The ethics of randomised controlled trials from the perspectives of patients, the public, and healthcare professionals

[Perceptions of patients and physicians involved in clinical trials: an overview of the literature]

OBJECTIVE - METHOD: The purpose of this review is to explore the expectations of patients and physicians prior to participate to a clinical trial and their positive or negative experiences after participating. A systematic review of Medline database from 1966 to 2005 identified 79 papers reported patients and physicians perceptions of clinical trials (only 3 in French), whom 27 English surveys conducted on patients and physicians.

RESULTS

If primary patients' motivation for enrolment was altruistic, physicians wish to help their patient. After enrolment, the most perceived positive benefit for patients and physicians are, respectively, the emotional improvement and the greater opportunity for personal benefit offered to enrolled patients. Most physicians' negative experience included logistical difficulties while patients are unease with randomisation and often uncomfortable with medical procedures. Unlike patients, all physicians' expectations seem to be fulfilled.

CONCLUSION

The knowledge of patients' and physicians' perception of participation may improve recruitment in clinical trials.

Do cancer patients fully understand clinical trial participation? A pilot study to assess informed consent and patient expectations

BACKGROUND

Accepted practices of informed consent often result in suboptimal patient understanding of research studies.

METHODS

This pilot study aimed to assess trial-specific tailored materials, compared to a widely used generic booklet about clinical trials, randomly assigned to 118 candidates for cancer clinical trials. Study outcomes were: satisfaction with decision-making; satisfaction with materials; and subjective understanding of the clinical trial.

RESULTS

There were no major differences between groups. Participants rated tailored materials higher as a useful reference.

CONCLUSIONS

Trial-specific materials hold utility for reference during clinical trials. Studies of informed consent are feasible, although important factors limit research.

Discussing the relationship between quality care and cost-effective care in Swiss pediatric wound care

The growing individual and public demand for high-quality care within a context of restricted budgets dominates the political as well as medical agenda. This demand for "quality care" has developed an "industry" and lobby relating to auditing practice even in the small subpopulation of pediatric surgical patients. With children, complex and nonhealing wounds are quite rare, but there are pressures to provide modern and high-quality wound care even in Switzerland. Thus, in accordance with practice in neighboring countries, guidelines for wound care have been established in the Swiss healthcare sector. Their validity and reliability in the context of cost-effective versus quality care are critically discussed in this paper.

Duty, desire or indifference? A qualitative study of patient decisions about recruitment to an epilepsy treatment trial

BACKGROUND

Epilepsy is a common neurological condition, in which drugs are the mainstay of treatment and drugs trials are commonplace. Understanding why patients might or might not opt to participate in epilepsy drug trials is therefore of some importance, particularly at a time of rapid drug development and testing; and the findings may also have wider applicability. This study examined the role of patient perceptions in the decision-making process about recruitment to an RCT (the SANAD Trial) that compared different antiepileptic drug treatments for the management of new-onset seizures and epilepsy.

METHODS

In-depth interviews with 23 patients recruited from four study centres. All interviews were tape-recorded and transcribed; the transcripts were analysed thematically using a qualitative data analysis package.

RESULTS

Of the nineteen informants who agreed to participate in SANAD, none agreed for purely altruistic reasons. The four informants who declined all did so for very specific reasons of self-interest. Informants' perceptions of the nature of the trial, of the drugs subject to trial, and of their own involvement were all highly influential in their decision-making. Informants either perceived the trial as potentially beneficial or unlikely to be harmful, and so agreed to participate; or as potentially harmful or unlikely to be beneficial and so declined to participate.

CONCLUSION

Most patients applied 'weak altruism', while maintaining self-interest. An emphasis on the safety and equivalence of treatments allowed some patients to be indifferent to the question of involvement. There was evidence that some participants were subject to 'therapeutic misconceptions'. The findings highlight the individual nature of trials but nonetheless raise some generic issues in relation to their design and conduct.

"It's no skin off my nose": why people take part in qualitative research

In this article, the authors analyze participants' accounts of why they took part in a repeat-interview study exploring newly diagnosed patients' perceptions of diabetes service provision in Lothian, Scotland. The study involved three semistructured in-depth interviews with each patient (N = 40), which spanned a year. The authors provide a thematic discursive analysis of responses to the question, Can I ask you what made you decide to part in the study and why you've stayed involved over the past year? The main themes are (a) recruitment within health contexts ("the nurse said it would help"), (b) altruism ("if it can help somebody"), (c) qualitative research being seen as inherently innocuous ("nothing to lose"), and (d) therapeutic aspects of interviewing ("getting it off my chest"). The analysis contributes both to the qualitative literature about generic research participation and to a germinal literature exploring qualitative health research participation.

Perception des essais cliniques par les patients et les investigateurs : enquête à l’hôpital Neuro-Cardiologique de Lyon

OBJECTIVES

We report the first survey on French physicians and patients participating to assess motivations prior enrolment and benefits and constraints perceived after participation.

METHOD

Twenty physicians were interviewed and 37 patients completed a questionnaire during clinical study participation.

RESULTS

If the main patient's motivation is altruistic, physician wish their own patient feel better. After participation, patient is satisfied with being part of a research effort and contributing to medical science. Effect of trial treatment on physical well-being seems less pronounced. Main constraint is the randomisation to placebo group. For physicians, the main benefit is getting research experience and training. Main constraints are logistical. Otherwise, perceptions on the same clinical trial depend on participant. In fact, physician usually overestimates constraints of clinical trial for patient.

CONCLUSION

The knowledge of patients and physicians perceptions of clinical trials and its taking into account should probably reduce difficulties in the recruitment in France.

Understanding the decisions of cancer clinical trial participants to enter research studies: factors associated with informed consent, patient satisfaction, and decisional regret

OBJECTIVE

To understand the psychosocial outcomes related to decision-making processes of individuals eligible for participation in clinical trials.

METHODS

Individuals eligible to participate in selected clinical trials were contacted to complete two surveys; one shortly after participants were identified, and the second 6 weeks after the first survey was completed (N=50). Measures included subjective informed consent; satisfaction with decision-making; decisional regret; and timing of consent (early versus late signers). ANOVA and correlation coefficients were used to test the relationships between variables.

RESULTS

Early signers reported themselves to be less informed about the details of their particular clinical trials than later signers (M=81.9 versus 91.2; F=5.5; p=.02). There was a non-significant trend for early signers to be less satisfied with their decisions than late signers. Satisfaction with decision-making and subjective informed consent were both strongly associated with later decisional regret (r=-.32 and -.30, respectively). However, there was no relationship between timing of consent and decisional regret.

CONCLUSION

Participants who enroll in clinical trials quickly may not believe they fully understand the implications of trial participation. In general, participants who do not believe they fully understand the implications of trial participation, or who are less satisfied with their decision to enroll in the trial may ultimately feel regret about their decision to participate.

PRACTICE IMPLICATIONS

More effort is needed to ensure that clinical trial participants fully understand the risks and benefits of participation and are satisfied with their decision to enroll in a trial prior to signing consent forms.

Consent for neonatal research

Inherent to all medical research is respect for the rights of the individual. Neonatal research is made more complex by the issue of proxy consent. Obtaining valid informed consent for entry of an infant into a research project needs to deal with this complexity. New evidence on the role and responsibilities of parents in giving consent has implications for all clinical staff that are considering embarking on and/or recruiting infants in research projects. This review explores the issues around informed consent for neonatal research and provides a framework by which consent could be improved. It is to be hoped that such improvements to the process will increase recruitment of infants to research studies while enhancing the validity of the consent process.

Descriptive ethics: a qualitative study of local research ethics committees in Mexico

OBJECTIVE

To describe how local research ethics committees (LRECs) consider and apply research ethics in the evaluation of biomedical research proposals.

DESIGN

A qualitative study was conducted using purposeful sampling, focus groups and a grounded theory approach to generate data and to analyse the work of the LRECs.

SETTING AND PARTICIPANTS

11 LRECs of the Mexican Institute of Social Security (IMSS).

RESULTS

LRECs considered ethics to be implicit in all types of research, but that ethics reviews were only necessary for projects that included the direct participation of human beings. The LRECs appeared to understand the importance of consent, as in the completion of a consent form, but did not emphasise the importance of the process of acquiring 'informed' consent. The committees considered their main roles or functions to be: (a) to improve the methodological quality of research and to verify - if applicable - the ethical aspects; (b) to encourage personnel to undergo research training; (c) to follow-up research to oversee the adherence to norms and compliance with a specified research timetable.

CONCLUSIONS

This study provides a valuable insight into how these LRECs understand the ethical review process. The emphasis of the committees was on rules, regulations, improving research methodology and research training, rather than a focus on efforts to protect the rights and well being of research subjects. The results encourage further normative and descriptive lines of investigation concerning education and the development of LRECs.

Are You Sitting Comfortably? Perspectives of the Researchers and the Researched on “Being Comfortable”

In a study of volunteers in medical research, we found contrasting readings of "being comfortable" by the volunteer research subjects and the researchers. Although the experimental process (testing a new kind of diagnostic technology) involved some physical discomfort--and the researchers focused on this--the volunteers' concerns centred on feeling socially comfortable and managing feelings of embarrassment or isolation, and they generally made light of the physical aspects. The bias of volunteer concerns, which is understandable in terms of the different situations of researchers and volunteers and the different tensions they create, has potential implications for the engagement of researchers with their research subjects and prevailing standards for the ethical and accountable conduct of research.

Patients or research subjects? A qualitative study of participation in a randomised controlled trial of a complex intervention

OBJECTIVE

To explore participants' understandings regarding treatment decisions, made within an efficacy randomised controlled trial (RCT) of decision-support tools.

METHODS

Qualitative study: interviews (audio-recorded) with participants. Participants were interviewed 3-5 days after using a decision-support tool (n=30) and again at 3 months (n=26). Transcripts were analysed using a constant comparative approach.

RESULTS

Participants' understandings were shaped by the ways in which they made sense of their participation. Participants made attributions about their trial identity that fell on a continuum. At one end we found participants who identified as 'experienced medical volunteers', and at the other those who identified as 'real patients'. In the participants' accounts, a trial identity of 'patient' accompanied an expectation that the decision-support tools offered a means of making treatment decisions. 'Volunteers', however, saw the interventions as tasks to be completed for the purposes of the trial team.

CONCLUSION

In our study, trial identity shaped participants' understandings regarding treatment decisions and all other aspects of the trial.

PRACTICE IMPLICATIONS

Different understandings regarding the appropriate response to trial tasks may affect behaviour and therefore outcomes in some trials. Further research is required to unravel the relationship between trial identities, understanding and behaviour.

Evidence-based medicine and its role in ethical decision-making

The recent emergence of evidence-based medicine (EBM) presents medical ethics with the challenge of analyzing what is the current best medical evidence in ethical decision making. This article concludes that the use of the best available, most recently published research findings is a primary moral obligation. However, this does not automatically mean that the use of these research findings will lead to better ethical decision making. Research data can be distorted by methodological failings in the design and reporting of experiments, or by technical and commercial bias. Moreover, the introduction of norms, values, principles and ethical theories can lead to other choices than those proposed by empirical research findings. Ethical decision making must be informed and legitimated by the best available medical research. Nevertheless, ethical decision making is still primarily a choice based on values and norms.

Retention in a Breast Cancer Risk Information Trial: Motivations of a Population-Based Sample of Women

A better understanding of factors influencing retention in breast cancer risk education and prevention programs can improve the design and effectiveness of such programs. Such information may also be useful to researchers seeking to maximize full retention in research trials involving low risk and low perceived benefit by the participants. These data are from a population-based study of 481 women from the Seattle, Washington, area, with diverse levels of breast cancer risk. This study sought to describe motivations for retention, to relate motivation variables to demographic characteristics, and to evaluate predictors of retention. Increasing age predicted study assessment completion, and both cancer worry and White ethnicity predicted intervention retention.

Perspectives on medical research involving men in schizophrenia and HIV-related protocols

Ethical issues in research on serious physical and mental illnesses have received great attention, and yet little is known about how the perspectives of clinical research participants with different diagnoses may compare. We conducted a preliminary study to examine the attitudes of men enrolled in schizophrenia-related protocols and in HIV-related protocols regarding the importance of medical research, key aspects of research participation, and the acceptability of research involvement by various groups. A total of 33 men enrolled in schizophrenia protocols and 15 men enrolled in HIV-related protocols volunteered for our study. Respondents affirmed the importance of medical research and endorsed many positive things about participation. Autonomy and altruism were identified as motivators for research involvement. Participation by diverse groups was seen as acceptable. Respondents expressed comfort and little stress with the interview process. Men in different diagnostic groups largely saw the issues the same. Our findings thus suggest that people with schizophrenia and HIV/AIDS who are enrolled in protocols may share a number of core attitudes or beliefs related to ethical aspects of research participation. Further study is needed to explore how research involvement may influence perspectives and whether differences in views exist across people with diverse physical and mental illnesses.

A brief measure of perceived understanding of informed consent in a clinical trial was validated

BACKGROUND AND OBJECTIVE

To develop and evaluate an Informed Consent Questionnaire (ICQ) for measuring self-reported perceived understanding of informed consent in a randomized clinical trial.

METHODS

The study was embedded in a Department of Veterans Affairs randomized clinical trial of Gulf War veterans' illnesses (CSP#470). The trial was initiated in May 1999 at 20 hospitals and concluded in September 2001; 1,092 participants were enrolled and followed for 12 months. The reliability and validity sample included 1,086 participants evaluated at baseline, 906 at 3 months, 929 at 6 months, and 910 at 12 months. The psychometric evaluations included tests of acceptability (based on missing data, endorsement frequencies, and floor/ceiling effects), item reduction, internal consistency, and construct validity (based on Cronbach's alpha coefficients, item-total correlations, and principal components analysis).

RESULTS

The ICQ had >5% missing information on some questions at baseline, indicating poor acceptability prior to the initiation of the trial; however, the scale had good acceptability at each of the follow-up visits. Psychometric evaluation following standard item reduction techniques confirmed the reliability and validity of a four-item subscale of the ICQ (ICQ-4).

CONCLUSIONS

The ICQ-4 is a simple and psychometrically sound self-report measure of perceived understanding of informed consent.

Difficultés du transfert d’information en vue d’un consentement éclairé

PURPOSE OF THE STUDY

Delivering information to the patient, an ethical obligation recognized for years, has recently become a legal obligation. Proof of information delivery has become the legal responsibility of the surgeon. We conducted a prospective study to evaluate the quality of information transfer by assessing patient comprehension of information delivered in an orthopedic surgery unit.

MATERIAL AND METHODS

All patients attending consultations before undergoing arthroscopic treatment for rotator cuff tendinopathy were enrolled in this study when the consultation was conducted in the presence of an observer. Two questionnaires, one for the patient and one for the surgeon, were used to collect given information about the pathological condition, the modalities of treatment, and the expected results of the treatment and its complications.

RESULTS

All 21 patients included in the study considered they had been well informed and that they had understood their pathological condition as well as the complications of the proposed treatment. However, agreement between their stated comprehension and the information delivered was poor, varying from 15 to 50%. Furthermore, 90% of the patients stated they had understood the potential complications of the surgical procedure, despite the fact that the consulting surgeons had not (generally) provided information on such complications.

DISCUSSION

There is a gap between what the surgeon says (or thinks he/she says) and what the patient understands. Potential biases in this study (non-unbiased observer) might explain this discordance which was probably related to the unequal relationship between the patient and the physician for any consultation. Therefore, the basis of informed consent cannot be found in the details concerning complications actually delivered to the patient. Surgeons must become aware that the patients understand very little of their explanations. This does not mean that the information should not be delivered but on the contrary that it must be. The important point is not necessarily the information content but rather the quality of the human relationship enabling information transfer.

Willingness of subjects with thought disorder to participate in research

Greater attention is being focused on the willingness and motivations of potential subjects who are recruited for research protocols. Given the importance of subjects' abilities to choose freely and reason through their decisions about entering psychiatric research, empirical researchers have been developing assessment and education tools that address the potential vulnerabilities of research subjects. In this study subjects' responses and reasons for or against participation were elicited as part of an assessment of their research decision making. Fifty-two persons diagnosed with a thought disorder were asked to consider a hypothetical research study using the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR). Their responses were documented, coded for content, and correlated with demographic characteristics and scores on scales rating psychosis, cognition, and health-related quality of life. Subjects expressed common considerations that have been identified by other psychiatric investigators, as well as by those studying nonpsychiatric protocols. In general, reasons were both appropriate to the study being considered and appropriately linked to common considerations that flowed logically from the study. However, elements of the therapeutic misconception were evident as well. Willingness to participate was correlated with higher MacCAT-CR scores on certain scales, better education, and lower levels of psychosis and cognitive impairment. These findings highlight both the strengths and weaknesses of the decision making of research subjects with thought disorder. Research protections and assessments may consequently be appropriately targeted to specific vulnerabilities. Because of differences in severity of illness, cognition, and reasoning among subjects who decline to participate in research, greater attention to this population appears warranted.

Informed consent and participant perceptions of influenza vaccine trials in South Africa

BACKGROUND AND OBJECTIVES

There are few insights from sub-Saharan Africa on research participants' experiences of the informed consent process, particularly in the context of randomised controlled trials, where issues of randomisation and the use of placebos may be confusing concepts for participants. This study investigated the knowledge and perceptions of the informed consent process among individuals participating in influenza vaccine trials in two disadvantaged communities in South Africa.

METHOD

Four to 12 months after completion of the trials, participants were contacted to return to participate in the informed consent study. The semistructured questionnaire administered to assess recall of trial procedures and the informed consent process covered key issues including: purpose of the study; awareness that the study was not part of routine treatment; voluntary nature of participation and freedom to withdraw; randomisation; placebos; and remuneration.

RESULTS

A total of 334 participants (93% of the original vaccine trial sample; mean age 68 years, median level of education grade 8, 69% women) completed the questionnaire. Only 21% were able to recall that they were allocated randomly to the different treatment arms. Only 19% of those involved in the placebo controlled study had interpreted the concept of placebo as an inactive medication.

CONCLUSION

Although a good general recall of trial concepts was demonstrated, only a small proportion of the participants correctly interpreted and recalled the concepts of randomisation and placebos. Informed consent in this and similarly disadvantaged communities may often be inadequate and new ways to improve understanding of the research process should be explored.

The ethics of placebo-controlled trials: a comparison of inert and active placebo controls

Because of the recent and controversial example of sham surgery for the evaluation of fetal tissue transplants for Parkinson's disease, there is renewed interest in the ethics of using "active" placebos in surgical trials, where otherwise there are no inert procedures available, and in pharmacological trials, where there are inert substances, but where patients may guess to which arm they have been allocated. This paper seeks to clarify the ethical arguments surrounding the use of active placebos in trials, and to set up a notation for assessing the ethics of trials more generally. We first establish an framework by which ethics committees can analyze such trials. We examine (1) the scientific value of the research; (2) the expected risks and benefits to individual patients, and (3) the voluntary nature of consent. We then contrast the implications of this framework for inert and active placebo-controlled trials, respectively. In particular, we analyze their relative expected utility using three main utility factors, namely, treatment effects, placebo effects, and altruism. We conclude that, when the intervention is already widely available, active placebo trials rely more heavily on altruism than do inert placebo trials and, when the intervention is restricted, this excess reliance may not be needed. What our analysis provides is the explicit justification for the apparent caution of Institutional Review Boards or ethics committees when reviewing sham operations, especially when the expected harm is not trivial and the risk of exploitation is high.

Volunteer human subjects' understandings of their participation in a biomedical research experiment

The paper focuses on how volunteer human subjects in research understand their own participation in experimentation. We ask how they view their own role, the experimental setting, and how they articulate their understanding of the researcher-subject relationship. The empirical basis of the study is participant-observation and qualitative semi-structures interviews with volunteers in an experimental setting far removed from the more commonly studied randomised control trial (RCT), namely, the early stage testing of a prototype instrument for breast imaging. Analysis of this empirical data leads us to conclude that research subjects do not conform solely to one or other of the models of the researcher-subject relationship suggested in the literature. Rather, the interaction needs to be considered as a social situation which volunteer subjects actively negotiate in real time. They move through multiple roles and identities as part of the navigation through unfamiliar social territory, in order to establish a relationship in which they can feel socially comfortable and appropriately valued.

Research participation and the right to withdraw

Most ethics committees which review research protocols insist that potential research participants reserve unconditional or absolute 'right' of withdrawal at any time and without giving any reason. In this paper, I examine what consent means for research participation and a sense of commitment in relation to this right to withdraw. I suggest that, once consent has been given (and here I am excluding incompetent minors and adults), participants should not necessarily have unconditional or absolute rights to withdraw. This does not imply that there should be a complete absence of rights, or, indeed, an abandonment of the right to withdraw. The point of this paper is to show that the supposed unconditional or absolute nature of these rights may be self-defeating and so fail to respect the autonomy of participants. In addition, and on a more positive note, I suggest that, attaching certain conditions on the right to withdraw, may better respect the autonomy of these participants by underlining the idea that autonomy is more than mere whim or indifference to the fate of others. On the contrary, research staff are currently unable to 'push' participants, who may merely have logistical difficulties unrelated to the research itself, but who really want to stay the course, for fear of coercing them. Furthermore, researchers now try to 'screen out' people they think may be unreliable to protect the science of the study and so groups at risk of dropping out may be unfairly denied access to research treatments. I conclude that on-going negotiation between the relevant parties could be on balance the only truly acceptable way forward but concede certain important limitations to take into account.

The Study Centre of the German Surgical Society--rationale and current status

BACKGROUND

The concept of evidence-based medicine was introduced into surgery in the mid-1990s, initially focussing on the integration of best research evidence, surgeons' expertise and patients' value. The lack of relevant external evidence [randomised controlled trials (RCTs), systematic reviews] in favour of surgical procedures has led to the need for a new approach in clinical research.

DESIGN

Development and implementation of the Study Centre of the German Surgical Society (SDGC) in order to design, perform and analyse multicentre randomised controlled trials in surgery.

RESULTS

The German Surgical Society has recently initiated four surgical RCTs within the SDGC in order to improve the national infrastructure for clinical research and its international scientific standing. All surgical trials focus on procedures in various fields (thyroid and parathyroid diseases, pancreatic surgery, abdominal wall closure) and are designed to fit the specific needs of each study (blinding of patients and assessors, ranking of endpoints, patients' perspective). Additionally, in a nationwide survey of 1,274 surgical departments in Germany, 307 replied, of which 237 (19%) were willing to participate in multicentre projects.

CONCLUSION

Evidence-based medicine has changed surgical practice, leading to an increase in demand for RCTs and requiring a new infrastructure in surgical departments and scientific societies.

Factors associated with patients' loss to follow-up after finishing randomized clinical trial participation

OBJECTIVES

To study patient's follow-up after finishing participation in randomized clinical trials (RCTs), and to identify factors associated with loss to follow-up (FU).

PATIENTS AND METHODS

Medical charts of 212 rheumatoid arthritis (RA) and osteoarthritis (OA) patients from a rheumatological out-patient center were analyzed. Loss to FU was considered when patients did not return to their regular appointments within the first year after finishing their participation in an RCT assessing anti-cyclooxygenase-2 non-steroidal anti-inflammatory drugs (anti-COX-2 NSAIDs). Mann-Whitney U-test, chi2 test and Wilcoxon test were performed as appropriate. Logistic regression was performed to identify factors which might be related to loss to FU. A survey was conducted to obtain lost to FU patients' opinions. p values less than 0.05 were considered significant.

RESULTS

The mean frequency of patients' visits in the year before enrollment in an RCT was 3.73 SD 2.06, and during the year after participation was 2.6 SD 1.96 (p<0.0001). Fifty patients (23.6%) did not return to their usual rheumatologic visit. On multivariate analysis, the number of daily tablets of study medication (odds ratio (OR)=2.64, 95% confidence interval (CI) 1.1 to 6.3) and the frequency of clinical visits (OR=0.56, 95% CI 0.37 to 0.85) were associated with loss to FU (p<0.008). Lost to FU patients' opinions did not support these findings.

CONCLUSIONS

After participating in a RCT assessing anti-COX-2 NSAIDs, many patients return with less frequency, or do not return at all to their regular rheumatologic visit. Although a high number of tablets of the investigational drug and a low frequency of protocol visits may be contributors to patient loss to FU, investigators should consider that personal situations not related to the RCTs may also influence patients' return to consultation in the private setting.

Attitudes of health-care providers towards research with newborn babies

CONTEXT

By providing information and possibly shaping parents' preferences, health-care providers are thought to play a critical role in parental decisions to enroll their infants in research. Yet, little is known about health-care providers' beliefs about research with newborns. Previous studies suggest that parents and health-care providers are often at odds regarding attitudes towards research.

OBJECTIVE

To examine the attitudes of health-care providers concerning the acceptability of research with newborn babies and the degree of research-related risk to which they would be willing to expose their own infant. These findings were compared with a previous study of parental attitudes.

DESIGN, SETTING AND PARTICIPANTS

A survey (pretested questionnaire with 20 scaled items and five case scenarios) of 50 doctors and 64 nurses conducted in a large tertiary care center in western Canada.

RESULTS

Study limitations were a response rate of 64.5% among nurses but only 22% among physicians. Both doctors and nurses were strongly supportive of research with newborns, but nurses were more averse to exposing infants to risk. Only 76.0% of nurses, compared to 92.2% of physicians, agreed that informed consent should be sought for all forms of research. When results were compared with parental perceptions, health-care providers were more likely to believe that research should be conducted for the good of all babies. Parents were generally less aware of the existence of an approval process for research in general. In responding to hypothetical scenarios with risk and direct benefit, parents were less willing to enroll their infants than were health-care providers. Approximately 30% of both groups would be willing to enroll their infants in a study involving moderate risk and no direct benefit.

CONCLUSIONS

Views of nurses, physicians, and parents regarding research with newborns are different. Overall, there is support for research; however, nurses are more likely to never enroll their own baby and enroll babies into minor studies without consent.

Current practice for the laparoscopic diagnosis and treatment of endometriosis: a national questionnaire survey of consultant gynaecologists in UK

OBJECTIVE

To determine current practice regarding laparoscopic diagnosis and treatment of endometriosis.

DESIGN

A prospective questionnaire survey.

SETTING

The United Kingdom.

POPULATION

All 1411 UK consultant gynaecologists identified from a Royal College of Obstetricians and Gynaecologists database.

METHODS

A postal questionnaire was sent to all consultants with reply paid envelopes. A postal reminder was sent three months following the initial questionnaire.

MAIN OUTCOME MEASURE

Current practice for the laparoscopic diagnosis and treatment of endometriosis and willingness to participate in a randomised trial.

RESULTS

The response rate was 66% (893/1411). Diagnostic laparoscopy was performed by 87% (772/893) of respondents. Seventy-six percent of these (58/772) were confident to visually diagnose endometriosis and 6% (47/772) routinely verified the diagnosis histologically. Laparoscopic surgery was routinely undertaken by 41% (318/772) of respondents. Ablative therapy was the most frequently employed technique utilised [620/653 (95%)] and electrodiathermy was the most popular energy modality (80%). Among respondents expressing a preference, excision of disease was believed to be more effective, but less safe compared with ablation. One-third of respondents (273/893) were willing to enter patients into a randomised controlled trial to compare laparoscopic treatments for pelvic pain associated with endometriosis.

CONCLUSION

Laparoscopic surgery for endometriosis associated with pelvic pain is routinely undertaken by a large number of UK consultant gynaecologists, but techniques used and beliefs about efficacy vary. In view of this division of opinion regarding the relative roles of laparoscopic treatment methods, a randomised trial comparing the efficacy and safety of these methods is urgently needed.

Developing ethical strategies to assist oncologists in seeking informed consent to cancer clinical trials

Randomised clinical trials have come to be regarded as the gold standard in treatment evaluation. However, many doctors see the discussion of a clinical trial as an intrusion into the doctor-patient relationship and find these discussions difficult to initiate. Detailed informed consent is now a requirement of patient participation in trials; however, it is known that patients commonly fail to understand and recall the information conveyed. These difficulties for doctors and patients raise questions about the ethical integrity of the informed consent process. In this study, we have developed a set of communication strategies underpinned by ethical, linguistic and psychological theory, designed to assist doctors in this difficult task. Initially, audiotape transcripts of 26 consultations in which 10 medical oncologists invited patients to participate in clinical trials were analysed by expert ethicists, linguists, oncologists and psychologists, using rigorous qualitative methodology. A subset of seven of these was subjected to detailed linguistic analysis. A strategies document was developed to address themes which emerged from these analyses. This document was presented to relevant expert stakeholders. Their feedback was incorporated into the final document. Four themes emerged from the analysis; (a) shared decision-making, (b) the sequence of moves in the consultation, (c) the type and clarity of the information provided and (d) disclosure of controversial information and coercion. Detailed strategies were developed to assist doctors to communicate in these areas. We have developed a set of ethical strategies which may assist health professionals in this difficult area. A training package based on these strategies is currently being evaluated in a multi-centre randomised controlled trial.

Potential research participants' views regarding researcher and institutional financial conflicts of interest

BACKGROUND

Financial conflict of interest in clinical research is an area of active debate. While data exist on the perspectives and roles of academic institutions, investigators, industry sponsors, and scientific journals, little is known about the perspectives of potential research participants.

METHODS

The authors surveyed potential research participants over the internet, using the Harris Interactive Chronic Illness Database. A potential research participant was defined by: (1) self report of diagnosis by a health care professional and (2) willingness to participate in clinical trials. Email invitations were sent to 20 205 persons with coronary artery disease, breast cancer, or depression; a total of 6363 persons were screened; of these, 86% or 5478 met inclusion criteria and completed the survey. The outcome measures were respondents' ratings on: importance of knowing conflict of interest information, whether its disclosure ought to be required, and its effect on willingness to participate-across seven widely discussed scenarios of financial conflicts of interest (ranging from commercial funding to equity ownership).

RESULTS

Majority responded that knowing conflict of interest information was "extremely" or "very" important; a larger majority felt financial conflicts of interest should be disclosed as part of informed consent (64% to 87%). In all seven scenarios, a majority was still willing to participate but in some scenarios a sizable minority would be wary of participation. Respondents were more wary of individual than institutional conflicts of interest. Illness group and sociodemographic factors had modest effects and did not affect the main trends.

CONCLUSIONS

The prevailing practice of non-disclosure of financial conflicts of interest in clinical research appears contrary to the values of potential research participants.

Benefits and burdens of placebos in psychiatric research

RATIONALE

The debate over the use of placebos in clinical trials when proven treatments exist continues to be lively, especially in psychiatric research. Current practice permits placebos in such settings, as long as the benefits outweigh the risks and burdens.

OBJECTIVES

To examine in depth the risk-benefit framework typically used to justify placebo controls in psychiatric drug development, by making explicit the implicit ethical tradeoffs.

METHODS

Analysis informed by a review of currently available data on the benefits and burdens of exposing psychiatric research subjects to placebos.

RESULTS

Various risk/burden thresholds for limiting placebo controls have been proposed, ranging from the currently used standards of no increased mortality or permanent morbidity to more recent proposals of 'serious but reversible harm' and 'severe discomfort.' Placebo exposure in antidepressant and antipsychotic trials appears not to increase mortality by suicide. Direct data on long-term effects are lacking. Symptom-related burdens of placebos need to be better quantified and more integrated into the ethical analysis of placebos. While the perspective of those who benefit from the practice of using placebo controls is well represented, virtually no data from the perspective of potential subjects exist.

CONCLUSIONS

The ethical analysis of placebos in psychiatric research has an important but limited evidence base. Suggestions for areas of further inquiry to increase that evidence base are given.

Pediatric clinical trial experience: government, child, parent and physician's perspective

In contrast to investigations in adults, investigation of drugs via clinical trials has been lacking in the pediatric population. Until recently there was little incentive on the part of the pharmaceutical industry to conduct clinical trials of new drugs in children. However, government legislation approved in the late 1990s has promoted efforts to investigate the effects of drugs in the treatment of a variety of children's diseases. Such data provide important and needed information on appropriate dosing, rates and types of adverse reactions and efficacy for treatment of pediatric illnesses. The conduct of clinical trials in children is dependent on a careful dialogue between the investigator, child and guardians wherein a detailed description of benefits vs. risks is conveyed. The focus of this paper is to summarize various perspectives on conducting clinical trials in children, including those of the government, the child, the parents or guardians and the investigator. Although children now have access to new medicines during the development process, their participation in clinical trials must still protect them from undue risk and secure their well being.

Occlusion: Reflections on science and clinical reality

The last 50 years have seen progress in emphasizing scientific evidence as a basis for dental practice, including occlusal therapy. Although a proper understanding of the contributory role of occlusion to temporomandibular disorders should not be minimized, the importance of occlusion in other areas of dental education and practice should not be overlooked. The primary objective of this article is to discuss the nature of this problem as it relates to the duality of science and clinical reality in the evidence-based paradigm, information transfer, quality of evidence, clinical trials, and clinical aspects of occlusion. Some suggested solutions for the problem and thoughts on past and future perspectives of occlusion are expressed in context of inquiry.

Ethical aspects of placebo in migraine research

Randomized placebo-controlled clinical trials have been the 'golden standard' during the last decades in the development of new drug therapies. This scientifically valid approach has recently been questioned in the fifth revised version of the Declaration of Helsinki, which states that the use of placebo-controlled clinical trials is only acceptable when no proven treatment exists for the studied disease. The World Medical Association further claims that no national ethical, legal or regulatory requirements should be allowed to reduce or eliminate any of the statements in the declaration. In spite of this, the document is not generally accepted as the world ethical standard, as demonstrated by its lack of adoption by many professional associations. In the evaluation process for a drug to be approved in many countries today, clinical investigators at the hospitals and researchers at the pharmaceutical companies are obliged to use study protocols that would be rejected if the new declaration were to be fully adopted. Adherence to the clinical trial guidelines of the International Headache Society could also mean violation of the new Helsinki declaration of ethics. Some ethics committees have already adopted the new declaration, which has caused concern among clinical investigators, who find this document to be vastly out of the line with common practice. At the moment, the situation is unclear and debated with increasing polarity concerning the scientific and ethical issues regarding the use of placebo in clinical trials.

Research methods: beyond the clinical trial

Emergency medicine differs from other specialties in that it has few restrictions in terms of pathology or patient group but is instead defined by time, with patients being selected on the basis of urgency. The important research questions generated by emergency medicine are therefore often complex and relate to organizational, economic, or social issues. Clinical trials have a limited role to play in these circumstances, and concepts such as the hierarchy of evidence might be unhelpful if the best methodology is not appropriate to the research question. Emergency medicine researchers therefore need to be prepared to use a wide range of methods, often in combination and often drawing on the social sciences. This article will introduce readers to methods from clinical epidemiology, operational research, health economics, and qualitative research, discussing the value of these approaches and identifying potential pitfalls.

Participating in the United Kingdom Prospective Diabetes Study (UKPDS): a qualitative study of patients' experiences

The United Kingdom Prospective Diabetes Study (UKPDS) is one of the longest and largest clinical trials ever conducted. It explored the effects of intensive blood glucose and blood pressure control on the development of complications in patients with type 2 diabetes. Patients took part in this trial for up to 20 years and the drop-out rate was extremely low. The aim of this discussion paper is to explore patients' motivations for joining the UKPDS and for remaining in the trial, and to examine the implications of findings for good practice before, during, and after clinical trials. A qualitative, exploratory study was undertaken, involving former UKPDS patients (n = 10) at Northampton General Hospital, England. In-depth, semi-structured interviews were undertaken and the data analysed using grounded theory approaches. The results showed that patients were motivated to join the UKPDS because they believed this would give them the best clinical care and reduce the threat of the disease. However, all of the patients identified unanticipated benefits of trial participation, to which they attributed their strong commitment to the UKPDS. These included the reassurance provided by regular clinical examinations, the personal nature of clinical care, and the welcome discipline imposed by UKPDS professionals. Transition back to primary care at trial closure could be a lonely experience, despite follow-up being seen as competent. Practitioners involved in recruiting patients for clinical trials should be aware that participants may be motivated by the desire for better clinical care, irrespective of randomisation consequences. Those taking back the clinical care of trial participants with chronic disease may wish to consider a 're-entry' interview, to minimise trial bereavement.

What is the best way to help caregivers in cancer and palliative care? A systematic literature review of interventions and their effectiveness

Informal carers in cancer and palliative care are known to have high needs and psychological morbidity, yet a literature review identified few targeted interventions. This systematic review of interventions for carers of patients using home cancer and palliative care services searched Medline, CancerLit, Psycinfo and Cinahl databases. The terms used were carer(s), caregiver(s), palliative and cancer. Papers that reported interventions for adults actively providing informal care for noninstitutionalized cancer and palliative care patients were reviewed. Twenty-two interventions were identified, comprising home nursing care (four), respite services (three), social networks and activity enhancement (two), problem solving and education (three) and group work (10). Of these, nine were delivered solely to carers (i.e., were targeted services). Only six of the carers' interventions had been evaluated, two of these had used a randomized control trial (RCT; grades IB), three employed a single group methodology (two prospective grades IIIC and one retrospective grade IIIC) and one was evaluated using facilitator feedback. There was a lack of outcome evaluation designs, small sample sizes and a reliance on intervention descriptions and formative evaluations. Methodological challenges may mean alternatives to 'pure' RCTs should be considered. The current evidence contributes more to understanding feasibility and acceptability than to effectiveness. Practitioners and evaluators must prioritize the further development of intervention studies.

Ethics, data-dependent designs, and the strategy of clinical trials: time to start learning-as-we-go?

The seeds of modern clinical trials were unwittingly sown with the first use of randomization in a 1920s agricultural field experiment. The historical development of trials is briefly reviewed here, as are multifarious pressures and problems faced by those involved with clinical trials today. These challenges include recruitment difficulties, the emerging role of patient support groups, and legal threats over informed consent, to name three. Fundamentally, they reflect an overall shift towards patient-centred, individual ethics. I suggest many problems may be overcome by increased implementation of hitherto neglected, data-dependent designs for clinical trials. Over a dozen arguments against their use are countered, primarily through ethical considerations. Benefits and costs of refining clinical trials strategy are explored hypothetically under enhanced use of such 'learn-as-you-go' designs, in contrast to traditional, equal-allocation, fixed-sample-size and frequentist-based designs. These latter methods mirror crop field trials in which one cannot make scientific progress until after gathering objective data at harvest time. Some attempts to alleviate certain problems, such as Zelen randomization to boost recruitment, or over-reliance on 'large and simple trials' to detect moderate-sized treatment effects, are discussed and found inadequate. A proposal for wider discussion is made to assist the selective introduction of 'small and complex trials,' which could simultaneously expedite medical research, satisfy the concerns of regulators, statisticians, and doctors alike, and help address the growing demands of 21st-century patients.

Informing breast cancer patients about clinical trials: a randomized clinical trial of an educational booklet

BACKGROUND

To evaluate the impact of an educational booklet on women's knowledge of and willingness to participate in a randomized clinical trial of treatment for breast cancer.

MATERIALS AND METHODS

Women undergoing surgery for newly diagnosed early stage breast cancer were randomized to receive, or not, an information booklet explaining the need for and manner in which randomized trials are conducted.

RESULTS

Eighty-three women with newly diagnosed early stage breast cancer completed a questionnaire assessing attitudes to random clinical trials (RCTs) and were randomized to receive usual information treatment options provided from their oncologist, or the educational booklet in addition to usual information from their oncologist (42 usual information, 41 booklet). Fewer women who received the clinical trials booklet (40% versus 47%) would consider participating in the hypothetical clinical trial (P = 0.6). Mean knowledge scores increased for both groups; moreover, women who did not receive the booklet showed similar improvements to women who received the booklet [mean difference 0.09, 95% confidence interval (CI) -0.66 to 0.83]. In a multivariate analysis women who would consider participating in the clinical trial were more anxious [odds ratio (OR) 5.9, P = 0.02] had involved lymph nodes (OR 5.8, P = 0.02) and were less influenced by negative aspects of clinical trials (OR 7.7, P = 0.0001). After adjustment for these variables women who received the educational booklet were significantly less likely to consider trial participation (OR 0.22, P = 0.05).

CONCLUSIONS

Educating women about clinical trials in this manner appears ineffective in improving recruitment to RCTs. Women appear to be more influenced by their perception of risk than understanding. This finding has ethical implications for communication of information about RCTs.

Patients' perceptions of information provided in clinical trials

BACKGROUND

According to the Declaration of Helsinki, patients who take part in a clinical trial must be adequately informed about the trial's aims, methods, expected benefits, and potential risks. The declaration does not, however, elaborate on what "adequately informed" might amount to, in practice. Medical researchers and Local Research Ethics Committees attempt to ensure that the information which potential participants are given is pitched at an appropriate level, but few studies have considered whether the patients who take part in such trials feel they have been given adequate information, or whether they feel able to understand that information.

OBJECTIVES

To explore trial participants' views (i) on the amount of information provided, and (ii) of their own understanding of that information.

DESIGN

Structured interviews of patients participating in clinical trials for the treatment of chronic medical condition.

FINDINGS

Patients generally felt they were given an appropriate amount of information, and that they were able to understand all or most of it. They felt they were given adequate time to ask questions before agreeing to take part. In comparison with treatment given out with the research setting, patients generally felt they received more information when participating in a clinical trial.

CONCLUSIONS

Researchers sometimes complain that patients are given too much information during clinical trials, and have limited understanding of that information. The present study shows that this perception is not necessarily shared by patients. More research is needed in this area, particularly to gauge whether patient understanding is indeed accurate.

Attitudes towards clinical research amongst participants and nonparticipants

OBJECTIVES

To investigate attitudes to clinical research amongst cancer trial participants and nonparticipants, and to compare results with those from previous studies amongst participants in noncancer trials.

DESIGN

Trial participating respondents were given three questionnaires during the clinical trials. Respondents amongst patients declining randomization answered a single questionnaire.

SETTING

Participants and nonparticipants in randomized clinical cancer trials.

SUBJECTS

Forty-one participants and 47 nonparticipants in cancer trials.

RESULTS

Altruistic motives of physicians to conduct medical research were highly rated. Attitudes towards clinical research were positive in all groups, with nonparticipant respondents being the least positive. Eight to nine tenths found scientific testing necessary before general health service implementation. Trial participants were, as compared with nonparticipating respondents, more positive towards both participation of self and others. Both personal and altruistic motives for participation were highly rated. Primary reasons for nonparticipation were fear of 'the unknown' and/or unease with randomization. Only a minority felt a moral problem created by declining trial participation. Respondents amongst noncancer participants were more satisfied with the information given than both cancer participants and cancer nonparticipants. Negative experiences in cancer participants generally dealt with frustration related to seeing too many physicians at check-up appointments.

CONCLUSION

Attitudes towards clinical research are generally positive even in cancer nonparticipants. Both personal and altruistic motives for participation were highly rated. A fear of 'the unknown' and resentments towards randomization were primary reasons to renounce participation. Seeing too many physicians at check-up appointments seems to be an important factor for negative experiences in cancer trial participants.

Placebos, placebo effect, and the response to the healing situation: the evolution of a concept

In spite of its impressive progress, medicine has been strongly criticized for relying on its modern biomedical tradition to the neglect of the psychosocial aspects of health. This neglect may account for patients' dissatisfaction and eventual use of alternative health approaches. The concept of placebo has sustained dramatic "protean" metamorphoses through the ages. For centuries, placebos have been regarded as powerful deceptive therapies. From the middle of the twentieth century, however, conventional medicine has used placebos as methodologic tools to distinguish the specific from the nonspecific ingredients in treatments. In modern medical research, the double-blind, placebo-controlled, randomized clinical trial has been established as the gold standard for the assessment of any new treatment. Recently a new trend regarding placebos seems to have emerged. The placebo and other nonspecific effects elicited by the "healing situation" have been independently subjected to scientific study. Progress in this area may promote useful clinical applications, enabling physicians to broaden their perspectives on the healing process. We present the historical changes of the concept of placebo and the ethical issues raised by their use.

Ethics and evidence-based medicine

Concerns about the ethics of evidence-based medicine (EBM) relate to possible alterations in the humane basis of clinical care. In collecting the evidence for EBM, scientists and doctors, not consumers, determine research objectives, interpret the data and implement the findings, and in doing so may disregard patients' priorities. Ethical standards, and what counts as evidence, are determined by socially or commercially powerful groups connected to powerful institutions. Such groups can generate evidence and determine "gold standard" knowledge, filtering out other, "inferior" knowledge. Applying the available evidence to predicting outcomes for individual patients involves uncertainty. Full disclosure of this uncertainty is a component of informed consent, but requires sensitivity to patients' tolerance of ambiguity. Ongoing debate about the ethics of EBM on all levels will ensure that EBM manifests intended and preferred social values and takes its rightful place in the practice of medicine and the development of health policy.

Involving consumers in designing, conducting, and interpreting randomised controlled trials: questionnaire survey

OBJECTIVE

To assess the extent to which consumers are involved in the work of clinical trial coordinating centres in the United Kingdom and the nature of consumers' involvement in randomised trials coordinated by these centres.

DESIGN

National surveys using structured questionnaires with some open ended sections.

SETTING

103 clinical trial coordinating centres in the United Kingdom identified through a database assembled in 1997 by the NHS clinical trials adviser.

PARTICIPANTS

Named contacts at 62 coordinating centres and investigators in 60 trials that were identified as involving consumers.

MAIN OUTCOME MEASURES

Number of coordinating centres and number of trials in which consumers were involved and the nature of consumers' involvement.

RESULTS

Of the 62 eligible centres, 23 reported that consumers had already been involved in their work, and most respondents were positive about this involvement. 17 centres planned to involve consumers. 15 centres had no plans to involve consumers, but only four of these considered such involvement irrelevant. Responses from investigators about the 48 individual trials were mostly positive, with respondents commenting that input from consumers had helped refine research questions, improve the quality of patient information, and make the trial more relevant to the needs of patients.

CONCLUSIONS

Consumer involvement in the design and conduct of controlled trials seems to be growing and seems to be welcomed by most researchers. Such involvement seems likely to improve the relevance to consumers of the questions addressed and the results obtained in controlled trials.

Results of an intervention study to improve communication about randomised clinical trials of cancer therapy

We report results from an intervention study to improve communication during consultations about randomised clinical trials of cancer therapy. Patients, eligible for a trial, completed questionnaires about information preferences and attitudes to trials prior to seeing their doctors, who were either shown these questionnaires (intervention) or not (control). Fifteen doctors participated and invited 265 patients to join one of 40 different randomised clinical trials. Most patients (77.4%) agreed to trial entry and this was predicted by the Patient's Attitudes to Trials questionnaire with an 80.4% accuracy. Accrual, length of consultation, doctor and patient satisfaction were not associated with the intervention. Further research to explore the potential use of written interventions to facilitate communication and accrual to randomised clinical trials is recommended.