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Walker RL, Cottingham MD, Fisher JA. Serial Participation and the Ethics of Phase 1 Healthy Volunteer Research. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2019; 43:83-114. [PMID: 29342285 PMCID: PMC5901090 DOI: 10.1093/jmp/jhx033] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Phase 1 healthy volunteer clinical trials-which financially compensate subjects in tests of drug toxicity levels and side effects-appear to place pressure on each joint of the moral framework justifying research. In this article, we review concerns about phase 1 trials as they have been framed in the bioethics literature, including undue inducement and coercion, unjust exploitation, and worries about compromised data validity. We then revisit these concerns in light of the lived experiences of serial participants who are income-dependent on phase 1 trials. We show how participant experiences shift attention from discrete exchanges, behaviors, and events in the research enterprise to the ongoing and dynamic patterns of serial participation in which individual decision-making is embedded in collective social and economic conditions and shaped by institutional policies. We argue in particular for the ethical significance of structurally diminished voluntariness, routine powerlessness in setting the terms of exchange, and incentive structures that may promote pharmaceutical interests but encourage phase 1 healthy volunteers to skirt important rules.
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Affiliation(s)
- Rebecca L Walker
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Jill A Fisher
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Abstract
Vulnerable groups are often excluded from clinical research on the basis of scientific, ethical and practical reasons. Although intended to protect vulnerable people and maintain study integrity, exclusion of vulnerable groups from research through use of standard exclusion criteria may not always be necessary and may result in findings that are not generalisable. Achieving a balance between the competing needs to protect vulnerable people and to make progress in our understanding of disorders and their management through research requires a reconsideration of exclusion criteria and consent processes to ensure vulnerable people are appropriately represented in clinical research. Reasons for development of broad exclusion criteria include both concrete barriers and intangible discouraging factors. This paper examines this situation and its consequences, perceived and real barriers to inclusion of vulnerable people in research, and suggests methods for overcoming these barriers and applying thoughtful exclusion criteria.
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Chattopadhyay S, Gillon JJ, De Vries R. Where are all the bioethicists when you need them? J R Soc Med 2012; 105:143-5. [PMID: 22532653 PMCID: PMC3343708 DOI: 10.1258/jrsm.2012.110284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2024] Open
Affiliation(s)
- Subrata Chattopadhyay
- Department of Physiology and Institutional Review Board, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim 737102, India
| | - John J Gillon
- Center for Clinical Bioethics, Georgetown University Medical Center, Washington, DC 20057, USA
| | - Raymond De Vries
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan 48109-5429, USA
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Fisher JA, Kalbaugh CA. Challenging assumptions about minority participation in US clinical research. Am J Public Health 2011; 101:2217-22. [PMID: 22021285 DOI: 10.2105/ajph.2011.300279] [Citation(s) in RCA: 170] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Although extensive research addresses minorities' low participation in clinical research, most focuses almost exclusively on therapeutic trials. The existing literature might mask important issues concerning minorities' participation in clinical trials, and minorities might actually be overrepresented in phase I safety studies that require the participation of healthy volunteers. It is critical to consider the entire spectrum of clinical research when discussing the participation of disenfranchised groups; the literature on minorities' distrust, poor access, and other barriers to trial participation needs reexamination. Minority participation in clinical trials is an important topic in public health discussions because this representation touches on issues of equality and the elimination of disparities, which are core values of the field.
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Affiliation(s)
- Jill A Fisher
- Center for Biomedical Ethics and Society, Vanderbilt University, Nashville, TN 37203, USA.
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CQ Sources/Bibliography. Camb Q Healthc Ethics 2009. [DOI: 10.1017/s0963180109090252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
These CQ Sources were compiled by Bette Anton.
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Iltis AS. Payments to normal healthy volunteers in phase 1 trials: avoiding undue influence while distributing fairly the burdens of research participation. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2009; 34:68-90. [PMID: 19190076 PMCID: PMC2682181 DOI: 10.1093/jmp/jhn036] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Clinical investigators must engage in just subject recruitment and selection and avoid unduly influencing research participation. There may be tension between the practice of keeping payments to participants low to avoid undue influence and the requirements of justice when recruiting normal healthy volunteers for phase 1 drug studies. By intentionally keeping payments low to avoid unduly influenced participation, investigators, on the recommendation or insistence of institutional review boards, may be targeting or systematically recruiting healthy adult members of lower socio-economic groups for participation in phase 1 studies. Investigators are at risk of routinely failing to fulfill the obligation of justice, which prohibits the systematic targeting and recruiting of subjects for reasons unrelated to the nature of the study. Insofar as we take seriously the obligation to engage in just subject recruitment and selection, I argue that we must acknowledge the implications low payments might have for subject recruitment and selection and examine the effect of low payments. If low payments de facto target the less well-off for phase 1 studies, we must defend the priority ranking of the obligation to avoid undue influence over the obligation of justice or adopt an alternative recruitment approach. This paper identifies a number of alternatives to the current system of low-value payments to research participants.
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Affiliation(s)
- Ana S Iltis
- Health Care Ethics, Saint Louis University, St. Louis, Missouri 63103-2006, USA.
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Iltis AS. Introduction: Vulnerability in biomedical research. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2009; 37:6-11. [PMID: 19245597 DOI: 10.1111/j.1748-720x.2009.00345.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Ana S Iltis
- Health Care Ethics at Saint Louis University in St. Louis, MO, USA
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Sillup GP, Porth SJ. Ethical issues in the pharmaceutical industry: an analysis of US newspapers. INTERNATIONAL JOURNAL OF PHARMACEUTICAL AND HEALTHCARE MARKETING 2008. [DOI: 10.1108/17506120810903953] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
AIM This paper is a report of a study to document researcher, healthcare provider and programme administrators' experiences with ethical issues in research with homeless youths in North America. BACKGROUND While there are legal and ethical guidelines for research with adolescents and with vulnerable populations in general, there are no specific guidelines for the ethical conduct of research with homeless youths. METHODS Using a web-based questionnaire, healthcare and social service providers, programme administrators and researchers working with homeless young people throughout the United States of America and Canada were surveyed in 2005. The survey group consisted of 120 individuals; a total of 72 individuals completed the survey. Survey questions included experiences with using incentives in research with homeless youths, consent and experiences with ethics review boards. Numerical data were analysed using frequencies and cross-tabulations. Text data were analysed qualitatively. FINDINGS Researchers doing mental health and/or substance use research tended to use money as a research incentive, whereas healthcare providers and programme administrators tended to use non-monetary incentives. The majority of respondents reported using written consent for research from homeless youths, including minors. Respondents reporting difficulties with ethics review boards were mainly involved with intervention research. CONCLUSION Consensus is needed from a variety of stakeholders, including homeless youths and service providers, on use of various types of research incentives for different types of research, as well as use of consent for homeless youths who are minors.
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Affiliation(s)
- Josephine Ensign
- Department of Psychosocial and Community Health, University of Washington, Seattle, Washington, USA.
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De Vries RG, Keirns CC. Does money make bioethics go 'round? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2008; 8:65-67. [PMID: 18802872 PMCID: PMC2712296 DOI: 10.1080/15265160802342931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Raymond G. De Vries
- Bioethics Program, University of Michigan, 300 North Ingalls Street, Rm 7C27, Ann Arbor, MI 48109, tel: 734-936-5222, fax: 734-936-8944,
| | - Carla C. Keirns
- University of Michigan, 6312 Medical Science Building 1, 1150 W. Medical Center Drive, Ann Arbor, MI 48105-5604, voice 734-647-4844, fax 734-647-3301,
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Slomka J, McCurdy S, Ratliff EA, Timpson S, Williams ML. Perceptions of financial payment for research participation among African-American drug users in HIV studies. J Gen Intern Med 2007; 22:1403-9. [PMID: 17668270 PMCID: PMC2305851 DOI: 10.1007/s11606-007-0319-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2006] [Revised: 02/07/2007] [Accepted: 07/17/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Financial compensation for participating in research is controversial, especially when participants are recruited from economically disadvantaged and/or marginalized populations such as drug users. Little is known about these participants' own views regarding payment for research participation. OBJECTIVE The objective of the study was to elicit underserved minority drug users' views about monetary payments for participating in research. DESIGN Semi-structured in-depth interview study of motivations for and perceptions of participation in research was used. PARTICIPANTS Thirty-seven adult, economically disadvantaged African-American crack cocaine smokers were the participants of the study. APPROACH Participants were recruited from among those taking part in three HIV prevention studies. Interviews were conducted at one of 2 research field offices located in underserved minority neighborhoods in Houston, Texas. Interviews lasting 30-45 min were recorded, transcribed, coded, and analyzed for categories and themes using both conventional and directed qualitative content analysis. This report addresses themes under the broad category of financial motivations for participating in research. RESULTS Participants viewed monetary payment for research as essential to attract participation and desirable to provide optional income. Payment for research participation was perceived as one potential income source among others. Participants considered self-determination a prerogative for themselves and others. They rejected the notion of payment for participation as encouraging drug use or as inducing risk taking. CONCLUSIONS Research regulators should consider participants' views of their desires and capacity for autonomous decisions about financial compensation for research rather than assume participants' diminished capacity due to poverty and/or drug use. Payment for research participation appears to be part of the "informal economy" that has been observed in underserved communities.
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Affiliation(s)
- Jacquelyn Slomka
- Division of Health Promotion and Behavioral Sciences, School of Public Health, University of Texas Health Science Center at Houston, 7000 Fannin, Houston, TX 77030, USA.
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Laneader A, Angelos P, Ferrell BR, Kolker A, Miner T, Padilla G, Swaney J, Krouse RS, Casarett D. Ethical issues in research to improve the management of malignant bowel obstruction: challenges and recommendations. J Pain Symptom Manage 2007; 34:S20-7. [PMID: 17532176 DOI: 10.1016/j.jpainsymman.2007.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2007] [Accepted: 04/12/2007] [Indexed: 10/23/2022]
Abstract
Research to improve the care of patients with malignant bowel obstruction (MBO) is urgently needed. In particular, there is an urgent need for high-quality descriptive research, including prospective cohort studies, as well as randomized controlled trials to define optimal management strategies. However, investigators and clinicians face numerous barriers in conducting high-quality research in this patient population. These barriers include lack of funding, difficulties in identifying eligible patients, and a variety of practical and methodological challenges of designing these studies. In addition, there are a variety of ethical challenges that arise in the design and conduct of studies of MBO and particularly in the conduct of clinical trials. In this article, we address four categories of ethical issues: study design, recruitment, informed consent, and Institutional Review Board review. For each, we outline salient issues and suggest recommendations for enhancing the ethics of MBO studies, including interventional trials.
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Affiliation(s)
- Alice Laneader
- Research Compliance and Quality Improvement, University of Pennsylvania, Philadelphia, Pennsylvania 10104, USA
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Kass NE, Myers R, Fuchs EJ, Carson KA, Flexner C. Balancing justice and autonomy in clinical research with healthy volunteers. Clin Pharmacol Ther 2007; 82:219-27. [PMID: 17410122 DOI: 10.1038/sj.clpt.6100192] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In clinical research, ethics review generally first examines whether study risks are reasonable in light of benefits provided. Through informed consent, then, prospective subjects consider whether the risk/benefit balance and procedures are reasonable for them. Unique ethics issues emerge in clinical research with healthy volunteers. Certain types of studies only recruit healthy volunteers as participants. Phase 1 studies, for example, including first time in human studies of investigational drugs and vaccines, generally are conducted in healthy volunteers. Although such research carries inherent and often unknown risks, healthy subjects provide the most efficient target population in which to conduct such research, as these volunteers generally are free of concurrent diseases or medications that could confound interpretation of toxicity. Other studies enrolling healthy volunteers often are simply looking for the most scientifically sound population for the study of normal human physiology.
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Affiliation(s)
- N E Kass
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Berman Institute of Bioethics, Baltimore, Maryland, USA.
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Nickel PJ. Vulnerable populations in research: the case of the seriously ill. THEORETICAL MEDICINE AND BIOETHICS 2006; 27:245-64. [PMID: 16763881 DOI: 10.1007/s11017-006-9000-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
This paper advances a new criterion of a vulnerable population in research. According to this criterion, there are consent-based and fairness-based reasons for calling a group vulnerable. The criterion is then applied to the case of people with serious illnesses. It is argued that people with serious illnesses meet this criterion for reasons related to consent. Seriously ill people have a susceptibility to "enticing offers" that hold out the prospect of removing or alleviating illness, and this susceptibility reduces their ability to safeguard their own interests. This explains the inclusion of people with serious illnesses in the Belmont Report's list of populations needing special protections, and supports the claim that vulnerability is the rule, rather than the exception, in biomedical research.
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Affiliation(s)
- Philip J Nickel
- Department of Philosophy, University of California, Humanities Office Building 2, Irvine, California 92697-4555, USA.
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Affiliation(s)
- Carl Elliott
- Center for Bioethics, University of Minnesota, Minneapolis, MN 55455-0346, USA.
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Affiliation(s)
- Robyn Martin
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, Herts AL10 9AB, UK.
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