [Indexed: 12/22/2022] Open
Abstract
Pediatric biobanking is considered important for generating biomedical knowledge and improving (pediatric) health care. However, the inclusion of children’s samples in biobanks involves specific ethical issues. One of the main concerns is how to appropriately engage children in the consent procedure. We suggest that children should be involved through a personalized assent procedure, which means that both the content and the process of assent are adjusted to the individual child. In this paper we provide guidance on how to put personalized assent into pediatric biobanking practice and consider both the content and process of personalized assent. In the discussion we argue that the assent procedure itself is formative. Investing in the procedure should be a requirement for pediatric biobank research. Although personalized assent will require certain efforts, the pediatric (biobank) community must be aware of its importance. The investment and trust earned can result in ongoing engagement, important longitudinal information, and stability in/for the research infrastructure, as well as increased knowledge among its participants about research activity. Implementing personalized assent will both respect the child and support biobank research.
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Kalkman S, van Thiel GJMW, Grobbee DE, Meinecke AK, Zuidgeest MGP, van Delden JJM. Stakeholders' views on the ethical challenges of pragmatic trials investigating pharmaceutical drugs. Trials 2016; 17:419. [PMID: 27550379 PMCID: PMC4994208 DOI: 10.1186/s13063-016-1546-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 08/09/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We explored the views of key stakeholders to identify the ethical challenges of pragmatic trials investigating pharmaceutical drugs. A secondary aim was to capture stakeholders' attitudes towards the implementation of pragmatic trials in the drug development process. METHODS We conducted semistructured, in-depth interviews among individuals from different key stakeholder groups (academia and independent research institutions, the pharmaceutical industry, regulators, Health Technology Assessment (HTA) agencies and patients' organizations) through telephone or face-to-face sessions. Interviews were structured around the question "what challenges were experienced or perceived during the design, conduct and/or review of pragmatic trials." Respondents were additionally asked about their views on implementation of pragmatic trials in the drug development process. Thematic analysis was used to identify the ethically relevant features across data sets. RESULTS We interviewed 34 stakeholders in 25 individual sessions and four group sessions. The four perceived challenges of ethical relevance were: (1) less controlled conditions creating safety concerns, (2) comparison with usual care potentially compromising clinical equipoise, (3) tailored or waivers of informed consent affecting patient autonomy, and (4) minimal interference with "real-world" practice reducing the knowledge value of trial results. CONCLUSIONS We identified stakeholder concerns regarding risk assessment, use of suboptimal usual care as a comparator, tailoring of informed consent procedures and ensuring the social value of pragmatic trials. These concerns increased when respondents were asked about pragmatic trials conducted before market authorization.
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Kalis A, Schermer MHN, van Delden JJM. Ideals Regarding a Good Life for Nursing Home Residents with Dementia: views of professional caregivers. Nurs Ethics 2016; 12:30-42. [PMID: 15685966 DOI: 10.1191/0969733005ne756oa] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This study investigates what professional caregivers working in nursing homes consider to be a good life for residents suffering from dementia. Ten caregivers were interviewed; special attention was paid to the way in which they deal with conflicting values. Transcripts of the interviews were analysed qualitatively according to the method of grounded theory. The results were compared with those from a similar, earlier study on ideals found in mission statements of nursing homes. The concepts that were mentioned by most interviewed participants as important for a good life were ‘peace and quiet’, ‘going along with subjective experience’ and ‘no enforcement: the way the resident wants it’. A considerable overlap was found between the interviews and the mission statements; however, when compared with the mission statements, the interviews put less emphasis on individuality and on giving meaning, and more on offering residents pleasant activities. When faced with conflicting values, caregivers tend to make pragmatic and more or less intuitive decisions. Although this has its merits, it may be desirable to stimulate conscious reflection regarding conflict between different values.
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Mostert M, Bredenoord AL, Biesaart MCIH, van Delden JJM. Big Data in medical research and EU data protection law: challenges to the consent or anonymise approach. Eur J Hum Genet 2016; 24:956-60. [PMID: 26554881 PMCID: PMC5070890 DOI: 10.1038/ejhg.2015.239] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 09/16/2015] [Accepted: 10/13/2015] [Indexed: 12/14/2022] Open
Abstract
Medical research is increasingly becoming data-intensive; sensitive data are being re-used, linked and analysed on an unprecedented scale. The current EU data protection law reform has led to an intense debate about its potential effect on this processing of data in medical research. To contribute to this evolving debate, this paper reviews how the dominant 'consent or anonymise approach' is challenged in a data-intensive medical research context, and discusses possible ways forwards within the EU legal framework on data protection. A large part of the debate in literature focuses on the acceptability of adapting consent or anonymisation mechanisms to overcome the challenges within these approaches. We however believe that the search for ways forward within the consent or anonymise paradigm will become increasingly difficult. Therefore, we underline the necessity of an appropriate research exemption from consent for the use of sensitive personal data in medical research to take account of all legitimate interests. The appropriate conditions of such a research exemption are however subject to debate, and we expect that there will be minimal harmonisation of these conditions in the forthcoming EU Data Protection Regulation. Further deliberation is required to determine when a shift away from consent as a legal basis is necessary and proportional in a data-intensive medical research context, and what safeguards should be put in place when such a research exemption from consent is provided.
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Bernabe RDLC, van Thiel GJMW, van Delden JJM. What do international ethics guidelines say in terms of the scope of medical research ethics? BMC Med Ethics 2016; 17:23. [PMID: 27117273 PMCID: PMC4847236 DOI: 10.1186/s12910-016-0106-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 04/18/2016] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND In research ethics, the most basic question would always be, "which is an ethical issue, which is not?" Interestingly, depending on which ethics guideline we consult, we may have various answers to this question. Though we already have several international ethics guidelines for biomedical research involving human participants, ironically, we do not have a harmonized document which tells us what these various guidelines say and shows us the areas of consensus (or lack thereof). In this manuscript, we attempted to do just that. METHODS We extracted the imperatives from five internationally-known ethics guidelines and took note where the imperatives came from. In doing so, we gathered data on how many guidelines support a specific imperative. RESULTS We found that there is no consensus on the majority of the imperatives and that in only 8.2% of the imperatives were there at least moderate consensus (i.e., consensus of at least 3 of the 5 ethics guidelines). Of the 12 clusters (Basic Principles; Research Collaboration; Social Value; Scientific Validity; Participant Selection; Favorable Benefit/Risk Ratio; Independent Review; Informed Consent; Respect for Participants; Publication and Registration; Regulatory Sanctions; and Justified Research on the Vulnerable Population), Informed Consent has the highest level of consensus and Research Collaboration and Regulatory Sanctions have the least. CONCLUSION There was a lack of consensus in the majority of imperatives from the five internationally-known ethics guidelines. This may be partly explained by the differences among the guidelines in terms of their levels of specification as well as conceptual/ideological differences.
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Verberne WR, Geers ABMT, Jellema WT, Vincent HH, van Delden JJM, Bos WJW. Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis. Clin J Am Soc Nephrol 2016; 11:633-40. [PMID: 26988748 PMCID: PMC4822664 DOI: 10.2215/cjn.07510715] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 12/14/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Outcomes of older patients with ESRD undergoing RRT or conservative management (CM) are uncertain. Adequate survival data, specifically of older patients, are needed for proper counseling. We compared survival of older renal patients choosing either CM or RRT. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A retrospective survival analysis was performed of a single-center cohort in a nonacademic teaching hospital in The Netherlands from 2004 to 2014. Patients with ESRD ages ≥70 years old at the time that they opted for CM or RRT were included. Patients with acute on chronic renal failure needing immediate start of dialysis were excluded. RESULTS In total, 107 patients chose CM, and 204 chose RRT. Patients choosing CM were older (mean±SD: 83±4.5 versus 76±4.4 years; P<0.001). The Davies comorbidity scores did not differ significantly between both groups. Median survival of those choosing RRT was higher than those choosing CM from time of modality choice (median; 75th to 25th percentiles: 3.1, 1.5-6.9 versus 1.5, 0.7-3.0 years; log-rank test: P<0.001) and all other starting points (P<0.001 in all patients). However, the survival advantage of patients choosing RRT was no longer observed in patients ages ≥80 years old (median; 75th to 25th percentiles: 2.1, 1.5-3.4 versus 1.4, 0.7-3.0 years; log-rank test: P=0.08). The survival advantage was also substantially reduced in patients ages ≥70 years old with Davies comorbidity scores of ≥3, particularly with cardiovascular comorbidity, although the RRT group maintained its survival advantage at the 5% significance level (median; 75th to 25th percentiles: 1.8, 0.7-4.1 versus 1.0, 0.6-1.4 years; log-rank test: P=0.02). CONCLUSIONS In this single-center observational study, there was no statistically significant survival advantage among patients ages ≥80 years old choosing RRT over CM. Comorbidity was associated with a lower survival advantage. This provides important information for decision making in older patients with ESRD. CM could be a reasonable alternative to RRT in selected patients.
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Abstract
Noor Giesbertz and colleagues consider different re-contact policy designs that could be used by biobanks to obtain permission for the continued use of samples collected from children.
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Boers SN, van Delden JJM, Knoers NV, Bredenoord AL. Postmortem disclosure of genetic information to family members: active or passive? Trends Mol Med 2016; 21:148-53. [PMID: 25743261 DOI: 10.1016/j.molmed.2015.01.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 12/22/2014] [Accepted: 01/07/2015] [Indexed: 01/19/2023]
Abstract
Advances in next-generation DNA sequencing (NGS) now make it possible, and affordable, to sequence the entire genome of an individual. Routine clinical application is on the horizon. There is a consensus that some subsets of genetic information should be disclosed to patients, but disclosure to their relatives is less consensual. This issue becomes especially salient after a patient's death, when permission can no longer be sought. There has however been little debate on postmortem disclosure. We identify and explain the arguments in favor of and against disclosure of genetic information to the relatives of a deceased patient. We conclude that there are valid reasons to communicate some subsets of genetic information to family members after death, and we propose a passive postmortem disclosure policy.
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van der Zande ISE, van der Graaf R, Browne JL, van Delden JJM. Fair Inclusion of Pregnant Women in Clinical Research: A Systematic Review of Reported Reasons for Exclusion. RESEARCH ETHICS FORUM 2016. [DOI: 10.1007/978-3-319-26512-4_5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Habets MGJL, van Delden JJM, Bredenoord AL. Studying the lay of the land: views and experiences of professionals in the translational pluripotent stem cell field. Regen Med 2015; 11:63-71. [PMID: 26679636 DOI: 10.2217/rme.15.78] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
AIM The inherent uncertainty of first-in-human trials, combined with the technical complexity of pluripotent stem cells (PSCs), makes early phase PSC studies ethically challenging. Conducting parallel bioethics research based on experiences and views of professionals in the stem cell field is therefore important. MATERIALS & METHODS We conducted semistructured interviews with various stakeholders to get a lay of the land of ethical issues professionals find relevant to the translation of PSCs. RESULTS We identified four themes in the interviews: the uniqueness of PSCs, the suitability of the current research paradigm, the justification for early phase PSC studies and the involvement of patients and research participants. CONCLUSION We conclude that a debate should take place discussing the suitability of the current research paradigm for translational PSC studies.
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Niemansburg SL, Habets MGJL, Dhert WJA, van Delden JJM, Bredenoord AL. Participant selection for preventive Regenerative Medicine trials: ethical challenges of selecting individuals at risk. JOURNAL OF MEDICAL ETHICS 2015; 41:914-916. [PMID: 26340912 DOI: 10.1136/medethics-2014-102625] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 08/17/2015] [Indexed: 06/05/2023]
Abstract
The innovative field of Regenerative Medicine (RM) is expected to extend the possibilities of prevention or early treatment in healthcare. Increasingly, clinical trials will be developed for people at risk of disease to investigate these RM interventions. These individuals at risk are characterised by their susceptibility for developing clinically manifest disease in future due to the existence of degenerative abnormalities. So far, there has been little debate about the ethical appropriateness of including such individuals at risk in clinical trials. We discuss three main challenges of selecting this participant model for testing RM interventions: the challenge of achieving a proportional risk-benefit balance; complexities in the trial design in terms of follow-up and sample size; and the difficulty of obtaining informed consent due to the many uncertainties. We conclude that selecting the model is not ethically justifiable for first-in-man trials with RM interventions due to the high risks and uncertainties. However, the model can be ethically appropriate for testing the efficacy of RM interventions under the following conditions: interventions should be low risk; the degenerative abnormalities (and other risk factors) should be strongly related with disease within a short time frame; robust preclinical evidence of efficacy needs to be present; and the informed consent procedure should contain extra safeguards with regard to communication on uncertainties.
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de Hoop E, van der Tweel I, van der Graaf R, Moons KGM, van Delden JJM, Reitsma JB, Koffijberg H. The need to balance merits and limitations from different disciplines when considering the stepped wedge cluster randomized trial design. BMC Med Res Methodol 2015; 15:93. [PMID: 26514920 PMCID: PMC4627408 DOI: 10.1186/s12874-015-0090-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 10/19/2015] [Indexed: 12/27/2022] Open
Abstract
Background Various papers have addressed pros and cons of the stepped wedge cluster randomized trial design (SWD). However, some issues have not or only limitedly been addressed. Our aim was to provide a comprehensive overview of all merits and limitations of the SWD to assist researchers, reviewers and medical ethics committees when deciding on the appropriateness of the SWD for a particular study. Methods We performed an initial search to identify articles with a methodological focus on the SWD, and categorized and discussed all reported advantages and disadvantages of the SWD. Additional aspects were identified during multidisciplinary meetings in which ethicists, biostatisticians, clinical epidemiologists and health economists participated. All aspects of the SWD were compared to the parallel group cluster randomized design. We categorized the merits and limitations of the SWD to distinct phases in the design and conduct of such studies, highlighting that their impact may vary depending on the context of the study or that benefits may be offset by drawbacks across study phases. Furthermore, a real-life illustration is provided. Results New aspects are identified within all disciplines. Examples of newly identified aspects of an SWD are: the possibility to measure a treatment effect in each cluster to examine the (in)consistency in effects across clusters, the detrimental effect of lower than expected inclusion rates, deviation from the ordinary informed consent process and the question whether studies using the SWD are likely to have sufficient social value. Discussions are provided on e.g. clinical equipoise, social value, health economical decision making, number of study arms, and interim analyses. Conclusions Deciding on the use of the SWD involves aspects and considerations from different disciplines not all of which have been discussed before. Pros and cons of this design should be balanced in comparison to other feasible design options as to choose the optimal design for a particular intervention study.
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Kars MC, Grypdonck MHF, de Bock LC, van Delden JJM. The parents' ability to attend to the "voice of their child" with incurable cancer during the palliative phase. Health Psychol 2015; 34:446-52. [PMID: 25822058 DOI: 10.1037/hea0000166] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE In pediatric oncology, parents want, and are expected, to act and decide in the best interest of their child. A recent qualitative study (PRESENCE study) indicated that parents had difficulty in doing so. The aim of this subanalysis was to describe and offer an explanation for the parents' actions in expressing and handling of "the voice of the child." METHOD A multicenter, qualitative research study comprising 37 interviews conducted with 34 parents of 17 children with incurable cancer, cared for at home, during the palliative phase. A thematic analysis was conducted. RESULTS The "voice of the child" becomes manifest in the parents' expressions of the child's needs and perceptions. Parents who actively searched to understand their child's inner perspective used direct and indirect strategies. Parents preferred indirect strategies when their child avoided talking or when they considered the conversation as threatening for the child, or for themselves. Even if the parents show an intense involvement in the care and support of their child; they can still have difficulty acknowledging the child's perspective. An inability to take into account the child's perspective was largely due to the parents' own struggle to cope with loss. CONCLUSIONS Whether or not the voice of children approaching the end-of- life is heard, often depends on their parents' ability to give them a voice. Professional caregivers have a difficult task in supporting parents in giving their child his or her voice, while at the same time preserving their, and their parents', ability to cope.
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Niemansburg SL, Tempels TH, Dhert WJA, van Delden JJM, Bredenoord AL. Societal impacts of regenerative medicine: reflections on the views of orthopedic professionals. Regen Med 2015; 10:17-24. [PMID: 25562349 DOI: 10.2217/rme.14.69] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
As the amount of clinical studies in orthopedic regenerative medicine (RM) is increasing, it is time to take into account its impact on society. A total of 36 biomedical professionals working at the front row of orthopedic RM were interviewed to explore their attitudes, opinions and expectations regarding the societal impacts of RM. Professionals mainly recognized the societal impacts of counteraction of aging, prevention of disease and social justice. The 'soft' sides of these impacts were hardly mentioned. Whereas they did not perceive themselves in the position to mitigate these impacts, professionals should take up their role as actor and become involved in the societal debate. This is important as they can co-shape the societal impacts during the developmental process of technologies and thereby stimulate responsible innovation.
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Dekking SAS, van der Graaf R, de Vries MC, Bierings MB, van Delden JJM, Kodish E, Lantos JD. Is a New Protocol for Acute Lymphoblastic Leukemia Research or Standard Therapy? Pediatrics 2015; 136:566-70. [PMID: 26283776 PMCID: PMC4893943 DOI: 10.1542/peds.2014-2327] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2014] [Indexed: 11/24/2022] Open
Abstract
In the United States, doctors generally develop new cancer chemotherapy for children by testing innovative chemotherapy protocols against existing protocols in prospective randomized trials. In the Netherlands, children with leukemia are treated by protocols that are agreed upon by the Dutch Childhood Oncology Group. Periodically, the Dutch Childhood Oncology Group revises its protocols. Sometimes, these revisions are categorized as research, sometimes as treatment. In this Ethics Rounds, we analyze whether enrollment in a new protocol ought to be considered research and, if so, we discuss the implications of that designation. Our discussion highlights the different ways different countries approach complex issues of research ethics.
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Martins Pereira S, Pasman HR, van der Heide A, van Delden JJM, Onwuteaka-Philipsen BD. Old age and forgoing treatment: a nationwide mortality follow-back study in the Netherlands. JOURNAL OF MEDICAL ETHICS 2015; 41:766-770. [PMID: 25896928 DOI: 10.1136/medethics-2014-102367] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 02/27/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND The ageing of the population raises the need to study forgoing treatment decisions among older people. AIM To describe the incidence and decision-making of forgoing treatment and identify age-related differences. METHODS A nationwide study of a stratified sample from the Statistics Netherlands death registry to which all deaths were reported in 2010. All attending physicians of those deaths received a questionnaire about end-of-life decisions. 6600 cases were studied. We examined three age groups: 17-64, 65-79, and 80 and above. Logistic regression analyses were performed to identify age-related differences controlling for other patient characteristics. RESULTS Forgoing treatment occurred in 37% of the total population, with a significant increase in the incidence across age. The most common treatments withheld/withdrawn were artificial hydration/nutrition, medication and antibiotics. Age-related differences were found, especially for withholding artificial hydration/nutrition among patients aged 65-79 (OR 2.04), and for withdrawing medication (OR 2.51) and antibiotics (OR 2.10) among the oldest when compared to the youngest patients. The most common reason for making the decision was 'no chance of improvement'. The likelihood of forgoing treatment due to 'loss of dignity' was higher for the oldest (OR 2.32), as well as due to the request/wish of the patient (OR 1.97), when compared to the youngest patients. CONCLUSIONS Forgoing treatment occurred in a substantial proportion of older people, and more often than in younger age groups. The avoidance of burdensome treatment solely to prolong life suggests a better acceptance that these patients are nearing death.
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Schouten HJ, Geersing GJ, Oudega R, van Delden JJM, Moons KGM, Koek HL. Response to Richard Schreiber: diagnosing pulmonary embolism in frail older adults out of the hospital. J Am Geriatr Soc 2015; 63:1049-50. [PMID: 25989582 DOI: 10.1111/jgs.13419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Dekking SAS, van der Graaf R, Kars MC, Beishuizen A, de Vries MC, van Delden JJM. Balancing research interests and patient interests: a qualitative study into the intertwinement of care and research in paediatric oncology. Pediatr Blood Cancer 2015; 62:816-22. [PMID: 25728244 DOI: 10.1002/pbc.25444] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 01/05/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Traditionally, in ethical guidelines and in research ethics literature, care and research are clearly separated based on their different objectives. In contrast, in paediatric oncology, research and care are closely combined. Currently, it is unknown how relevant actors in paediatric oncology perceive this combination of research and care. We conducted a qualitative study into the experiences of those involved in Dutch paediatric oncology with the intertwinement of research and care and the dual role of paediatric oncologists as researchers and treating physicians. PROCEDURE A qualitative study approach, using two focus groups and 19 semi-structured, in-depth interviews with paediatric oncologists, research coordinators, parents of children with cancer, and adolescents with cancer. RESULTS Four themes characterize how actors experience the intertwinement of research and care in paediatric oncology. First, research is considered of major importance, and paediatric oncology professionals convey this message to patients and their parents. Second, there is ambiguity about categorization of studies into cancer therapy as either research or treatment. Third, role conflicts appear within the work of the paediatric oncologists. Finally, the various benefits of combining treatment with research are emphasized. CONCLUSIONS Research is regarded as a fundamental and indispensable characteristic of paediatric oncology practice. Paediatric oncology professionals, parents, and patients have a very positive outlook on combining research and care, but they may not be sufficiently critical with respect to potential conflicts. Increased reflection on how to optimally combine research and care could serve as an important protection of the interests of children with cancer and their parents.
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van der Graaf R, Koffijberg H, Grobbee DE, de Hoop E, Moons KGM, van Thiel GJMW, de Wit GA, van Delden JJM. The ethics of cluster-randomized trials requires further evaluation: a refinement of the Ottawa Statement. J Clin Epidemiol 2015; 68:1108-14. [PMID: 25910909 DOI: 10.1016/j.jclinepi.2015.03.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 02/24/2015] [Accepted: 03/23/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The Ottawa Statement is the first guidance document for the ethical and scientific conduct of cluster-randomized trials (CRTs). However, not all recommendations are straightforward to implement. In this paper we will reflect in particular on the recommendation on identifying human research subjects and the issue to what extent the randomization process should be disclosed if there is a risk of contamination. STUDY DESIGN AND SETTING The Ottawa Statement was thoroughly evaluated within a multidisciplinary research team, consisting amongst others of epidemiologists and ethicists. RESULTS Patients in a CRT may also be considered as research subjects if they are indirectly affected by the studied interventions in a CRT. Second, health care workers are research subjects in CRTs but have a different moral status compared with ordinary research participants. This different status has implications for withdrawal and the choice of the primary objective. Third, modified informed consent for CRTs may be obtained when researchers can demonstrate that disclosure of the randomization process would affect the validity of a CRT. CONCLUSION Recommendations of the Ottawa Statement on identifying the research subject and providing informed consent can and should be refined.
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