"Uniformed" consent and the wealthy volunteer: an analysis of patient volunteers in a clinical trial of a new anti-inflammatory drug

Disability Research in Australia: Deciding to Be a Research Participant and the Experience of Participation

Little is known about why people with disability choose to take part in disability research and what their experience is like. Knowledge of this may help researchers and research ethics committees improve the empowered and ethical participation of people with disability in disability, healthcare, and human service focussed research. This cross-sectional mixed-methods study explored the perspectives and experiences of a group of Australian adults with disability regarding their involvement in research. Online surveys (N = 29) and follow-up interviews (N = 15) were conducted. The study found the decision to participate was a complex appraisal of benefit to self and others, research relevance, value, comfort, convenience, safety and risk. The attitudes and behaviours of researchers in cultivating trust by adopting an empathic approach to the conduct of disability research appear to be an important aspect of participant experience. Research ethics committees may benefit from knowledge of the 'microethical' moments that occur in such research.

Trials need participants but not their feedback? A scoping review of published papers on the measurement of participant experience of taking part in clinical trials

Background

Participant recruitment and retention are long-standing problems in clinical trials. Although there are a large number of factors impacting on recruitment and retention, some of the problems may reflect the fact that trial design and delivery is not sufficiently ‘patient-centred’ (i.e., sensitive to patient needs and preferences). Most trials collect process and outcome measures, but it is unclear whether patient experience of trial participation itself is routinely measured. We conducted a structured scoping review of studies reporting standardised assessment of patient experience of participation in a trial.

Methods

A structured search of Medline, PsycINFO, Embase and CINAHL (Cumulative Index to Nursing and Allied Health Literature) and hand searching of included studies were conducted in 2016. Additional sources included policy documents, relevant websites and experts. We extracted data on trial context (type, date and location) and measure type (number of items and mode of administration), patient experience domains measured, and the results reported. We conducted a narrative synthesis.

Results

We identified 22 journal articles reporting on 21 different structured measures of participant experience in trials. None of the studies used a formal definition of patient experience. Overall, patients reported relatively high levels of global satisfaction with the trial process as well as positive outcomes (such as the likelihood of future participation or recommendation of the trial to others).

Conclusions

Current published evidence is sparse. Standardised assessment of patient experience of trial participation may provide opportunities for researchers to enhance trial design and delivery. This could complement other methods of enhancing the patient-centredness of trials and might improve recruitment, retention, and long-term patient engagement with trials.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3444-y) contains supplementary material, which is available to authorized users.

Trends of Informed Consent forms for industry-sponsored clinical trials in rheumatology over a 17-year period: Readability, and assessment of patients' health literacy and perceptions

OBJECTIVE

To assess trends in the length and readability of informed consent forms (ICFs) for industry-sponsored multinational clinical trials (RCTs) in rheumatology over a 17-year period. Additionally, to assess the health literacy (HL) and perceptions of ICFs among participants of current RCTs.

METHODS

The readability of ICFs conducted at an outpatient rheumatology clinic between 1999 and 2016 were assessed using the INFLESZ scale. Patients' HL was assessed using SALHSA-50 and STOFHLA. Patient opinions were assessed using a self-reported, in-office questionnaire with an independent patient sample who had signed an ICF in the past 6 months.

RESULTS

Thirty-nine ICFs about 22 drugs from 13 pharmaceutical companies were analyzed. The global mean readability was 57 ± 3 (95% CI: 56-58), and all ICFs were categorized as either "somewhat difficult to read" or "average." Readability remained at these levels without significant changes from 1999 to 2016. The mean length of the ICFs written between 1999 and 2005 was 13 ± 5 pages, with a significant increase thereafter (mean 22 ± 8 pages, p = 0.004). Depending on the instrument, of 95 patients participating in the HL assessment, between 18% and 44% had limited HL. Of 90 patients participating in the perceptions questionnaire, 84% reported understanding the ICF well. However, 2-57% misunderstood basic concepts, including the study drug name and placebo.

CONCLUSIONS

The disparity between the readability of ICFs with patients' HL and their comprehension of ICFs continues, even after decades of attempts of regulatory agencies and numerous published suggestions.

Improving education and coping of scoliosis patients undergoing surgery, and their families, using e-health

PURPOSE

Healthcare providers have limited time to spend with scoliosis patients who are considering surgery and their families. The purpose of this study was to evaluate an e-health strategy to increase knowledge and coping in patients with scoliosis who are surgical candidates and their families.

METHODS

We enrolled patients with scoliosis who were candidates for surgery and their families. Patients and their families completed the scoliosis knowledge questionnaire, meaning of illness questionnaire, social support and coping questionnaires before and after access to a comprehensive evidence-based scoliosis website ( http://www.aboutkidshealth.ca/scoliosis ).

RESULTS

Seventy-four patients and 71 parents completed the evaluation. While both patients and parents improved their knowledge of scoliosis (p = 0.001 and p = 0.003, respectively), the scores of patients were consistently lower than those of the parents both before and after website use (p = 0.0001). Only parents demonstrated a change in the meaning of illness questionnaire, with a small increase in the negative attitude towards illness and a small decrease in the positive attitude towards illness (p = 0002 and p = 0.01, respectively). Of the 12 coping methods examined on the Adolescent Coping Orientation for Problem Experiences (A-COPE) instrument, patients were slightly more likely than parents to use relaxing and solving family problems as tools to cope following website access (p = 0.02 and p = 0.09, respectively). Parents demonstrated no significant changes in the four methods of coping on the Coping Health Inventory for Parents (CHIP) after website exposure. While the majority of patients and parents reported receiving sufficient support, over half of the patients indicated a need for more support in social participation.

CONCLUSION

An evidence-based website increased the knowledge of patients and parents but simply providing access to the website had minimal impact on their coping and perceptions of social support. The website, however, provides users with the opportunity to absorb vital information about scoliosis across several media.

Research participants' perceptions and views on consent for biobank research: a review of empirical data and ethical analysis

BACKGROUND

Appropriate information and consent has been one of the most intensely discussed topics within the context of biobank research. In parallel to the normative debate, many socio-empirical studies have been conducted to gather experiences, preferences and views of patients, healthy research participants and further stakeholders. However, there is scarcity of literature which connects the normative debate about justifications for different consent models with findings gained in empirical research. In this paper we discuss findings of a limited review of socio-empirical research on patients' and healthy research participants' experiences and views regarding consent to biobank research in light of ethical principles for appropriate information and consent.

METHODS

Review question: Which empirical data are available on research participants' perceptions and views regarding information and elicitation of consent for biobank research? Search of articles published till March 1st 2014 in Pubmed. Review of abstracts and potentially relevant full text articles by two authors independently. As categories for content analysis we defined (i) understanding or recall of information, (ii) preferences regarding information or consent, and (iii) research participants' concerns.

RESULTS

The search in Pubmed yielded 337 abstracts of which 10 articles were included in this study. Approaches to information and consent varied considerably across the selected studies. The majority of research participants opted for some version of limited consent when being informed about such possibility. Among the factors influencing the type of preferred consent were information about sponsoring of biobank research by pharmaceutical industry and participants' trade-off between privacy and perceived utility. Studies investigating research participants' understanding and recall regarding the consent procedure indicated considerable lack of both aspects. Research participants' perceptions of benefits and harms differ across those studies.

CONCLUSION

The knowledge, perceptions and views of research participants who have undergone a consent procedure within the context of biobank research raise several questions on the issue of how to inform and elicit consent in an ethically acceptable way. In our empirical-ethical analysis we develop suggestions on how the practice of eliciting consent in the biobank context should be improved.

More than the money: a review of the literature examining healthy volunteer motivations

BACKGROUND AND OBJECTIVE

Few existing data report the motivations of healthy volunteers in clinical research trials. Some worry that volunteers consider only financial motivations. This study summarized and analyzed existing empirical research on self-reported motivations of healthy volunteers participating in studies not intended to offer benefit from participation.

STUDY SELECTION

A systematic PubMed search was conducted. Inclusion criteria captured English-language empirical studies on the self-reported motivations, reasons, or factors influencing the decision of healthy volunteers to enroll in clinical research. Thirteen studies involving more than 2000 healthy volunteers met the criteria and were included in this review.

DATA EXTRACTION

Independent review by the authors and extraction of information about the sample, methodology and objectives of the motivations study, description of the clinical trial and whether participation was actual or hypothetical, reported primary and secondary motivations of the healthy volunteers, risk evaluation, and reported differences in motivations related to sociodemographic variables.

RESULTS

This review showed that although financial reward is the primary motivation for healthy volunteers to participate in clinical trials, financial motivations are one among many other reported motivations, including contributing to science or the health of others, accessing ancillary healthcare benefits, scientific interest or interest in the goals of the study, as well as meeting people and curiosity. Volunteers consider risk when making a decision about participation.

CONCLUSIONS

Although financial incentives are important in recruiting healthy volunteers, their motivations are not limited to financial motivations. Further research is needed to examine motivations in different contexts and countries, the decision making of healthy volunteers, and the dynamics of repeat participation.

Readability of spine-related patient education materials from subspecialty organization and spine practitioner websites

STUDY DESIGN

Analysis of spine-related websites available to the general public.

OBJECTIVE

To assess the readability of spine-related patient educational materials available on professional society and individual surgeon or practice based websites.

SUMMARY OF BACKGROUND DATA

The Internet has become a valuable source of patient education material. A significant percentage of patients, however, find this Internet based information confusing. Healthcare experts recommend that the readability of patient education material be less than the sixth grade level. The Flesch-Kincaid grade level is the most widely used method to evaluate the readability score of textual material, with lower scores suggesting easier readability.

METHODS

We conducted an Internet search of all patient education documents on the North American Spine Society (NASS), American Association of Neurological Surgeons (AANS), the American Academy of Orthopaedic Surgeons (AAOS), and a sample of 10 individual surgeon or practice based websites. The Flesch-Kincaid grade level of each article was calculated using widely available Microsoft Office Word software. The mean grade level of articles on the various professional society and individual/practice based websites were compared.

RESULTS

A total of 121 articles from the various websites were available and analyzed. All 4 categories of websites had mean Flesch-Kincaid grade levels greater than 10. Only 3 articles (2.5%) were found to be at or below the sixth grade level, the recommended readability level for adult patients in the United States. There were no significant differences among the mean Flesch-Kincaid grade levels from the AAOS, NASS, AANS, and practice-based web-sites (P = 0.065, ANOVA).

CONCLUSION

Our findings suggest that most of the Spine-related patient education materials on professional society and practice-based websites have readability scores that may be too high, making comprehension difficult for a substantial portion of the United States adult population.

NSAIDs: a clinical approach to the problems of gastrointestinal side-effects

Despite the fact that non-steroidal anti-inflammatory drugs (NSAIDs) are among the most widely used drugs in medicine today, 2-10% of patients must discontinue their use primarily due to gastrointestinal (GI) side-effects. While the development of non-aspirin NSAIDs (NA-NSAIDs) has significantly reduced GI side-effects, major problems persist. A practical clinical approach to these problems includes informing the patient about the risks and benefits of NSAIDs, risk management during treatment with NSAIDs and investigation of symptomatic side-effects during treatment. Prophylaxis of GI side-effects is feasible in selected populations, but it has not been studied widely and may not be cost-effective. At present, costs of prophylaxis in all but selected populations with multiple risks probably outweight the benefits.

Pharmacogenetics: the bioethical problem of DNA investment banking

Concern about the ethics of clinical drug trials research on patients and healthy volunteers has been the subject of significant ethical analysis and policy development--protocols are reviewed by Research Ethics Committees and subjects are protected by informed consent procedures. More recently attention has begun to be focused on DNA banking for clinical and pharmacogenetics research. It is, however, surprising how little attention has been paid to the commercial nature of such research, or the unique issues that present when subjects are asked to consent to the storage of biological samples. Our contention is that in the context of pharmacogenetic add-on studies to clinical drug trials, the doctrine of informed consent fails to cover the broader range of social and ethical issues. Applying a sociological perspective, we foreground issues of patient/subject participation or 'work', the ambiguity of research subject altruism, and the divided loyalties facing many physicians conducting clinical research. By demonstrating the complexity of patient and physician involvement in clinical drug trials, we argue for more comprehensive ethical review and oversight that moves beyond reliance on informed consent to incorporate understandings of the social, political and cultural elements that underpin the diversity of ethical issues arising in the research context.

The participation of cognitively impaired elderly in research

It is critical that cognitively impaired adults be permitted to participate in research in order to develop a greater understanding of the underlying causes of the impairments and strategies to prevent or ameliorate their impact. Significant ethical and legal issues may arise in the recruitment and enrollment of these persons as study participants, due to difficulties in understanding information, uncertainty regarding the existence of sufficient mental capacity to provide informed consent to participate, and the potential for coercion to participate as a function of limited capacity and dependence on others for care. This article explores these issues and suggests mechanisms to maximize the understanding of information and facilitate the cognitively impaired elders' expression of choice during incapacity.

Empty ethics: the problem with informed consent

Informed consent is increasingly heralded as an ethical panacea, a tool to counter autocratic and paternalistic medical practices. Debate about the implementation of informed consent is constricted and polarised, centring on the right of individuals to be fully informed and to freely choose versus an autocratic, paternalistic practice that negates individual choice. A bioethical framework, based on a principle-led form of reductive/deductive reasoning, dominates the current model of informed consent. Such a model tends to abstract the process of consent from its clinical and social setting. By fleshing out the social process involved whe patients and healthy volunteer subjects consent to take part in clinical drug trials, this paper attempts to address the problem arising from the current 'empty ethics' model. My arguments are substantiated by qualitative interview data drawn from a study I conducted on the process of consent as experienced by participants in clinical drug trials.

Informed consent in a clinical trial of a novel treatment for rheumatoid arthritis

OBJECTIVE

To evaluate the informed consent process for a clinical trial of intravenous doxycycline for rheumatoid arthritis.

METHODS

Participants completed a self-administered questionnaire about the consent process at baseline and 16 weeks following enrollment in a clinical trial.

RESULTS

Respondents (n = 30) affirmed voluntary participation in the parent trial. Participants acknowledged hope and altruism as reasons for entering the trial more than expectation of personal benefit or outside influences. Many respondents did not understand randomization (14/30), placebos (15/30), or risks of study medications; 11/30 respondents believed that the study drug was completely safe.

CONCLUSION

Respondents generally understood the experimental nature of the trial and confirmed their participation was voluntary. However, gaps existed in participants understanding of trial design, raising the question of whether they were adequately informed about the research study prior to enrollment. Further education of potential participants in clinical trials may be required to achieve valid informed consent.

Informed consent for medical research by the elderly

Much has been written about the possible lack of capacity of the elderly, especially certain vulnerable populations of older individuals, to give informed consent for medical research. Several small studies have shown a deficit for comprehension of consent material, by the elderly, especially those with less education, but this appears small in comparison to an overall deficit in the general population. A number of investigations have suggested that deficits in executive control functions (ECFs) may be related to lack of capacity to make clinical judgments, but these have yet to be applied to research. Many methods have been piloted to measure capacity and to improve comprehension, some of which may help, although none has been proved conclusively to do either. As the elderly experience significant morbidity and mortality from a vast array of illnesses, the use of the elderly as subjects of medical research is especially important. To prevent older individuals from being coerced into participating or potentially being harmed by scientific investigation, they must give informed consent to their involvement. However, there are many studies to suggest that they are not well informed. A discussion ensued in the 1970s and 1980s about whether or not the elderly deserved special protection as a class of individuals, based on their possible increased risk during medical experimentation, but it was ultimately decided that, because the majority of elderly are perceived to be cognitively intact, they need not receive additional safeguards (High & Doole, 1995, Behavioral Science and Law, 13, 319-335). The U.S. Department of Health and Human Services in 2000 (Federal Registrar Rules and Regulations, 46, 8366-8392) reviewed existing protections for subjects of human research and deemed they were inadequate, issuing new guidelines. This article reviews evidence that differences exist between the ability of young and old in their capacity to give consent. Alterations in methods of obtaining consent may help individuals to give a more informed consent, and even enable subjects who lack the capacity to consent, such as cognitively impaired individuals, to participate in research. However an ideal means of screening or altering the consent process has yet to be devised. Many of these methods are briefly considered.

Why analysis of variance is inappropriate for multiclinic trials

Violations of the assumptions behind analysis of variance (ANOVA) models do not tend to affect the alpha-level but can greatly decrease the power of a clinical trial to detect treatment effects. The very nature of multiclinic studies guarantees the violation of some of these assumptions. In this article, I explore the reduction in power that results from two of these violations--heterogeneity of variance across sites and the existence of "floor" and "ceiling" effects. I propose other methods of statistical analysis that avoid this loss of power.

Documentation and informed consent

Documentation remains the key factor that leads to success or failure of a claim in a significant number of cases. Since the time of a trial is often years later, an accurate memory can only be reflected by the records kept by the physician in question. This article focuses on developing good habits of documentation in areas such as medical record maintenance, handwriting, informed consent, and record tampering. Guidelines for improved record keeping are also presented in this article.

Informed consent for clinical trials: in search of the "best" method

OBJECTIVE

To review the literature on comparisons between different methods of obtaining informed consent for clinical trials.

DESIGN

Eight hundred and twelve articles were traced, in the process of conducting a systematic review of the ethics of clinical trials, by searching a number of sources: bibliographic databases (Medline, Psychlit and BIDS science and social science indices), hand searches, personal contacts, an original collection and a systematic follow-up of reference lists. Fourteen research reports were found which provided comparative data on different methods of obtaining informed consent. Eleven of these used a randomised design. Studies were classified according to three outcome measures (anxiety, consent rate and understanding).

RESULTS

The results of the various studies suggest that giving people more information and more time to reflect tends to be associated with a lower consent rate. There seems to be an optimal level of information about side-effects such that patients are not overburdened by detail, while grasping the most important risks. More information in general is associated with greater awareness of the research nature of the trial, voluntariness of participation, right to withdraw and (available) alternative treatments. This result does not, however, extend to explanations of the concept of randomisation on which the literature is contradictory--sometimes more information is associated with increased understanding of the concept and sometimes it is not. Although divulging less information seems to be associated with less anxiety, there is evidence of an interaction with knowledge--high levels of knowledge are significantly associated with less anxiety, irrespective of consent method. The more that patients know before they are invited to participate in a trial, the better equipped they are to cope with the informed consent procedure.

CONCLUSION

There is some evidence to suggest that there is an optimal amount of information which enhances patient understanding and which might, in turn, reduce anxiety. However. the studies were not altogether conclusive. More work needs to be carried out, especially on public understanding of science and on how different ways of explaining scientific concepts affect that understanding.

Getting meaningful informed consent from older adults: a structured literature review of empirical research

OBJECTIVES

To perform a structured literature review of the published empirical research on informed consent with older adults in order to make recommendations to improve the informed consent process and to highlight areas needing further examination.

DESIGN

Relevant literature was identified by searching electronic databases (AGELINE, BIOETHICSLINE, CancerLit, Ethics Index, Health, LegalTrac, MEDLINE, PAIS International, PsycInfo, and Sociofile). Studies were included if they were reports of primary research data about informed consent and, if patients or other subjects were used, older subjects were included in the sample. Data related to the aspect of informed consent under study (recruitment, decision-making capacity, voluntariness, disclosure of information, understanding of information, consent forms, authorization, and policies and procedures) were abstracted and entered into a specially designed database.

MEASUREMENTS

Characterization of the population, age of subjects, setting, whether informed consent was being studied in the context of research or treatment, study design, the nature of outcome or dependent variables, independent variables (e.g., experimental conditions in a randomized controlled trial or patient/subject characteristics in a nonrandomized comparison), and results according to the aspect of informed consent under study.

RESULTS

A total of 99 articles met all the inclusion criteria and posed 289 unique research questions covering a wide range of aspects of informed consent: recruitment (60); decision making capacity (21); voluntariness (6); disclosure (30); understanding (139); consent forms (7); authorization (11); policies (13); and other (2). In the secondary analyses of numerous studies, diminished understanding of informed consent information was associated with older age and fewer years of education. Older age was also sometimes associated with decreased participation in research. Studies of disclosure of informed consent information suggest strategies to improve understanding and include a variety of novel formats (e.g., simplified, storybook, video) and procedures (e.g., use of health educators, quizzing subjects, multiple disclosure sessions).

CONCLUSIONS

A systematic review of the published literature on informed consent reveals evidence for impaired understanding of informed consent information in older subjects and those with less formal education. Effective strategies to improve the understanding of informed consent information should be considered when designing materials, forms, policies, and procedures for obtaining informed consent. Other than empirical research that has investigated disclosure and understanding of informed consent information, little systematic research has examined other aspects of the informed consent process. This deficit should be rectified to ensure that the rights and interests of patients and of human subjects who participate in research are adequately protected.

Making sense of randomization; responses of parents of critically ill babies to random allocation of treatment in a clinical trial

Randomized controlled trials (RCTs) are widely accepted by the scientific community as the most rigorous way of evaluating interventions in health care. Although their central feature, random allocation of treatment, is generally seen as methodologically appropriate, its application has caused much debate amongst health professionals and ethicists. This paper describes the views of parents who consented that their critically ill newborn baby should be enrolled in a neonatal trial. In-depth interviews were used to determine their response to the trial and randomization. The nature of the trial was often poorly understood. The random basis of the allocation of treatment and the rationale behind this approach were also problematic issues. Some parents did not perceive a random element in the process at all. These findings advance understanding of the perceptions of trial participants and raise important issues for those concerned with RCTs. Greater understanding of participants' views provides the potential to improve the management of future trials and so the experience of those agreeing to take part.

Motivation for participation in clinical trials of drugs for the treatment of asthma, seasonal allergic rhinitis, and perennial nonallergic rhinitis

BACKGROUND

While previous studies of enrollment motivation have been conducted with either healthy subjects or subjects with certain other diseases, little is known about the motives of subjects with asthma or rhinitis symptoms who seek to enter clinical trials.

OBJECTIVE

This study was conducted to assess the self-reported role that altruism, healthcare receipt, and financial gain play in the motivation of subjects with symptoms of bronchial asthma, seasonal allergic rhinitis, and perennial nonallergic rhinitis who attempted to enroll in clinical trials.

METHODS

Subjects with symptoms of asthma, allergic rhinitis, and perennial nonallergic rhinitis who sought to enroll in phase III clinical trials completed surveys from December 1991 to August 1992 (n = 295). The importance of altruistic and nonaltruistic motives was rated on numerical scales.

RESULTS

Improved control of symptoms and learning more about the illness and medications for treatment were the most important nonaltruistic motives (P less than .05). Financial motives and second opinion were moderately important but less important than healthcare motives (P less than .05). This population as a whole agreed that the altruistic motives listed in the survey were reasons to enroll.

CONCLUSION

Subjects with symptoms of asthma, allergic rhinitis, and perennial nonallergic rhinitis entered clinical trials for altruistic reasons and to receive healthcare treatment for their chronic illness including related health education. For the entire group, self-reported financial motives were less important than illness-related healthcare.

Informed consent for treatment of childhood cancer: factors affecting parents' decision making

Both the treatment for childhood cancer and the legal requirements for gaining parents' consent to treatment have become increasingly complex. The purpose of the exploratory investigation reported here was to identify influential circumstances surrounding the consent process in the pediatric setting, to describe the relationship of parental anxiety to these factors, and to delineate related practice and research implications. Twenty-eight parents of children entered on one of four protocols for the treatment of newly diagnosed acute lymphoblastic leukemia at the Childrens Hospital Los Angeles and the University of California San Francisco were asked to complete two questionnaires within 48 hours after consenting to treatment: the State-Trait Anxiety Index and the Parent Informed Consent Questionnaire. Results of the study confirmed clinical experience that parents are given complex information and asked to make decisions about their child's life in a highly anxious state. Although participants were generally satisfied with the informed consent process 48 hours after signing a consent form, further research is needed to document how well parents understand and remember key information, as well as the influence of time, experience, and changes in state anxiety on their perceptions of the adequacy of the consent process. In current clinical practice, simple strategies can be applied to improve the informed consent process for families of children with cancer.

Implementation of a multicomponent process to obtain informed consent in the Diabetes Control and Complications Trial. The DCCT Research Group

The Diabetes Control and Complications Trial (DCCT) is a multicenter, randomized clinical trial studying the effects of two different diabetes treatment regimens on the development and progression of early vascular complications in persons with insulin-dependent diabetes mellitus. A multicomponent program that utilized audiovisual and written material as well as behavioral practice was developed to educate prospective volunteers so that they could make an enlightened decision about participation in this complex and demanding long-term trial. The efficacy of this multicomponent approach was evaluated by administering a standardized test of knowledge about the trial and its requirements following the intensive educational process and again after 1 year's participation in the study. A mean score of 97% was achieved on the first test. The mean score of 91% 1 year after randomization indicated excellent retention of information. Moreover, the high degree of adherence during the first year of the trial suggests that the informed consent process provided the subjects with a realistic portrayal of the trial demands. The multicomponent informed consent process developed for the DCCT may serve as a model for other complex and demanding clinical trials where prospective subjects must be highly educated about the trial in order to participate effectively.

Comprehension of informed consent information by young-old through old-old volunteers

Comprehension of typewritten informed consent information was evaluated for young-old (60-69 years) through old-old (80-89 years) volunteers as a function of years of education (less than 12, 12, and greater than 12), readability of information (low [college level] vs high [7th grade]), and typeface used in the preparation of the materials (Prestige Elite 72, Letter Gothic, and Orator). All volunteers (N = 235) read a typewritten information sheet and retained it for review while answering eight multiple choice questions. Immediate feedback was provided, and a second test was administered if any answers were incorrect. The findings indicated that comprehension varied directly with education and inversely with age. Typeface and age interacted due to age-related differences with the two smaller (Prestige Elite and Letter Gothic), but not with the largest of the typefaces (Orator). These findings suggest that the observed age-related differences may have been due to visual and not cognitive deficits. Readability did not affect performance either by itself or in combination with any other variable.

Does informed consent influence therapeutic outcome? A clinical trial of the hypnotic activity of placebo in patients admitted to hospital

To examine whether written informed consent might influence the results of clinical trials the effect of placebo when given with or without informed consent to patients suffering from insomnia was studied. The study was a single blind observer blinded trial, and patients were paired according to sex, age, and hospital environment. Randomisation assigned the first patient of each pair to the control group (without informed consent) or the group to give informed consent. Of the 56 patients, 26 refused to give informed consent, and the age and sex distribution of these differed significantly (p less than 0.02) from the 30 pairs of patients ultimately enrolled into the study. In this "biased" sample, the hypnotic activity of placebo was significantly higher in the control group (p less than 0.05). It is concluded that the informed consent procedure biases the results of clinical trials and might affect their general applicability.

Informed consent for research. Effects of readability, patient age, and education

Comprehension of informed consent materials from a study of psychological variables associated with chest pain was evaluated as a function of age (27 to 69 years), education (5 to 20 years), and readability of information [low (college level) versus high (7th grade)]. The potentially confounding effect of memory was eliminated by allowing patients to use the written information sheets to find answers to the multiple choice test. Feedback and a repeat test were provided if any answers were incorrect. The findings indicated that comprehension varied inversely with age and directly with education. It is suggested that while ensuring informed consent may be difficult for all volunteers, it may be a critical problem for elderly patients with low education. The effects of readability were not consistent, suggesting that simplifying informed consent materials by shortening words and sentences may not, by itself, be sufficient to improve comprehension.

Coping with the complexities of informed consent in dermatologic surgery

Few medico-legal issues have generated as much controversy as informed consent--the right of patients to be fully informed about the risks, complications, and alternatives to a medical treatment or surgical procedure before deciding whether or not to submit to it. This paper discusses the complexities inherent in the legal doctrine of informed consent and their implications for dermatologic surgery. Particular emphasis is placed on the legal requirements for informed consent, as well as the problems associated with informing patients and their potential solutions.

Factors influencing a person's reaction to informed consent

The present study examined how social and physical demand characteristics influenced the willingness of 128 volunteer undergraduates to participate in a drug experiment. Subjects read an informed consent form about an experiment and then received different amounts of supplemental information about the study presented orally by a physician-confederate in a medical school setting. After making an initial decision about participation in the study, participants were tested for their comprehension about the experiment. All subjects who indicated an interest in the project were asked to attend a second meeting in the Psychology Department when they were asked if they wished to change their original decisions. Because high trust was placed in the physician-confederate, there were no differences, no effect for the differing oral presentations was found. However, a significant number of subjects changed their decisions to participate at the second session. The relationship of these and other findings to clinical research and practice were discussed.

Ethical concerns and guidelines in research in geriatric pharmacology and therapeutics: individualization, not codification

Compared with people of other ages, the elderly are much more heterogeneous in terms of physical and mental status, and they are subject to more day-to-day variability. However, some see the institutionalized elderly as stereotypes, having little autonomy and being easily subjugated such that they will consent to take part in any sort of experiment. Thus, a counter-productive paternalism may lead them to protect elderly patients by making such choices for them. The interests of the incompetent elderly must be scrupulously protected, but competent elderly potential subjects can appropriately be assumed to be responsible and should be accorded the dignity of making their own choices. The consent process should be individualized rather than codified for the elderly, as for potential subjects of other ages.

The effect of repeated testing upon comprehension of informed consent materials by elderly volunteers

One hundred elderly adults (mean = 71.3 years of age, range = 59-88 years) in four WAIS vocabulary subgroups (less than 40, 40-49, 50-59, greater than or equal to 60) served in an evaluation of the effects of using multiple comprehension test trials to improve informed consent procedures. Participants in Group I were given a single comprehension test and feedback before signing consent documents, while those in Group II were provided with as many as three comprehension trials, if necessary. All participants were tested for memory of the information 2-3 weeks later. Results indicated that both comprehension and memory performance varied directly with vocabulary level. The multi-trial approach improved comprehension scores at all vocabulary levels, but had no effect upon memory.

Patient consent in seven medical-care institutions

An exploratory study of the patient consent process was conducted in seven large medical-surgical institutions. Analysis of the most recent literature on consent and of data provided by knowledgeable persons in each facility led to the conclusions that (1) the primary intent of obtaining patient consent is to legally protect the hospital and the physician, (2) legal and educational objectives are confused and entangled in the consent process, (3) legal objectives are not adequately met in any facility, and (4) the potential for sophisticated patient education is dim given existing procedures.

How informed is informed consent? The BHAT experience

In the Beta-blocker Heart Attack Trial (BHAT) a number of strategies were implemented to increase the probability of informed voluntary consent among survivors of an acute myocardial infarction. To evaluate the subjects' comprehension of the study, a bioethicist conducted in-depth home interviews with a random sample of 64 participants from 11 geographic areas. The great majority of respondents proved to be well informed about the study design, its scientific logic, and possible risks of the experimental drug. However, five subjects (8% of the sample) appeared to believe they were involved in a therapeutic program rather than a research project. The analysis of predictor variables indicates that education, race, and age were associated with the degree of respondent awareness of fundamental aspects of the trial.

Is it ethical to conduct volunteer studies within the pharmaceutical industry?

There is a case for appropriately selected drug studies within the pharmaceutical industry in which employee volunteers are used. Provided the organisation and conduct of such studies are approached in an ethical manner, with attention to safe-guarding the volunteer and recognising the limitations, this work can be done expeditiously, cheaply, and safely. Some details are given of the arrangements made for volunteer studies within a company.