1
|
Binik A. Should Children Be Included in Human Challenge Studies? Ethics Hum Res 2024; 46:2-15. [PMID: 38629235 DOI: 10.1002/eahr.500208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Human challenge studies, in which human research subjects are intentionally exposed to pathogens to contribute to scientific knowledge, raise many ethical complexities. One controversial question is whether it is ethically permissible to include children as participants. Commentary of the past decades endorses the exclusion of children, while new guidance suggests that pediatric human challenge studies can be ethically permissible. This paper argues that neither children's exclusion nor their inclusion are well justified. I examine and reject three arguments for exclusion, but suggest that these arguments establish pediatric human challenge studies as a complex ethical category of research that requires caution. I then argue for a strong presumption against children's inclusion, by drawing on an analogy to children's inclusion in phase I trials, emphasizing a requirement of necessity, and suggesting that accommodating children's vulnerability promotes an age de-escalation approach for pediatric human challenge studies research. In the final section, I suggest a procedure for ethics review.
Collapse
Affiliation(s)
- Ariella Binik
- Associate professor of philosophy at McMaster University
| |
Collapse
|
2
|
Torrance RJ, Mormina M, Sayeed S, Kessel A, Yoon CH, Cislaghi B. Is the UN receiving ethical approval for its research with human participants? JOURNAL OF MEDICAL ETHICS 2024:jme-2023-109146. [PMID: 38413189 DOI: 10.1136/jme-2023-109146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 02/15/2024] [Indexed: 02/29/2024]
Abstract
This paper examines the institutional mechanisms supporting the ethical oversight of human participant research conducted by the United Nations (UN). The UN has served an instrumental role in shaping international standards on research ethics, which invariably require ethical oversight of all research studies with human participants. The authors' experiences of conducting research collaboratively with UN agencies, in contrast, have led to concern that the UN frequently sponsors, or participates in, studies with human participants that have not received appropriate ethical oversight. It is argued that the institutional mechanisms in place to prevent research with human participants from being undertaken by the UN without ethical oversight do not, at present, extend substantively beyond the provision of guidelines and online training offered by a minority of UN bodies. The WHO and UNICEF are identified as notable exceptions, having implemented various measures to prevent health research with human participants from being undertaken without ethical oversight. Yet, it is highlighted that the WHO and UNICEF are not the only UN bodies that undertake health research with human participants and there are countless actors under the umbrella of the UN system that are regularly involved in non-health research with human participants. Arguments for the pursuit of the highest standard of ethical oversight by UN bodies are presented. Moving forward, the paper asks the question: is it time for the UN to set the standards for the oversight of ethical oversight?
Collapse
Affiliation(s)
- Robert James Torrance
- London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Maru Mormina
- African Centre of Epistemology and Philosophy of Science, University of Johannesburg, Johannesburg, South Africa
| | - Sadath Sayeed
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Anthony Kessel
- London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | | | - Beniamino Cislaghi
- London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| |
Collapse
|
3
|
Greer RC, Kanthawang N, Roest J, Wangrangsimakul T, Parker M, Kelley M, Cheah PY. Vulnerability and agency in research participants' daily lives and the research encounter: A qualitative case study of participants taking part in scrub typhus research in northern Thailand. PLoS One 2023; 18:e0280056. [PMID: 36696400 PMCID: PMC9876277 DOI: 10.1371/journal.pone.0280056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 12/20/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Researchers have a responsibility to protect all participants, especially vulnerable participants, from harm. Vulnerability is increasingly understood to be context specific, yet limited guidance is available regarding the vulnerability and agency of research participants in different cultural settings. This study aims to explore research participants' daily vulnerability and agency, and how these interact with participants' research experiences in their own words. Researchers' views and responses were also explored. METHODS A qualitative study was conducted around two scrub typhus research studies in northern Thailand. A thematic analysis was carried out on 42 semi-structured interviews with research participants, their families, researchers and key informants. RESULTS The majority of the research participants belonged to a hill tribe ethnic minority group. Common challenges were related to Thai language barriers, travel difficulties, uncertain legal status, unstable employment, lack of education and healthcare. We did not identify new vulnerabilities but we found that the extent of these vulnerabilities might be underestimated or even hidden from researchers in some cases. Despite these challenges people demonstrated agency in their daily lives and were often motivated and supported in this by family members. The majority of perceived research benefits were related to healthcare and gaining knowledge, while attending follow-up visits could be a burden for some. CONCLUSIONS Our approach to research in culturally and socioeconomically diverse settings should be more responsive to participants' specific vulnerabilities and abilities evidenced in their daily life, rather than attributing vulnerability on the basis of membership of pre-defined 'vulnerable groups'. Researchers need to be aware and responsive towards the challenges participants face locally in order to minimise the burdens of research participation whilst allowing participants to benefit from research.
Collapse
Affiliation(s)
- Rachel C. Greer
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Nipaphan Kanthawang
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Jennifer Roest
- Wellcome Centre for Ethics & Humanities, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Tri Wangrangsimakul
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Michael Parker
- Wellcome Centre for Ethics & Humanities, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Maureen Kelley
- Wellcome Centre for Ethics & Humanities, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Phaik Yeong Cheah
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
4
|
Sanchini V, Sala R, Gastmans C. The concept of vulnerability in aged care: a systematic review of argument-based ethics literature. BMC Med Ethics 2022; 23:84. [PMID: 35974362 PMCID: PMC9379886 DOI: 10.1186/s12910-022-00819-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 07/29/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Vulnerability is a key concept in traditional and contemporary bioethics. In the philosophical literature, vulnerability is understood not only to be an ontological condition of humanity, but also to be a consequence of contingent factors. Within bioethics debates, vulnerable populations are defined in relation to compromised capacity to consent, increased susceptibility to harm, and/or exploitation. Although vulnerability has historically been associated with older adults, to date, no comprehensive or systematic work exists on the meaning of their vulnerability. To fill this gap, we analysed the literature on aged care for the meaning, foundations, and uses of vulnerability as an ethical concept. METHODS Using PRISMA guidelines, we conducted a systematic review of argument-based ethics literature in four major databases: PubMed, Embase®, Web of Science™, and Philosopher's Index. These covered biomedical, philosophy, bioethical, and anthropological literature. Titles, abstracts, and full texts of identified papers were screened for relevance. The snowball technique and citation tracking were used to identify relevant publications. Data analysis and synthesis followed the preparatory steps of the coding process detailed in the QUAGOL methodology. RESULTS Thirty-eight publications met our criteria and were included. Publication dates ranged from 1984 to 2020, with 17 publications appearing between 2015 and 2020. Publications originated from all five major continents, as indicated by the affiliation of the first author. Our analyses revealed that the concept of vulnerability could be distinguished in terms of basic human and situational vulnerability. Six dimensions of older adults' vulnerability were identified: physical; psychological; relational/interpersonal; moral; sociocultural, political, and economic; and existential/spiritual. This analysis suggested three ways to relate to older adults' vulnerability: understanding older adults' vulnerability, taking care of vulnerable older adults, and intervening through socio-political-economic measures. CONCLUSIONS The way in which vulnerability was conceptualised in the included publications overlaps with distinctions used within contemporary bioethics literature. Dimensions of aged care vulnerability map onto defining features of humans, giving weight to the claim that vulnerability represents an inherent characteristic of humans. Vulnerability is mostly a value-laden concept, endowed with positive and negative connotations. Most publications focused on and promoted aged care, strengthening the idea that care is a defining practice of being human.
Collapse
Affiliation(s)
- Virginia Sanchini
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
- Department of Public Health and Primary Care, Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium.
| | - Roberta Sala
- Vita-Salute San Raffaele University, Milan, Italy
| | - Chris Gastmans
- Department of Public Health and Primary Care, Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
| |
Collapse
|
5
|
Maeckelberghe E. Ethical implications of COVID-19: vulnerabilities in a global perspective. Eur J Public Health 2021; 31:iv50-iv53. [PMID: 34751361 PMCID: PMC8576294 DOI: 10.1093/eurpub/ckab158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The COVID-19 pandemic has highlighted a number of ethical issues that typically have not been addressed openly in public debate. The argument 'protect the vulnerable' has been a mantra to motivate all sorts of measures, many of them not scientifically motivated. In this article, the concept of 'vulnerability' is analyzed, and a model is suggested to distinguish layers of vulnerability that may or may not result in poor outcomes, depending on how many layers are present and how they interact. Ethical aspects also need to be considered at the global level, where the issue of vaccine distribution illustrates that stronger obligations and responsibilities need to be taken to fulfil wishes and declarations on the fair distribution of resources.
Collapse
Affiliation(s)
- Els Maeckelberghe
- Wenckebach Institute for Medical Education and Training, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Section Ethics in Public Health, European Public Health Association (EUPHA), Utrecht, The Netherlands
| |
Collapse
|
6
|
Molyneux S, Sukhtankar P, Thitiri J, Njeru R, Muraya K, Sanga G, Walson JL, Berkley J, Kelley M, Marsh V. Model for developing context-sensitive responses to vulnerability in research: managing ethical dilemmas faced by frontline research staff in Kenya. BMJ Glob Health 2021; 6:e004937. [PMID: 34244204 PMCID: PMC8268889 DOI: 10.1136/bmjgh-2021-004937] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 05/20/2021] [Indexed: 01/02/2023] Open
Abstract
Health research in low-resource settings often involves individuals and populations defined as 'vulnerable'. There is growing attention in the literature to the ethical dilemmas that frontline research staff face while conducting such research. However, there is little documented as to how research staff might support one another in identifying and handling these dilemmas in different contexts. Over the course of conducting empirical ethics research embedded in the Childhood Acute Illness & Nutrition Network, we developed an approach to examine and respond to the ethical issues and dilemmas faced by the study teams, particularly frontline staff. In this paper we describe the specific tools and approach we developed, which centred on regular cross-team ethics reflection sessions, and share lessons learnt. We suggest that all studies involving potentially vulnerable participants should incorporate activities and processes to support frontline staff in identifying, reflecting on and responding to ethical dilemmas, throughout studies. We outline the resources needed to do this and share piloted tools for further adaptation and evaluation. Such initiatives should complement and feed into-and certainly not in any way replace or substitute for-strong institutional ethics review, safeguarding and health and safety policies and processes, as well broader staff training and career support initiatives.
Collapse
Affiliation(s)
- Sassy Molyneux
- KEMRI-Wellcome Research Programme, Centre for Geographic Medicine Research Coast, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Priya Sukhtankar
- Department of Child Health, Gloucester Hospitals NHS Foundation Trust, Gloucester, UK
| | - Johnstone Thitiri
- KEMRI-Wellcome Research Programme, Centre for Geographic Medicine Research Coast, Kilifi, Kenya
| | - Rita Njeru
- Ethox Centre and Wellcome Centre for Ethics & Humanities, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kui Muraya
- Kemri-Wellcome Trust, Centre for Geographic Medicine Research Coast, Nairobi, Kenya
| | - Gladys Sanga
- KEMRI-Wellcome Research Programme, Centre for Geographic Medicine Research Coast, Kilifi, Kenya
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - James Berkley
- KEMRI-Wellcome Research Programme, Centre for Geographic Medicine Research Coast, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Maureen Kelley
- Ethox Centre and Wellcome Centre for Ethics & Humanities, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Vicki Marsh
- KEMRI-Wellcome Research Programme, Centre for Geographic Medicine Research Coast, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
7
|
Kapeller A, Felzmann H, Fosch-Villaronga E, Hughes AM. A Taxonomy of Ethical, Legal and Social Implications of Wearable Robots: An Expert Perspective. SCIENCE AND ENGINEERING ETHICS 2020; 26:3229-3247. [PMID: 32996058 PMCID: PMC7755623 DOI: 10.1007/s11948-020-00268-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/11/2020] [Indexed: 06/11/2023]
Abstract
Wearable robots and exoskeletons are relatively new technologies designed for assisting and augmenting human motor functions. Due to their different possible design applications and their intimate connection to the human body, they come with specific ethical, legal, and social issues (ELS), which have not been much explored in the recent ELS literature. This paper draws on expert consultations and a literature review to provide a taxonomy of the most important ethical, legal, and social issues of wearable robots. These issues are categorized in (1) wearable robots and the self, (2) wearable robots and the other, and (3) wearable robots in society.
Collapse
Affiliation(s)
- Alexandra Kapeller
- Department of Thematic Studies: Technology and Social Change, Linköping University, Linköping, Sweden
| | - Heike Felzmann
- Department of Philosophy, National University of Ireland, Galway, Ireland
| | | | - Ann-Marie Hughes
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| |
Collapse
|
8
|
Smilan LE. The Revised Common Rule and Mental Illness: Enduring Gaps in Protections. AMERICAN JOURNAL OF LAW & MEDICINE 2020; 46:413-444. [PMID: 33413011 DOI: 10.1177/0098858820975532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Lisa E Smilan
- Lisa E. Smilan, Visiting Scholar, Institute of Law, Psychiatry, and Public Policy, University of Virginia, Charlottesville, VA; J.D., George Washington University Law School, Washington, D.C.; LL.M., specialization in health law, University of Maryland Francis King Carey School of Law, Baltimore, MD; Member, National Institutes of Health Intramural Institutional Review Board, Bethesda, MD. The opinions here expressed are those of the Author and completely independent of the National Institutes of Health. The Author thanks Ellen Wright Clayton for supporting this scholarship and for comments on earlier drafts. Thanks, also, to Leslie Meltzer Henry for her guidance and encouragement, and both Richard Bonnie and Xuemei Ding for their hospitality at the University of Virginia and for facilitating access to university libraries. Finally, thanks to the anonymous peer reviewers for their observations, probing questions, and helpful suggestions, and AJLM editors Jessa Boubker and Sharon Jaquez for their dedication and meticulous care in preparing this Article for publication
| |
Collapse
|
9
|
Influence of gender norms in relation to child's quality of care: follow-up of families of children with SCD identified through NBS in Tanzania. J Community Genet 2020; 12:143-154. [PMID: 32789668 DOI: 10.1007/s12687-020-00482-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 07/31/2020] [Indexed: 02/07/2023] Open
Abstract
Introducing newborn screening (NBS) services for sickle cell disease (SCD) in Africa has been proven to be one of the most cost-effective approach to reducing morbidity and mortality associated with this condition. In view of this evidence, efforts have been made by countries in Africa where SCD prevalence is high to pilot NBS programmes and to strengthen comprehensive care services for SCD. While it is important to reap the benefits of NBS for SCD in Africa in terms of overall quantitative measures, it is also important to understand how certain social and cultural conditions may disproportionately influence the outcomes of screening for some groups. The aim of this study was to analyse the role of gender norms before and after NBS for SCD in Tanzania, and to assess how they influence the quality of care of diagnosed children. Using qualitative methods, we did in-depth interviews with families of children with SCD identified through the NBS services and focus group sessions with nurses working in neonatal and postnatal sections of regional referral hospitals in Dar es Salaam. By analysing the experiences of both the families and nurses, we were able to provide evidence on, firstly, the gendered relations that undergird childcare and, secondly, how those relations influence the quality of care the child may potentially receive. The results emphasize the importance of studying the social implications of SCD in Africa, especially with regard to improving the quality of care for patients with SCD in the region. We propose simple interventions, including gender-conscious health education and genetic counselling, which can help to improve the community understanding of genetic diseases while also reducing gender-related inequalities related to SCD care in Africa.
Collapse
|
10
|
Wallace C, Farmer J, White C, McCosker A. Collaboration with community connectors to improve primary care access for hardly reached people: a case comparison of rural Ireland and Australia. BMC Health Serv Res 2020; 20:172. [PMID: 32143692 PMCID: PMC7059343 DOI: 10.1186/s12913-020-4984-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 02/12/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study presents a way for health services to improve service access for hardly reached people through an exploration of how staff can find and collaborate with citizens (referred to as connectors) who span socio-cultural boundaries in their community. The study explored the local socio-cultural contexts of connectors' boundary spanning activities and if they are health related; boundary spanning occurring between connectors and health professionals at the interface of health systems and community; and the opportunities and barriers to actively seeking out and collaborating with community connectors to access marginalised and hardly reached people. METHODS We conducted a qualitative case comparison from rural Ireland and Australia. Following purposive snow-ball sampling techniques to recruit participants, semi-structured interviews were conducted with 34 community informants, 21 healthcare staff and 32 connectors. Transcripts were coded and analysed using an inductive approach to ascertain categories and overall themes. RESULTS We found a diverse sample of connectors relating to heterogenous, small and locally distinct groups of hardly reached people. Overall 26 connectors were active at the interface between health services and the community, with variation in how this occurred between cases. The majority (21) described one or more health related activities with hardly reached people. All connectors expressed a willingness to develop a relationship with local health services on issues they identified as relevant. Barriers to collaborations between connectors and health services related to bureaucracy, workload, and burnout. CONCLUSIONS Collaborating with connectors has potential as one strategy to improve access to health services for hardly reached people. To enact this, health staff need to identify local socio-cultural boundaries and associated connectors, facilitate two-way connections at the boundary between health services and community and enable collaboration by attending to activities in the community, at the interface between health services and community, and within the health system.
Collapse
Affiliation(s)
- Carolyn Wallace
- Swinburne University of Technology, Mail Services Unit, H25, PO Box 218, Hawthorn, VIC 3122 Australia
| | - Jane Farmer
- Swinburne University of Technology, Mail Services Unit, H25, PO Box 218, Hawthorn, VIC 3122 Australia
| | - Carolynne White
- Swinburne University of Technology, Mail Services Unit, H25, PO Box 218, Hawthorn, VIC 3122 Australia
- Mind Australia, PO Box 592, Heidelberg, VIC 3084 Australia
| | - Anthony McCosker
- Swinburne University of Technology, Mail Services Unit, H31, PO Box 218, Hawthorn, VIC 3122 Australia
| |
Collapse
|
11
|
Delgado J, de Groot J, McCaffrey G, Dimitropoulos G, Sitter KC, Austin W. Communities of practice: acknowledging vulnerability to improve resilience in healthcare teams. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2019-105865. [PMID: 31980462 PMCID: PMC8257551 DOI: 10.1136/medethics-2019-105865] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/19/2019] [Accepted: 01/13/2020] [Indexed: 05/11/2023]
Abstract
The majority of healthcare professionals regularly witness fragility, suffering, pain and death in their professional lives. Such experiences may increase the risk of burnout and compassion fatigue, especially if they are without self-awareness and a healthy work environment. Acquiring a deeper understanding of vulnerability inherent to their professional work will be of crucial importance to face these risks. From a relational ethics perspective, the role of the team is critical in the development of professional values which can help to cope with the inherent vulnerability of healthcare professionals. The focus of this paper is the role of Communities of Practice as a source of resilience, since they can create a reflective space for recognising and sharing their experiences of vulnerability that arises as part of their work. This shared knowledge can be a source of strength while simultaneously increasing the confidence and resilience of the healthcare team.
Collapse
Affiliation(s)
- Janet Delgado
- University Institute of Women's Studies, University of La Laguna, La Laguna, Spain
- NICU, University Hospital of the Canary Islands, La Laguna, Spain
| | - Janet de Groot
- University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Graham McCaffrey
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada
- University of Cambridge, Cambridge, Cambridgeshire, UK
| | | | - Kathleen C Sitter
- University of Calgary Faculty of Social Work, Calgary, Alberta, Canada
| | - Wendy Austin
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
12
|
Thomas L, Parker S, Song H, Gunatillaka N, Russell G, Harris M. Health service brokerage to improve primary care access for populations experiencing vulnerability or disadvantage: a systematic review and realist synthesis. BMC Health Serv Res 2019; 19:269. [PMID: 31035997 PMCID: PMC6489346 DOI: 10.1186/s12913-019-4088-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 04/09/2019] [Indexed: 11/28/2022] Open
Abstract
Background Individuals experiencing disadvantage or marginalisation often face difficulty accessing primary health care. Overcoming access barriers is important for improving the health of these populations. Brokers can empower and enable people to access resources; however, their role in increasing access to health services has not been well-defined or researched in the literature. This review aims to identify whether a health service broker working with health and social service providers in the community can (a) identify individuals experiencing vulnerability who may benefit from improved access to quality primary care, and (b) link these individuals with an appropriate primary care provider for enduring, appropriate primary care. Methods Six databases were searched for studies published between January 2008 and August 2015 that evaluated a health service broker intervention linking adults experiencing vulnerability to primary care. Relevant websites were also searched. Included studies were analysed using candidacy theory and a realist matrix was developed to identify mechanisms that may have contributed to changes in response to the interventions in different contexts. Results Eleven studies were included in the review. Of the eight studies judged to provide detailed description of the programs, the interventions predominately addressed two domains of candidacy (identification of candidacy and navigation), with limited applicability to the third and fourth dimensions (permeability of services and appearances at health services). Six of the eight studies were judged to have successfully linked their target group to primary care. The majority of the interventions focused on assisting patients to reach services and did not look at ways that providers or health services could alter the way they deliver care to improve access. Conclusions While specific mechanisms behind the interventions could not be identified, it is suggested that individual advocacy may be a key element in the success of these types of interventions. The interventions were found to address some dimensions of candidacy, with health service brokers able to help people to identify their need for care and to access, navigate and interact with services. More consideration should be given to the influence of providers on patient candidacy, rather than placing the onus on patients. Electronic supplementary material The online version of this article (10.1186/s12913-019-4088-z) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Louise Thomas
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW, 2052, Australia.
| | - Sharon Parker
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Hyun Song
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Nilakshi Gunatillaka
- The Southern Academic Primary Care Research Unit, School of Primary Health Care, Monash University, Notting Hill, Victoria, 3168, Australia
| | - Grant Russell
- The Southern Academic Primary Care Research Unit, School of Primary Health Care, Monash University, Notting Hill, Victoria, 3168, Australia
| | - Mark Harris
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW, 2052, Australia
| | | |
Collapse
|
13
|
Morse AR, Forbes O, Jones BA, Gulliver A, Banfield M. Australian Mental Health Consumer and Carer Perspectives on Ethics in Adult Mental Health Research. J Empir Res Hum Res Ethics 2019; 14:234-242. [PMID: 31018753 DOI: 10.1177/1556264619844396] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Barriers to research arise when national ethical guidelines governing the inclusion of consumers in mental health research are implemented at the local level. Equivalent guidelines for research involving carers are not available. A social science investigation of Australian mental health consumer and carer perspectives on research ethics procedures was conducted in two interlinked stages: (a) a discussion forum with consumers, carers, and lived-experience researchers and (b) in-depth interviews with consumers and carers. Data collection and analysis drew strongly on methodological features of grounded theory. Privacy, confidentiality, and stigmatizing ethics procedures were key issues for consumer and carer participants. Recommendations for research practice include the following: considering the impact of information sharing on participants' relationships and adopting individual-focused approaches to managing research risks.
Collapse
Affiliation(s)
- Alyssa R Morse
- 1 The Australian National University, Acton, Australian Capital Territory, Australia
| | - Owen Forbes
- 1 The Australian National University, Acton, Australian Capital Territory, Australia
| | - Bethany A Jones
- 1 The Australian National University, Acton, Australian Capital Territory, Australia
| | - Amelia Gulliver
- 1 The Australian National University, Acton, Australian Capital Territory, Australia
| | - Michelle Banfield
- 1 The Australian National University, Acton, Australian Capital Territory, Australia
| |
Collapse
|
14
|
DELGADO RODRIGUEZ JANET. THE RELEVANCE OF THE ETHICS OF VULNERABILITY IN BIOETHICS. LES ATELIERS DE L'ÉTHIQUE 2018. [DOI: 10.7202/1051280ar] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The concept of vulnerability is central to current developments in bioethics, not only because of its analytic nature, but also due to its capacity for criticism. However, this concept has not been sufficiently developed, neither in the area of moral philosophy nor in bioethics. For this reason, it is necessary to define and analyze the conceptual framework in which the notion of vulnerability has been developed within the scope of bioethics. Thus, the purpose of this paper is to indicate how the concept of vulnerability in the field of bioethics has been developed and what the main problems that derive from this approach are. Secondly, the paper analyzes some of the main philosophical approaches that I consider should be articulated in the expansion of a critical bioethics approach focused on the notion of vulnerability. To address this issue, I analyze the reflections that we find in the work of Martha Fineman, emphasizing the main relevant aspects for bioethics. Finally, I highlight the main implications of a theory of vulnerability for bioethics.
Collapse
|
15
|
Prioritising Supported Decision-Making: Running on Empty or a Basis for Glacial-To-Steady Progress? LAWS 2017. [DOI: 10.3390/laws6040018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
16
|
Bracken-Roche D, Bell E, Macdonald ME, Racine E. The concept of 'vulnerability' in research ethics: an in-depth analysis of policies and guidelines. Health Res Policy Syst 2017; 15:8. [PMID: 28173859 PMCID: PMC5297186 DOI: 10.1186/s12961-016-0164-6] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 12/14/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The concept of vulnerability has held a central place in research ethics guidance since its introduction in the United States Belmont Report in 1979. It signals mindfulness for researchers and research ethics boards to the possibility that some participants may be at higher risk of harm or wrong. Despite its important intended purpose and widespread use, there is considerable disagreement in the scholarly literature about the meaning and delineation of vulnerability, stemming from a perceived lack of guidance within research ethics standards. The aim of this study was to assess the concept of vulnerability as it is employed in major national and international research ethics policies and guidelines. METHODS We conducted an in-depth analysis of 11 (five national and six international) research ethics policies and guidelines, exploring their discussions of the definition, application, normative justification and implications of vulnerability. RESULTS Few policies and guidelines explicitly defined vulnerability, instead relying on implicit assumptions and the delineation of vulnerable groups and sources of vulnerability. On the whole, we found considerable richness in the content on vulnerability across policies, but note that this relies heavily on the structure imposed on the data through our analysis. CONCLUSIONS Our results underscore a need for policymakers to revisit the guidance on vulnerability in research ethics, and we propose that a process of stakeholder engagement would well-support this effort.
Collapse
Affiliation(s)
- Dearbhail Bracken-Roche
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal, 110 Avenue des Pins Ouest, Montréal, QC H2W 1R7 Canada
- Biomedical Ethics Unit and Division of Experimental Medicine, McGill University, Montréal, QC Canada
| | - Emily Bell
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal, 110 Avenue des Pins Ouest, Montréal, QC H2W 1R7 Canada
| | - Mary Ellen Macdonald
- Faculty of Dentistry, Oral Health and Society Research Unit, McGill University, 2001 McGill College, Suite 500, Montréal, QC H3A 1G1 Canada
| | - Eric Racine
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal, 110 Avenue des Pins Ouest, Montréal, QC H2W 1R7 Canada
- Biomedical Ethics Unit and Division of Experimental Medicine, McGill University, Montréal, QC Canada
- Department of Medicine and Department of Social and Preventive Medicine, Université de Montréal, Montréal, QC Canada
- Department of Neurology and Neurosurgery, McGill University, Montréal, QC Canada
| |
Collapse
|
17
|
Sherwin S, Stockdale K. Whither Bioethics Now? The Promise of Relational Theory. INTERNATIONAL JOURNAL OF FEMINIST APPROACHES TO BIOETHICS 2017. [DOI: 10.3138/ijfab.10.1.7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This article reflects on the work of feminist bioethicists over the past ten years, reviewing how effective feminists have been in using relational theory to reorient bioethics and where we hope it will go from here. Feminist bioethicists have made significant achievements using relational theory to shape the notion of autonomy, bringing to light the relevance of patients' social circumstances and where they are situated within systems of privilege and oppression. But there is much work to be done to reorient bioethics so that it is capable of addressing some current public health challenges. We argue that relational theory holds promise for beginning this work.
Collapse
|
18
|
Bracken-Roche D, Bell E, Racine E. The "Vulnerability" of Psychiatric Research Participants: Why This Research Ethics Concept Needs to Be Revisited. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2016; 61:335-9. [PMID: 27254842 PMCID: PMC4872238 DOI: 10.1177/0706743716633422] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Dearbhail Bracken-Roche
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, Québec Biomedical Ethics Unit, McGill University, Montréal, Québec
| | - Emily Bell
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, Québec
| | - Eric Racine
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, Québec Biomedical Ethics Unit, McGill University, Montréal, Québec Département de Médecine, Université de Montréal, Montréal, Québec
| |
Collapse
|
19
|
van der Zande ISE, van der Graaf R, Browne JL, van Delden JJM. Fair Inclusion of Pregnant Women in Clinical Research: A Systematic Review of Reported Reasons for Exclusion. RESEARCH ETHICS FORUM 2016. [DOI: 10.1007/978-3-319-26512-4_5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
20
|
Abstract
BACKGROUND In pediatric oncology, many oncologists invite their own patients to participate in research. Inclusion within a dependent relationship is considered to potentially compromise voluntariness of consent. Currently, it is unknown to what extent those involved in pediatric oncology experience the dependent relationship as a threat to voluntary informed consent, and what they see as safeguards to protect voluntary informed consent within a dependent relationship. AIM We performed a qualitative study among key actors in pediatric oncology to explore their experiences with the dependent relationship and voluntary informed consent. METHODS We conducted three focus groups and 25 semi-structured, in-depth interviews with pediatric oncologists, research coordinators, Research Ethics Committee members, parents of children with cancer, and adolescents with cancer. RESULTS Professionals regarded the dependent relationship both as a potential threat to and as a positive influence on voluntary decision making. Parents and adolescents did not feel as though dependency upon the oncologist influenced their decisions. They valued the involvement of their own physician in the informed consent process. The professionals suggested three strategies to protect voluntariness: emphasizing voluntariness; empowering families; involvement of an independent person. CONCLUSIONS Although the dependent relationship between pediatric oncologists, patients and parents may be problematic for voluntary informed consent, this is not necessarily the case. Moreover, the involvement of treating physicians may even have a positive impact on the informed consent process. Although we studied pediatric oncology, our results may also apply to many other fields of pediatric medicine where research and care are combined, for example, pediatric rheumatology, neurology and nephrology. Clinical trials in these fields are inevitably often designed, initiated and conducted by medical specialists closely involved in patient care.
Collapse
|
21
|
De Clercq E, Badarau DO, Ruhe KM, Wangmo T. Body matters: rethinking the ethical acceptability of non-beneficial clinical research with children. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2015; 18:421-431. [PMID: 25433817 DOI: 10.1007/s11019-014-9616-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The involvement of children in non-beneficial clinical research is extremely important for improving pediatric care, but its ethical acceptability is still disputed. Therefore, various pro-research justifications have been proposed throughout the years. The present essay aims at contributing to the on-going discussion surrounding children's participation in non-beneficial clinical research. Building on Wendler's 'contribution to a valuable project' justification, but going beyond a risk/benefit analysis, it articulates a pro-research argument which appeals to a phenomenological view on the body and vulnerability. It is claimed that children's bodies are not mere physical objects, but body-subjects due to which children, as persons, can contribute to research that may hold no direct clinical benefit to them even before they can give informed consent.
Collapse
Affiliation(s)
- Eva De Clercq
- Institute for Biomedical Ethics, University of Basel, Bernoullistr 28, 4056, Basel, Switzerland,
| | | | | | | |
Collapse
|
22
|
Handtke V, Bretschneider W, Elger B, Wangmo T. Easily forgotten: Elderly female prisoners. J Aging Stud 2015; 32:1-11. [DOI: 10.1016/j.jaging.2014.10.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 10/20/2014] [Accepted: 10/20/2014] [Indexed: 10/24/2022]
|
23
|
Luna F. 'Vulnerability', an Interesting Concept for Public Health: The Case of Older Persons. Public Health Ethics 2014. [DOI: 10.1093/phe/phu012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
24
|
Dekking SAS, van der Graaf R, van Delden JJM. Strengths and weaknesses of guideline approaches to safeguard voluntary informed consent of patients within a dependent relationship. BMC Med 2014; 12:52. [PMID: 24655604 PMCID: PMC3998040 DOI: 10.1186/1741-7015-12-52] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 02/24/2014] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND It is thought that a dependent relationship between patients and physicians who enroll their own patients in research compromises voluntary informed consent. Therefore, several ethical guidelines for human subject research provide approaches to mitigate these compromises. Currently, these approaches have not been critically evaluated. In this article, we analyze the approaches of ethical guidelines to manage the influence of a dependent relationship between patients and physicians on voluntary informed consent and discuss the strengths and weaknesses of these approaches. METHODS We performed a review of international ethical guidance documents on human subject research, listed in the Oxford Textbook of Clinical Research Ethics and found through cross referencing. We also searched Global Ethics Observatory (GEObs) and the World Health Organization (WHO) website. Guidelines from all years were eligible for inclusion. The date last searched was December 2013. DISCUSSION We identified two basic guideline approaches: 1. A process approach, which focuses on the person who obtains informed consent, that is, an independent individual, such as a research nurse or counselor; and 2. A content approach, emphasizing the voluntary nature of participation. Both approaches are valuable, either because the influence of the physician may diminish or because it empowers patients to make voluntary decisions. However, the approaches also face challenges. First, research nurses are not always independent. Second, physician-investigators will be informed about decisions of their patients. Third, involvement of a counselor is sometimes unfeasible. Fourth, the right to withdraw may be difficult to act upon in a dependent relationship. CONCLUSIONS Current guideline approaches to protect voluntary informed consent within a dependent relationship are suboptimal. To prevent compromises to voluntary informed consent, consent should not only be obtained by an independent individual, but this person should also emphasize the voluntary nature of participation. At the same time, dependency as such does not imply undue influence. Sometimes the physician may be best qualified to provide information, for example, for a very specialized study. Still, the research nurse should obtain informed consent. In addition, patients should be able to consult a counselor, who attends the informed consent discussions and is concerned with their interests. Finally, both physicians and research nurses should disclose research interests.
Collapse
Affiliation(s)
- Sara A S Dekking
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | | | | |
Collapse
|