Ethical considerations in clinical trials

Using numerical modeling and simulation to assess the ethical burden in clinical trials and how it relates to the proportion of responders in a trial sample

In order to propose a more precise definition and explore how to reduce ethical losses in randomized controlled clinical trials (RCTs), we set out to identify trial participants who do not contribute to demonstrating that the treatment in the experimental arm is superior to that in the control arm. RCTs emerged mid-last century as the gold standard for assessing efficacy, becoming the cornerstone of the value of new therapies, yet their ethical grounds are a matter of debate. We introduce the concept of unnecessary participants in RCTs, the sum of non-informative participants and non-responders. The non-informative participants are considered not informative with respect to the efficacy measured in the trial in contrast to responders who carry all the information required to conclude on the treatment's efficacy. The non-responders present the event whether or not they are treated with the experimental treatment. The unnecessary participants carry the burden of having to participate in a clinical trial without benefiting from it, which might include experiencing side effects. Thus, these unnecessary participants carry the ethical loss that is inherent to the RCT methodology. On the contrary, responders to the experimental treatment bear its entire efficacy in the RCT. Starting from the proportions observed in a real placebo-controlled trial from the literature, we carried out simulations of RCTs progressively increasing the proportion of responders up to 100%. We show that the number of unnecessary participants decreases steadily until the RCT's ethical loss reaches a minimum. In parallel, the trial sample size decreases (presumably its cost as well), although the trial's statistical power increases as shown by the increase of the chi-square comparing the event rates between the two arms. Thus, we expect that increasing the proportion of responders in RCTs would contribute to making them more ethically acceptable, with less false negative outcomes.

Respect for Human Vulnerability: The Emergence of a New Principle in Bioethics

Vulnerability has become a popular though controversial topic in bioethics, notably since 2000. As a result, a common body of knowledge has emerged (1) distinguishing between different types of vulnerability, (2) criticizing the categorization of populations as vulnerable, and (3) questioning the practical implications. It is argued that two perspectives on vulnerability, i.e., the philosophical and political, pose challenges to contemporary bioethics discourse: they re-examine the significance of human agency, the primacy of the individual person, and the negativity of vulnerability. As a phenomenon of globalization, vulnerability can only be properly addressed in a global bioethics that takes the social dimension of human existence seriously.

Statistical power, the Belmont report, and the ethics of clinical trials

Achieving a good clinical trial design increases the likelihood that a trial will take place as planned, including that data will be obtained from a sufficient number of participants, and the total number of participants will be the minimal required to gain the knowledge sought. A good trial design also increases the likelihood that the knowledge sought by the experiment will be forthcoming. Achieving such a design is more than good sense-it is ethically required in experiments when participants are at risk of harm. This paper argues that doing a power analysis effectively contributes to ensuring that a trial design is good. The ethical importance of good trial design has long been recognized for trials in which there is risk of serious harm to participants. However, whether the quality of a trial design, when the risk to participants is only minimal, is an ethical issue is rarely discussed. This paper argues that even in cases when the risk is minimal, the quality of the trial design is an ethical issue, and that this is reflected in the emphasis the Belmont Report places on the importance of the benefit of knowledge gained by society. The paper also argues that good trial design is required for true informed consent.

Research involving adolescents as subjects : ethical considerations

Research involving adolescents as subjects is much more difficult to carry out than it ought to be. The excessive burdens in the field are borne by those who design and carry out the research, and also by those who review and monitor such research to ensure compliance with regulations and other policies designed to protect the rights and welfare of research subjects. This chapter is an overview of issues that are specific to research that involves adolescents. Problems and challenges are reviewed, and potential solutions suggested. The chapter also provides suggestions for improving current regulatory policies and practices so as to reduce bureaucratic impediments.

Assessment of the impact of a patient clinical trials handbook among pharmacy students

BACKGROUND

Patient education in the basic concepts of clinical trials is necessary to promote understanding of the informed consent process and enhance patients' decision-making. It has been suggested that patients' knowledge and attitudes are improved by being given general written information about clinical trials.

OBJECTIVE

This pilot study was conducted to determine the effect of a patient education handbook on the knowledge, attitudes, and motivations of pharmacy students regarding clinical trials.

METHODS

A patient clinical trials handbook was developed at a 7th-grade reading level for the Department of Veterans Affairs Cooperative Studies Program and tested in PharmD students. Students were randomized to the experimental group (received handbook) or the control group (no handbook). They were given 15 to 20 minutes to read the handbook, after which they were asked to respond to a questionnaire adapted from previous studies. The questionnaire included 25 true/false questions testing participants' knowledge of clinical trials, 5 questions on attitudes toward clinical trials scored on a 5-point Likert scale, and 6 questions concerning their motivation toward participation in hypothetical clinical trial scenarios scored on a 5-point Likert scale. The experimental group was also asked to rate the informativeness, helpfulness, and clarity of the handbook on a 5-point Likert scale.

RESULTS

There were 40 students in the experimental group and 50 in the control group. Knowledge scores were significantly higher in the experimental group compared with the control group (mean [SD] percentage of correct answers, 88.7% [8.0%] vs 82.6% [9.0%], respectively; P < 0.001). Positive attitudes toward clinical trials were also increased in the experimental group compared with the control group; specifically, participants expressed significantly greater clarity of understanding of clinical trials (mean score, 1.4 [0.5] vs 0.8 [0.6]; P < 0.001) and relief associated with knowing about clinical trials (mean score, 0.8 [0.8] vs 0.4 [0.7]; P = 0.017). There were no between-group differences in students' motivation to participate in the hypothetical clinical trial scenarios. A high proportion of students (95%) found the handbook informative, helpful, and understandable.

CONCLUSIONS

The patient clinical trials handbook increased knowledge and positive attitudes regarding clinical trials among pharmacy students participating in this study.

La recherche médicale en pédiatrie : aspects éthiques

Since 1947 (the Nuremberg Code), the ethics of experimentation on human beings is based on the principle of the informed consent of the subjects participating in the research. In this context, research in paediatrics raised particular and difficult problems. International regulations have evolved in a way that has permitted paediatric research, within strict limits. However, recent studies have shown that the level of clinical paediatric research remains weak. There are economic reasons for this. But it also reveals the persistence of an ethical conflict: some people fear that a relativisation of the principle of consent (proxy consent) will lead to weakened protection for the most vulnerable subjects, including children. The ethics of responsibility requires a balance between the protection of the child as an individual (who should never become a medical guinea-pig) and the protection of children as a group (who should never be deprived of the benefits of the medical research).

NHPCO Task Force Statement on the Ethics of Hospice Participation in Research

There is an urgent need for robust empirical data to guide the assessment and treatment of patients near the end of life. Because they are important providers of end-of-life care in this country, hospices have an important role to play in facilitating this research. However, hospices may also face considerable ethical challenges in doing so. This task force statement begins by discussing the importance of hospices' potential contributions to research. Next, we describe ways in which characteristics of hospice patients, and hospices' structure, create ethical challenges that may limit these contributions. We conclude by proposing ways in which hospices and national professional organizations can begin to overcome some of these challenges.

Are special ethical guidelines needed for palliative care research?

Recent studies have made it clear that there are substantial opportunities to improve end-of-life care. Doing so will require solid evidence on which to base clinical and policy decisions and this, in turn, will require a focused research effort. However, research that involves patients near the end of life creates numerous ethical challenges. Moreover, the inclusion of dying patients in research may make many providers uncomfortable. In short, there seems to be something ethically unique, and uniquely challenging, about palliative care research. This paper considers 4 arguments for this unique status: 1) dying patients are especially vulnerable; 2) adequate informed consent may be difficult to obtain; 3) balancing research and clinical roles is particularly difficult; and 4) the risks and benefits of palliative research are difficult to assess. We conclude that the first three of these arguments are weak, and that special guidelines are not needed. We suggest, however, that the fourth argument may have some merit, and should be the focus of discussion among investigators, providers, and patients.

Components of a randomized clinical trial

The purpose of this paper is to discuss a number of components associated with the design, development and conduct of a randomized clinical trial (RCT). In a RCT, a patient is entered into a protocol in which therapy is randomly assigned. Thus, neither the patient nor the care provider have active roles in deciding treatment. The elements of informed consent were developed to ensure that the patient's interests are protected. The informed consent document serves as the cornerstone of a clinical study by introducing patients to the research protocol, informing them of their role as participants in the study, and educating them of their rights. Questions regarding ethics arise during all phases of a study. A study designed with insufficient sample size will provide inconclusive data, thus making participation in the study of limited to no value. Conversely, having patients enrolled in a RCT after data has proved superiority of an arm of the study postpones beneficial therapy for patients and society. Other ethical conflicts arise when subjects are recruited for clinical trials. Special care must be taken to avoid coercion in protected populations such as students, employees, the mentally challenged, and the indigent. Careful planning with adequate attention to consent from development can minimize problems and optimize patient care and research integrity.

Randomized clinical trials in periodontology: ethical considerations

Ethical justification for starting a clinical trial requires at the outset an accurate statement of "no difference" regarding the two or more agents to be compared. This may be expressed as "theoretical equipoise" (no data to support the superiority of one of the agents) or, preferably, as "clinical equipoise" (there are insufficient data to resolve controversy among experts as to which is superior). This presents a problem when a placebo control is proposed, particularly when the outcome measure entails irreversible loss of function; preliminary data often suggest the superiority of the "active agent." Informed consent should ordinarily include the fact that treatment assignments will be accomplished by a process of randomization and, in the case of double-blind designs, that neither the subject nor the investigator will know the subject's treatment assignment until the end of the trial. In general, clinical trials should be monitored by data and safety monitoring boards that have access to unblinded data; they should be guided by stopping rules that should be agreed upon by all concerned before the trial is begun. Women and minorities must be included unless there is strong justification for their exclusion. Care must be taken to balance the competing objectives of validity (the results will be correct), generalizability (the results will be broadly applicable), and efficiency (the study will not be unduly expensive).

An AVID dissent

Despite declarations to the contrary, AVID appears to be a study that is seriously flawed. It is unfairly biased against the ICD; it entails unresolved ethical questions; and it poses a basic question that is inappropriate and subject to broad misinterpretation. Whatever the outcome of the study, harm is likely to follow unless the results are viewed very circumspectly. Rather than conducting such a study, we instead should be directing research funds toward identifying subsets of patients who might best benefit from the ICD. To optimize the use of the ICD, we need to do more patient selection, not less. We need to define subsets of patients in whom the prevention of sudden death by the ICD yields a prolonged overall survival, as well as subsets of patients in whom the device offers little or no benefit. AVID not only fails to do this, but it also threatens to inappropriately curtail (or less likely, to inappropriately expand) the proper use this efficacious tool, the ICD.

Information for cancer patients entering a clinical trial--an evaluation of an information strategy

Informing patients before the start of antineoplastic treatment is important due to the anxiety and uncertainty felt by the patients and the legal aspects of trials. 34 women were interviewed 3 months after receiving information. Results show that the information was well remembered, patients were glad to bring a relative, two consultations with time for deliberation were well-received and that patients viewed written information as an important reinforcement. Overall, information provided was positively evaluated. Detailed information allowed patients to understand and participate in treatment decisions, thereby reducing their pretherapy anxiety. These results support expansion of the structured information programme to include all patients about to begin long-term cancer therapy.

Termination of a clinical trial with no treatment group difference: the Lupus Nephritis Collaborative Study

The Lupus Nephritis Collaborative Study (LNCS) was a multicenter randomized clinical trial designed to assess the effects of standard drug therapy alone versus drug therapy plus plasmapheresis (plasma exchange) on the incidence of fatal or nonfatal renal failure associated with lupus nephritis. After 86 patients had been entered, with a mean of 97 weeks of follow-up, the trial was terminated partly due to lack of a beneficial effect of plasmapheresis. Although there are numerous methods for the statistical analysis of emerging results in a clinical trial, there have been relatively few descriptions of the application of these methods to the termination of a clinical trial when no favorable difference exists between groups. This report presents a review of the statistical methods employed for the pivotal interim analyses of the LNCS that were performed in order to help reach the decision to terminate the trial. These included the assessment of unconditional power post-hoc and the assessment of conditional power using an exact method appropriate for small sample sizes. Conditional power was used to assess the likelihood of detecting a significant treatment effect in the future given the data thus far observed and given reasonable hypotheses regarding the nature of the possible differences between the treatment groups. In addition, weighted-likelihood ratios (Bayes odds ratios) were computed to assess the likelihood of various alternative hypotheses given the present data. We show how such analyses can be useful in reaching a decision to terminate a trial that fails to show a treatment effect.

Ethical issues in clinical trials

The oncology nurse may assume many different roles in clinical trials, including direct care provider, educator, advocate, data collector, primary investigator, and member of the IRB. Regardless of the role, the nurse is in a key position to promote the interests of the individual subject as well as helping to assure that the clinical trial is conducted with scientific and ethical integrity. The nurse can help to assure that the subject is adequately informed and facilitate rational decision making. The nurse can also assure that the requirements of the protocol are consistently attended to and that subjects are well monitored and data precisely collected. "In oncology, perhaps more than in any other medical specialty, there is a blurring of the distinction between research, therapeutic innovation, and medical practice. The frontiers of knowledge in cancer are continuously advancing. The final step in the process of procuring usable knowledge is the clinical trial, a meeting place of the practice of medicine and clinical research. Because of this there are many ethical considerations which must be attended to in the justification of and conduct of a clinical trial.

Protection of human subjects of biomedical research in the United States. A contrast with recent experience in the United Kingdom

In the U.S., the development of extensive regulations for the protection of human subjects of research began in the 1960s and continued through the 1970s. The substance of these regulations reflects the American social and political climate of the time. There is a focus on rights--e.g., to be left alone, to be self-determining--reflected in elaborate requirements to assure the validity and documentation of informed consent. There is also a focus on systems of disinterested review and monitoring procedures to assure uniform adherence to the requirements of the regulations. To the extent that the U.S. has developed extensive regulations in this field, it may be viewed as more advanced than the U.K. And yet, it is apparent that there remain on both sides of the Atlantic very difficult and similar problems regarding the definition of responsible research. Such problems are illustrated by consideration of current controversies about the ethical justification of RCTs. There are some features of the U.S. regulatory system that I can commend to the attention of other nations as they develop policies for the protection of human research subjects. For example, a uniform requirement for informed consent and committee review appears to be responsive to some problems currently encountered in the conduct of RCTs in the U.K. A note of caution is in order, however. Some features of our regulatory policy and practices are excessively inflexible, wasteful of human resources, and occasionally counterproductive.

Equipoise and the ethics of clinical research

The ethics of clinical research requires equipoise--a state of genuine uncertainty on the part of the clinical investigator regarding the comparative therapeutic merits of each arm in a trial. Should the investigator discover that one treatment is of superior therapeutic merit, he or she is ethically obliged to offer that treatment. The current understanding of this requirement, which entails that the investigator have no "treatment preference" throughout the course of the trial, presents nearly insuperable obstacles to the ethical commencement or completion of a controlled trial and may also contribute to the termination of trials because of the failure to enroll enough patients. I suggest an alternative concept of equipoise, which would be based on present or imminent controversy in the clinical community over the preferred treatment. According to this concept of "clinical equipoise," the requirement is satisfied if there is genuine uncertainty within the expert medical community--not necessarily on the part of the individual investigator--about the preferred treatment.

Ethical problems in clinical research: the need for empirical studies of the clinical trials process

Society's demand for progress in medicine is expressed in the form of large sums of money poured into medical research by national governments and voluntary agencies. It is widely accepted within the medical profession that society has a right to expect continuing progress in medical practice and it has been argued that the doctor must therefore sometimes weigh society's interests against those of his individual patient. This essay discusses the origin of the concept of the societal obligation of the physician and the difficult position of the clinician-scientist who attempts to meet society's demands for progress while maintaining his traditional loyalty to the individual patient. Empirical studies which describe the impact of the clinical trials process on the practice of medicine are discussed and it is shown that the large scale clinical trials of today may influence aspects of medical practice far removed from the immediate problems which they are designed to study. It is concluded that further research is needed to study the process of clinical experimentation and its societal implications and that the debate must extend beyond the medical profession to involve the general public.

Management of patient compliance in the treatment of hypertension. Report of the NHLBI Working Group

Low patient cooperation erodes many of the proven benefits of antihypertensive therapy. Over the last few years, there have been important advances in our understanding of the nature and management of patient compliance in hypertension and other chronic illness. In this article we review the theoretical foundation of compliance behavior; methods of measuring compliance; established and promising approaches to managing compliance; ethical consideration in measuring, improving, and researching compliance; the current state of implementation of compliance techniques in practice settings; and the efforts to disseminate information on compliance through undergraduate and continuing health professional education programs.

Ethical complications of clinical therapeutic research on children

Usual discussion by ethicists and physicians of the ethical implications of research on children with catastrophic disease, and the guidelines established by the Federal Government for this research, rest on applying general moral principles to problems. Whatever the merits of this approach for establishing policy, it does not adequately reflect the life situation of patients and the complexity of a single regimen which is simultaneously both therapeutic and research oriented. Also, the issues become more complex when there is disagreement among the parents about a course of treatment. It is our contention that such cases are properly resolved by considering the degree of paternalism to be exercised by the clinician-researcher.

Informed consent: a medical viewpoint

Clinical trials now have an established place in the evaluation of new cancer treatments. It is vital that there should be no conflict between the scientific aspects of clinical trials and the interests of patients with cancer. This conflict can be avoided if trial designs meet accepted standards, and if patients are able to make "informed" decisions abut participation. This process of obtaining informed consent is the subject of much debate. How the debate can be resolved by an individual clinician depends on his perception of a number of fundamental ethical principles. There is growing agreement, however, that regardless of the details of the process of obtaining informed consent, certain basic requirements must be met. The patient must be told that he is participating in a research procedure, that entry is optional, that withdrawal at any time is his right, and he must understand the nature of the trial and the likely effects of treatment, both good and bad.

Ethics education for clinical pharmacy practice

A review of the literature on pharmacy ethics found little concern for ethical issues that arise from pharmacist involvement in clinical practice. This lack of recognition and concern for ethical dilemmas that arise from new pharmacist roles has serious implications for clinical practitioners because of their close involvement in patient care and with other professionals. Also, implications for the profession are serious since a lack of internal control invites external control. Pharmacy educators must provide a leadership role in addressing this lack of concern by systematic evaluation and improvement of ethics education. A model of ethics education is presented that is based on a science education model--both a theoretical and a practical component leading to skill development in recognizing and resolving ethical dilemmas. In other words, pharmacy students will be trained to become their own ethics experts through the application of critical ethical thinking.