An analysis of common ethical justifications for compassionate use programs for experimental drugs

Oncologists' reflections on patient rights and access to compassionate use drugs: A qualitative interview study from an academic cancer center

The U.S. Food and Drug Administration (FDA) allows patients with serious illnesses to access investigational drugs for "compassionate use" outside of clinical trials through expanded access (EA) Programs. The federal Right-to-Try Act created an additional pathway for non-trial access to experimental drugs without institutional review board or FDA approval. This removal of oversight amplifies the responsibility of physicians, but little is known about the role of practicing physicians in non-trial access to investigational drugs. We undertook semi-structured interviews to capture the experiences and opinions of 21 oncologists all with previous EA experience at a major cancer center. We found five main themes. Participants with greater EA experience reported less difficulty accessing drugs through the myriad of administrative processes and drug company reluctance to provide investigational products while newcomers reported administrative hurdles. Oncologists outlined several rationales patients offered when seeking investigational drugs, including those with stronger health literacy and a good scientific rationale versus others who remained skeptical of conventional medicine. Participants reported that most patients had realistic expectations while some had unrealistic optimism. Given the diverse reasons patients sought investigational drugs, four factors-scientific rationale, risk-benefit ratio, functional status of the patient, and patient motivation-influenced oncologists' decisions to request compassionate use drugs. Physicians struggled with a "right-to-try" framing of patient access to experimental drugs, noting instead their own responsibility to protect patients' best interest in the uncertain and risky process of off-protocol access. This study highlights the willingness of oncologists at a major cancer center to pursue non-trial access to experimental treatments for patients while also shedding light on the factors they use when considering such treatment. Our data reveal discrepancies between physicians' sense of patients' expectations and their own internal sense of professional obligation to shepherd a safe process for patients at a vulnerable point in their care.

Educational needs, perception, and perspectives of oncologists regarding compassionate use programs in Asia

OBJECTIVE

This study was conducted to capture the educational needs, perceptions, and perspectives of oncologists towards Compassionate Use Programs (CUPs) in Asia, with the aim of gathering insights related to unmet needs for physician and patient assistance.

METHODS

The participants responded to a voluntary, self-administered, closed-ended questionnaire through an online platform between 29 April 2020 and 17 June 2020.

RESULTS

A total of 111 oncologists provided informed consent to participate in the study. Of these, 102 respondents fully completed the questionnaire and were included in the analyses. Maximum respondents (35.3%) had 10-20 years of experience after specialization with 19.6, 23.5, and 21.6% respondents having <5, 5-10, and ≥20 years of experience, respectively. Practice type plays a statistically significant role in the awareness of the existing compassionate program (p = .0066). While many respondents seem clear on the application process for CUP set in place by pharmaceutical companies, a higher number of respondents are unclear about the country regulations and processes for applying to CUPs set in place by regulatory authorities. Most respondents (75.5%) reported that there are no resources or training provided to them regarding CUPs. There was a significant association between the clarity of the application process for CUP set in place by the sponsors and the number of applications submitted (p = .0321).

CONCLUSIONS

Our study brings light on various issues faced by physicians in accessing CUPs especially related to the lack of education and training on utilizing CUPs. There are significant unmet needs related to improving the clarity for the application process, providing resources and related training, particularly for oncologists who do not have previous experience with CUPs.

Ethical Dimensions of Public Health Actions and Policies With Special Focus on COVID-19

During pandemics, the ethicists, public health professionals, and human rights advocates raise a red flag about different public health actions that should, at best, be addressed through integrated, global policies. How to rationalize the healthcare resources and prioritize the cases is not a recent challenge but the serious concern about that is how to achieve this while not increasing the vulnerability of the disadvantaged population. Healthcare professionals use different scoring systems as a part of their decision-making so the medical teams and triage committees can allocate resources for predictable health outcomes and prognosis as well as to appropriately triage the patients accordingly. However, the value of the existing scoring systems to manage COVID-19 cases is not well-established yet. Part of this problem includes managing non-COVID patients with chronic medical conditions like non-communicable diseases and addressing their medical needs during the pandemic complex context in a way to avoid worsening their conditions and, on the other hand, avoid hindering the establishment of comprehensive standards for dealing with COVID-19. In this article, we discuss this dilemma as well as how preexisting ethical standards were challenged by COVID-19. We also discuss how monitoring the consistent application of ethical standards during the medical trials of new medications, vaccines, or unproven medical interventions is also a critical issue.

The Role of Physicians in Expanded Access to Investigational Drugs: A Mixed-Methods Study of Physicians' Views and Experiences in The Netherlands

Treating physicians have key roles to play in expanded access to investigational drugs, by identifying investigational treatment options, assessing the balance of risks and potential benefits, informing their patients, and applying to the regulatory authorities. This study is the first to explore physicians' experiences and moral views, with the aim of understanding the conditions under which doctors decide to pursue expanded access for their patients and the obstacles and facilitators they encounter in the Netherlands. In this mixed-methods study, semi-structured interviews (n = 14) and a questionnaire (n = 90) were conducted with medical specialists across the country and analysed thematically. Typically, our respondents pursue expanded access in "back against the wall" situations and broadly support its classic requirements. They indicate practical hurdles related to reimbursement, the amount of time and effort required for the application, and unfamiliarity with the regulatory process. Some physicians are morally opposed to expanded access, with an appeal to safety risks, lack of evidence, and "false hope." Some of these moral concerns and practical obstacles may be essential targets for change, if expanded access to unapproved drugs is to become available for wider groups of patients for whom standard treatment options are not-or no longer-available, on a more consistent and equal basis.

Compassionate use of psychedelics

In the present paper, we discuss the ethics of compassionate psychedelic psychotherapy and argue that it can be morally permissible. When talking about psychedelics, we mean specifically two substances: psilocybin and MDMA. When administered under supportive conditions and in conjunction with psychotherapy, therapies assisted by these substances show promising results. However, given the publicly controversial nature of psychedelics, compassionate psychedelic psychotherapy calls for ethical justification. We thus review the safety and efficacy of psilocybin- and MDMA-assisted therapies and claim that it can be rational for some patients to try psychedelic therapy. We think it can be rational despite the uncertainty of outcomes associated with compassionate use as an unproven treatment regime, as the expected value of psychedelic psychotherapy can be assessed and can outweigh the expected value of routine care, palliative care, or no care at all. Furthermore, we respond to the objection that psychedelic psychotherapy is morally impermissible because it is epistemically harmful. We argue that given the current level of understanding of psychedelics, this objection is unsubstantiated for a number of reasons, but mainly because there is no experimental evidence to suggest that epistemic harm actually takes place.

Academic Advocacy: Opportunities to Influence Health and Science Policy Under U.S. Lobbying Law

Medical school faculty and their colleagues in schools of nursing, public health, social work, and elsewhere often research issues of critical importance to health and science policy. When academics engage with government policymakers to advocate for change based on their research, however, they may find themselves engaged in "lobbying," thereby entering a complex environment of legal requirements and institutional policies that they may not fully understand. To promote academic advocacy, this article explains what is and is not legally permitted when it comes to engaging with policymakers and encourages academic institutions to facilitate permissible advocacy activities.U.S. law permits academic researchers to conduct certain types of policy-focused advocacy without running afoul of legal restrictions on lobbying. Academics acting in their personal capacities and with their own resources may freely engage with policymakers in any branch of government to provide their expertise and advocate for desired outcomes. When acting in their professional capacities, academics are free to engage in most advocacy activities directed to the executive and judicial branches, and they also may advocate to influence legislation and legislators within certain limits that are particularly relevant to academic work. In all cases, academics must take care to not use restricted funds for lobbying.Academic researchers have an important role to play in advancing evidence-based health and science policy. They should familiarize themselves with legal restrictions and opportunities to influence policy based on their research, and their institutions should actively support them in doing so.

The Practice of Pharmaceutics and the Obligation to Expand Access to Investigational Drugs

Do pharmaceutical companies have a moral obligation to expand access to investigational drugs to patients outside the clinical trial? One reason for thinking they do not is that expanded access programs might negatively affect the clinical trial process. This potential impact creates dilemmas for practitioners who nevertheless acknowledge some moral reason for expanding access. Bioethicists have explained these reasons in terms of beneficence, compassion, or a principle of rescue, but their arguments have been limited to questions of moral permissibility, leaving for future research the question of whether expanded access is morally obligatory. We take up this further question and argue that pharmaceutical companies have a moral obligation to expand access. Our defense is not based on beneficence, compassion, or rescue, but instead on a reciprocal moral expectation resulting from existing social commitments that help ensure a robust pharmaceutical practice within the broader healthcare system. Our aim is to give this obligation, along with several others, a coherent and plausible structure within the wider clinical trial process so that one might better explain the sources of the dilemmas and their possible resolutions.

Compassionate use of unauthorized drugs: Legal regulations and ethical challenges

Compassionate use (also referred to as expanded access) is therapeutic use of unauthorized drugs outside of clinical trials. The objective of this review is to discuss practical aspects of the current legal regulations concerning compassionate use that have been introduced in the European Union, the USA (both the Food and Drug Administration regulations and Right-to-try laws), Canada and Australia. We also present main ethical challenges associated with use of unauthorized drugs such as possible difficulties with obtaining informed consent and fair patient selection. Moreover, we discuss guidelines, especially those contained in the Declaration of Helsinki, which may aid doctors in the ethical conduct of compassionate treatments.

Inappropriate medication use and polypharmacy in end-stage cancer patients: Isn't it the family doctor's role to de-prescribe much earlier?

BACKGROUND

Elderly patients are exposed to increased number of medications, often with no proof of a positive benefit/risk ratio. Unfortunately, this trend does not spare those with limited life expectancy, including end-stage cancer patients who require only palliative treatment. For many medications in this subpopulation, the risk of adverse drug events outweighs the possible benefits and yet, many are still poly-medicated during their last year of life.

AIM

To describe the extent of polypharmacy among end-stage cancer patients, at the time of admission to homecare hospice.

METHODS

A retrospective chart review of 202 patients admitted to Homecare Hospice of the Israel Cancer Association and died before January 2015.

RESULTS

Average lifespan from admission until death was 39.2 ± 5.4 days. 63% died within the first month, 89% within 3 months. Excluding oncological treatments, 181 (90%) and 46 (23%) patients were treated with ≥ 6 and ≥ 12 drugs for chronic diseases, respectively. Two months before death, 32 (16%) patients were treated with ≥ 3 blood pressure lowering drugs, 62 (31%) with statins and 48 (23%) with aspirin.

CONCLUSION

Though not representative of the whole end-stage cancer patient population, our study demonstrates that these patients are exposed to extensive polypharmacy. Most of these medications could have probably been safely de-prescribed much earlier in the course of the malignant disease. Considering the prolonged trust-based relationship with their patients, the family physicians are those who should be encouraged to implement the palliative approach and reduce polypharmacy much before reaching hospice settings.

Compassionate use programs in Italy: ethical guidelines

BACKGROUND

This article proposes a retrospective analysis of a compassionate use (CU), using a case study of request for Avelumab for a patient suffering from Merkel Cell Carcinoma. The study is the result of a discussion within a Provincial Ethics Committee (EC) following the finding of a high number of requests for CU program. The primary objective of the study is to illustrate the specific ethical and clinical profiles that emerge from the compassionate use program (CUP) issue. The secondary goals are: a) to promote a moral reflection among physicians who require approval for the CUP and b) provide the basis for recommendations on how to request CUP.

MAIN BODY

The instruments for carrying out the analysis of the case study and the discussion are as follows: Analysis of the audio-recording of the EC meeting regarding the selected Case study. In-depth discussion of topics that emerged during the meeting by means of administration of 5 semi-structured interviews with 2 doctors involved in the case (proposing physician and palliative physician) and with 3 components of the EC who played a major role in the EC internal discussion.

CONCLUSIONS

In an exploration of emerging clinical and ethical issues, four primary themes arise: 1. efficacy, safety of the treatment and patient's quality of life; 2. clear, realistic, adequate communication; 3. right to hope; 4. simultaneous Palliative Care approach. The results of ethical analysis carried out concern two areas: 1) ethical profiles relating to the use of CUP; 2) the role of the EC concerning the compassionate use of drugs and the need to provide recommendations on how to request CUP. With the aim of implementing these conclusions, the provincial EC of Reggio Emilia chose to steer the request for drugs for compassionate use through recommendations for good clinical and ethical practice based on the following assumptions: 1) the "simultaneous care" approach must be preferred. Secondly, 2) the EC's assessment must be part of the decision-making process that the care team conducts before proposing compassionate use to the patient.

Control of Antimicrobial Resistance Requires an Ethical Approach

Ethical behavior encompasses actions that benefit both self and society. This means that tackling antimicrobial resistance (AMR) becomes an ethical obligation, because the prospect of declining anti-infectives affects everyone. Without preventive action, loss of drugs that have saved lives over the past century, will condemn ourselves, people we know, and people we don't know, to unacceptable risk of untreatable infection. Policies aimed at extending antimicrobial life should be considered within an ethical framework, in order to balance the choice, range, and quality of drugs against stewardship activities. Conserving availability and effectiveness for future use should not compromise today's patients. Practices such as antimicrobial prophylaxis for healthy people 'at risk' should receive full debate. There are additional ethical considerations for AMR involving veterinary care, agriculture, and relevant bio-industries. Restrictions for farmers potentially threaten the quality and quantity of food production with economic consequences. Antibiotics for companion animals do not necessarily spare those used for humans. While low-income countries cannot afford much-needed drugs, pharmaceutical companies are reluctant to develop novel agents for short-term return only. Public demand encourages over-the-counter, internet, black market, and counterfeit drugs, all of which compromise international control. Prescribers themselves require educational support to balance therapeutic choice against collateral damage to both body and environment. Predicted mortality due to AMR provides justification for international co-operation, commitment and investment to support surveillance and stewardship along with development of novel antimicrobial drugs. Ethical arguments for, and against, control of antimicrobial resistance strategies are presented and discussed in this review.

Accelerating regenerative medicine: the Japanese experiment in ethics and regulation

In 2014, the Japanese National Diet introduced new laws aimed at promoting the clinical translation of stem cells and regenerative medicine. The basic action of these laws is to allow the early introduction of regenerative medicine products into the Japanese market through an accelerated approval process, while providing patients with access to certain types of stem cell and cell-based therapies in the context of private clinical practice. While this framework appears to offer enormous opportunities for the translation of stem cell science, it raises ethical challenges that have not yet been fully explored. This paper critically analyzes this framework with respect to the prioritization of safety over clinical benefit, distributive justice and public trust in science and medicine. It is argued that the framework unfairly burdens patients and strained healthcare systems without any clear benefits, and may undermine the credibility of the regenerative medicine field as it emerges.

The changing landscape of expanded access to investigational drugs for patients with unmet medical needs: ethical implications

When patients are told that standard medical treatment options have been exhausted, their treating physicians may start looking for promising new drugs that are not yet approved, and still under investigation. Some patients can be included in clinical trials, but others cannot. It is not widely known that these patients might still be eligible for trying investigational drugs, in a therapeutic context. Worldwide, public and private parties are seeking to change this by informing patients and physicians about opportunities for expanded access and/or by facilitating its processes. When expanded access becomes available to larger groups of patients, ethical issues gain prominence, including informed consent, funding issues, disparities in access, and potential adverse effects on clinical drug development. Physicians, patients and policy-makers should not shift the responsibility to address these issues to pharmaceutical companies, but work together to resolve them.