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Salayev K, Aslanova U, Munir K. Evaluating the Decisional Capacity for Informed Consent of Transition age Children to Adolescents in Human Subject Research. J Empir Res Hum Res Ethics 2024; 19:28-36. [PMID: 38073174 PMCID: PMC10957319 DOI: 10.1177/15562646231219384] [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: 03/22/2024]
Abstract
This study aimed to evaluate children's capacity for informed consent. We translated into Azerbaijani language and adapted the University of California, San Diego Brief Assessment of Capacity to Consent (UBACC). We enrolled four healthy groups: children aged 11, 12, and 13 years and adults. We provided the participants with information about the simulated research proposal and a related informed consent form. Subsequently, they were administered the UBACC. The mean total UBACC scores were 11.9 (11-year-olds), 12.7 (12-year-olds), 14.0 (13-year-olds), and 16.0 (adults). The gradual increase in the mean UBACC scores with age suggests the continuous maturation of the capacity to comprehend the informed consent process. There was no specific cutoff age to decide whether the children were competent enough to provide informed consent.
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Affiliation(s)
- Kamran Salayev
- Department of Neurology, Azerbaijan Medical University, Baku (Azerbaijan)
- Medina Medical Center, Baku (Azerbaijan)
| | | | - Kerim Munir
- Division of Developmental Medicine, Boston Children’s Hospital, Boston, Massachusetts (USA)
- Departments of Psychiatry and Pediatrics, Harvard Medical School, Boston, Massachusetts (USA)
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2
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Jacobson RM, Pignolo RJ, Lazaridis KN. Clinical Trials for Special Populations: Children, Older Adults, and Rare Diseases. Mayo Clin Proc 2024; 99:318-335. [PMID: 38309939 PMCID: PMC10842263 DOI: 10.1016/j.mayocp.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 03/02/2023] [Accepted: 03/13/2023] [Indexed: 02/05/2024]
Abstract
Research cannot maximize population health unless it improves health for all members of the public, including special populations such as children, older adults, and people living with rare diseases. Each of these categories require special considerations when planning and performing clinical trials, and common threads of ethical conduct of research in vulnerable populations appear throughout. In this review, definitions of each of the three categories of special population (children, older adults, and rare diseases) are discussed in terms of US research regulations, the unique challenges to conducting clinical trials for these special populations, critical ethical issues, and opportunities for innovative ways to design and operationalize clinical trials in special populations. Additional critical attention is focused on factors that influence the generalizability of study results to reduce health disparities, as well as the importance of community engagement and advocacy groups that can help to educate potential trial participants of the benefits of clinical trial participation.
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Affiliation(s)
- Robert M Jacobson
- Department of Pediatric and Adolescent Medicine and Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA.
| | - Robert J Pignolo
- Department of Medicine and Divisions of Hospital Internal Medicine and Endocrinology, Home of Medical Excellence in Geriatric Medicine and Gerontology, Department of Physiology and Biomedical Engineering, and Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN, USA
| | - Konstantinos N Lazaridis
- Center for Individualized Medicine, Department of Internal Medicine, Division of Gastroenterology, Mayo Clinic, Rochester, MN, USA
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3
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O'Hearn K, Cayouette F, Cameron S, Martin DA, Tsampalieros A, Menon K. Assent in Pediatric Critical Care Research: A Cross-Sectional Stakeholder Survey of Canadian Research Ethics Boards, Research Coordinators, Pediatric Critical Care Researchers, and Nurses. Pediatr Crit Care Med 2023; 24:e179-e189. [PMID: 36511694 DOI: 10.1097/pcc.0000000000003135] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Survey of four stakeholder groups involved in defining and obtaining assent for research in Canadian PICUs to better understand their perspectives and perceived barriers to assent. DESIGN Cross-sectional survey. SETTING Fourteen tertiary-care pediatric hospitals in Canada. PARTICIPANTS Research Ethics Board Chairs, pediatric critical care nurses, research coordinators, and researchers. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 193 participants responded. Thirty-seven percent (59/159) thought it was "Never/Almost Never" (59/159, 37%) feasible to obtain assent during the first 48 hours of PICU admission, and 112 of 170 (66%) indicated there are unique barriers to assent at the time of enrollment in PICU studies. Asking children for assent was most frequently rated as Important/Very Important for interviews/focus groups with the child (138/180, 77%), blood sample collection with a needle poke for research (137/178, 77%), and studies involving genetic testing with results communicated to the child/legal guardian (134/180, 74%). In two scenarios where a child and legal guardian disagreed about study participation, most respondents indicated that whether the child should still be enrolled would depend on the patient's age (34-36%), and/or the risk of the study (24-28%). There was a lack of consensus over how the assent process should be operationalized, and when and for how long children should be followed to seek assent for ongoing study participation. Most stakeholders (117/158, 74%) thought that children should have the opportunity to decide if their samples could stay in a biobank once they are old enough to do so. CONCLUSIONS There was an overall lack of consensus on the feasibility of, and challenges associated with, obtaining assent at the time of study enrollment and on how key aspects of the assent process should be operationalized in the PICU. This highlights the need for guidelines to clarify the assent process in pediatric critical care research.
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Affiliation(s)
- Katie O'Hearn
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Florence Cayouette
- Paediatric Intensive Care Unit, Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Saoirse Cameron
- Children's Hospital - London Health Sciences Centre, London, ON, Canada
| | - Dori-Ann Martin
- Section of Critical Care Medicine, Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada
| | - Anne Tsampalieros
- Children's Hospital of Eastern Ontario, Clinical Research Unit, Ottawa, ON, Canada
| | - Kusum Menon
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Children's Hospital of Eastern Ontario, Department of Pediatrics, Division of Critical Care, Ottawa, ON, Canada
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Taplin S, Chalmers J, Brown J, Moore T, Graham A, McArthur M. Human Research Ethics Committee Experiences and Views About Children's Participation in Research: Results From the MESSI Study. J Empir Res Hum Res Ethics 2021; 17:70-83. [PMID: 34636704 DOI: 10.1177/15562646211048294] [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] [Indexed: 11/17/2022]
Abstract
As part of a larger study, Australian Human Research Ethics Committee (HREC) members and managers were surveyed about their decision-making and views about social research studies with child participants. Responses of 229 HREC members and 42 HREC managers are reported. While most HREC members had received ethical training, HREC training and guidelines specific to research involving children were rare. Most applications involving children had to go through a full ethical review, but few adverse events were reported to HRECs regarding the conduct of the studies. Revisions to study proposals requested by HRECs were mostly related to consent processes and age-appropriate language. One-third of HREC members said that they would approve research on any topic. Most were also concerned that the methodology was appropriate, and the risks and benefits were clearly articulated. Specific training and guidance are needed to increase HREC members' confidence to judge ethical research with children.
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Affiliation(s)
- Stephanie Taplin
- Institute of Child Protection Studies, 94261Australian Catholic University, PO Box 256, Dickson, ACT 2602, Australia.,School of Public Health, Faculty of Health, 1994University of Technology Sydney, PO Box 123, Broadway, NSW 2007, Australia
| | - Jenny Chalmers
- 146817University of New South Wales, Sydney, NSW 2052, Australia
| | - Judith Brown
- Institute of Child Protection Studies, 94261Australian Catholic University, PO Box 256, Dickson, ACT 2602, Australia
| | - Tim Moore
- Australian Centre for Child Protection, 1067University of South Australia, Level 3, 195 North Terrace, Adelaide, SA 5000, Australia
| | - Anne Graham
- Centre for Children and Young People, 4571Southern Cross University, PO Box 157, Lismore, NSW 2480, Australia
| | - Morag McArthur
- Institute of Child Protection Studies, 94261Australian Catholic University, PO Box 256, Dickson, ACT 2602, Australia
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Abstract
Research ethics provide important and necessary standards related to the conduct and dissemination of research. To better understand the current state of research ethics discourse in social work, a systematic literature search was undertaken and numbers of publications per year were compared between STEM, social science, and social work disciplines. While many professions have embraced the need for discipline-specific research ethics subfield development, social work has remained absent. Low publication numbers, compared to other disciplines, were noted for the years (2006-2016) included in the study. Social work published 16 (1%) of the 1409 articles included in the study, contributing 3 (>1%) for each of the disciplines highest producing years (2011 and 2013). Comparatively, psychology produced 75 (5%) articles, psychiatry produced 64 (5%) articles, and nursing added 50 (4%) articles. The STEM disciplines contributed 956 (68%) articles between 2006 and 2016, while social science produced 453 (32%) articles. Examination of the results is provided in an extended discussion of several misconceptions about research ethics that may be found in the social work profession. Implications and future directions are provided, focusing on the need for increased engagement, education, research, and support for a new subfield of social work research ethics.
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Affiliation(s)
- Aidan Ferguson
- a College of Social Work , Florida State University , Tallahassee , USA
| | - James J Clark
- a College of Social Work , Florida State University , Tallahassee , USA
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Hawley K, Huang JS, Goodwin M, Diaz D, de Sa VR, Birnie KA, Chambers CT, Craig KD. Youth and Parent Appraisals of Participation in a Study of Spontaneous and Induced Pediatric Clinical Pain. ETHICS & BEHAVIOR 2018; 29:259-273. [PMID: 31768092 DOI: 10.1080/10508422.2018.1463163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The current study examined youths' and their parents' perceptions concerning participation in an investigation of spontaneous and induced pain during recovery from laparoscopic appendectomy. Youth (age range 5-17 years) and their parents independently completed surveys about their study participation. On a 0 (very negative) -to-10 (very positive) scale, both parents 9.4(1.3) [mean(SD)] and youth 7.9(2.4) rated their experience as positive. Among youth, experience ratings did not differ by pain severity and survey responses did not differ by age. Most youth (83%) reported they would tell another youth to participate. Ethical issues regarding instigation of pain in youth for research purposes are examined.
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Affiliation(s)
- Kara Hawley
- Department of Psychology, University of British Columbia, Vancouver, BC, Canada
| | - Jeannie S Huang
- Department of Pediatrics, University of California San Diego, La Jolla, CA 92093.,Division of Gastroenterology, Rady Children's Hospital, San Diego, CA 92123
| | - Matthew Goodwin
- Department of Health Sciences, Northeastern University, Boston, MA, 02115
| | - Damaris Diaz
- Department of Pediatrics, University of California San Diego, La Jolla, CA 92093
| | - Virginia R de Sa
- Department of Cognitive Science, University of California San Diego, La Jolla, CA 92093
| | - Kathryn A Birnie
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON.,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON
| | - Christine T Chambers
- Departments of Pediatrics, and Psychology & Neuroscience, Dalhousie University, Halifax, NS.,Centre for Pediatric Pain Research, IWK Health Centre, Halifax, NS
| | - Kenneth D Craig
- Department of Psychology, University of British Columbia, Vancouver, BC, Canada
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Flege MM, Thomsen SF. Institutional review boards' attitudes towards remuneration in paediatric research: Ethical considerations. J Paediatr Child Health 2017; 53:1149-1151. [PMID: 28905469 DOI: 10.1111/jpc.13711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 08/07/2017] [Indexed: 11/30/2022]
Abstract
Remuneration in paediatric research poses an ethical dilemma. Too large a sum might cause parents to enrol their children in research projects with no benefit for the child, whereas too modest a sum might hamper recruitment. The institutional review boards have the responsibility to only approve remuneration in paediatric trials with ethically sound research plans. However, little is known about which factors influence institutional review boards' evaluation of remuneration in paediatric research.
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Affiliation(s)
- Marius M Flege
- Department of Dermatology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Simon F Thomsen
- Department of Dermatology, Bispebjerg Hospital, Copenhagen, Denmark.,Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
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Shah SK. When to start paediatric testing of the adult HIV cure research agenda? JOURNAL OF MEDICAL ETHICS 2017; 43:82-86. [PMID: 27259546 PMCID: PMC5293843 DOI: 10.1136/medethics-2015-103116] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/09/2016] [Accepted: 02/15/2016] [Indexed: 06/05/2023]
Abstract
Ethical guidelines recommend that experimental interventions should be tested in adults first before they are tested and approved in children. Some challenge this paradigm, however, and recommend initiating paediatric testing after preliminary safety testing in adults in certain cases. For instance, commentators have argued for accelerated testing of HIV vaccines in children. Additionally, HIV cure research on the use of very early therapy (VET) in infants, prompted in part by the Mississippi baby case, is one example of a strategy that is currently being tested in infants before it has been well tested in adults. Because infants' immune systems are still developing, the timing of HIV transmission is easier to identify in infants than in adults, and infants who receive VET might never develop the viral reservoirs that make HIV so difficult to eradicate, infants may be uniquely situated to achieve HIV cure or sustained viral remission. Several commentators have now argued for earlier initiation of HIV cure interventions other than (or in addition to) VET in children. HIV cure research is therefore a good case for re-examining the important question of when to initiate paediatric research. I will argue that, despite the potential for HIV cure research to benefit children and the scientific value of involving children in this research, the HIV cure agenda should not accelerate the involvement of children for the following reasons: HIV cure research is highly speculative, risky, aimed at combination approaches and does not compare favourably with the available alternatives. I conclude by drawing general implications for the initiation of paediatric testing, including that interventions that have to be used in combination with others and cures for chronic diseases may not be valuable enough to justify early paediatric testing.
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Brown HR, Harvey EA, Griffith SF, Arnold DH, Halgin RP. Assent and Dissent: Ethical Considerations in Research With Toddlers. ETHICS & BEHAVIOR 2017. [DOI: 10.1080/10508422.2016.1277356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Hallie R. Brown
- Department of Psychological and Brain Sciences, University of Massachusetts Amherst
| | - Elizabeth A. Harvey
- Department of Psychological and Brain Sciences, University of Massachusetts Amherst
| | - Shayl F. Griffith
- Department of Psychological and Brain Sciences, University of Massachusetts Amherst
| | - David H. Arnold
- Department of Psychological and Brain Sciences, University of Massachusetts Amherst
| | - Richard P. Halgin
- Department of Psychological and Brain Sciences, University of Massachusetts Amherst
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Abstract
Informed consent should be seen as an essential part of health care practice; parental permission and childhood assent is an active process that engages patients, both adults and children, in their health care. Pediatric practice is unique in that developmental maturation allows, over time, for increasing inclusion of the child's and adolescent's opinion in medical decision-making in clinical practice and research. This technical report, which accompanies the policy statement "Informed Consent in Decision-Making in Pediatric Practice" was written to provide a broader background on the nature of informed consent, surrogate decision-making in pediatric practice, information on child and adolescent decision-making, and special issues in adolescent informed consent, assent, and refusal. It is anticipated that this information will help provide support for the recommendations included in the policy statement.
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11
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Sibley A, Pollard AJ, Fitzpatrick R, Sheehan M. Developing a new justification for assent. BMC Med Ethics 2016; 17:2. [PMID: 26754555 PMCID: PMC4709867 DOI: 10.1186/s12910-015-0085-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 12/23/2015] [Indexed: 05/28/2023] Open
Abstract
Background Current guidelines do not clearly outline when assent should be attained from paediatric research participants, nor do they detail the necessary elements of the assent process. This stems from the fact that the fundamental justification behind the concept of assent is misunderstood. In this paper, we critically assess three widespread ethical arguments used for assent: children’s rights, the best interests of the child, and respect for a child’s developing autonomy. We then outline a newly-developed two-fold justification for the assent process: respect for the parent’s pedagogical role in teaching their child to become an autonomous being and respect for the child’s moral worth. Discussion We argue that the ethical grounding for the involvement of young children in medical decision-making does not stem from children’s rights, the principle of best interests, or respect for developing autonomy. An alternative strategy is to examine the original motivation to engage with the child. In paediatric settings there are two obligations on the researcher: an obligation to the parents who are responsible for determining when and under what circumstances the child develops his capacity for autonomy and reasoning, and an obligation to the child himself. There is an important distinction between respecting a decision and encouraging a decision. This paper illustrates that the process of assent is an important way in which respect for the child as an individual can be demonstrated, however, the value lies not in the child’s response but the fact that his views were solicited in the first place. Summary This paper demonstrates that the common justifications for the process of assent are incomplete. Assent should be understood as playing a pedagogical role for the child, helping to teach him how specific decisions are made and therefore helping him to become a better decision-maker. How the researcher engages with the child supports his obligation to the child’s parents, yet why the researcher engages with the child stems from the child’s moral worth. Treating a child as having moral worth need not mean doing what they say but it may mean listening, considering, engaging or involving them in the decision.
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Affiliation(s)
- Amanda Sibley
- Department of Paediatrics, University of Oxford, Oxford, UK. .,NIHR Oxford Biomedical Research Centre, Centre for Clinical Vaccinology and Tropical Medicine (CCVTM), Churchill Hospital, Old Road, Oxford, OX3 7LE, UK.
| | - Andrew J Pollard
- Department of Paediatrics, University of Oxford, Oxford, UK. .,NIHR Oxford Biomedical Research Centre, Centre for Clinical Vaccinology and Tropical Medicine (CCVTM), Churchill Hospital, Old Road, Oxford, OX3 7LE, UK.
| | - Raymond Fitzpatrick
- Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford, OX3 7LF, UK.
| | - Mark Sheehan
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford, OX3 7LF, UK.
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Lantos JD, Wendler D, Septimus E, Wahba S, Madigan R, Bliss G. Considerations in the evaluation and determination of minimal risk in pragmatic clinical trials. Clin Trials 2015; 12:485-93. [PMID: 26374686 DOI: 10.1177/1740774515597687] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Institutional review boards, which are charged with overseeing research, must classify the riskiness of proposed research according to a federal regulation known as the Common Rule (45 CFR 46, Subpart A) and by regulations governing the US Food and Drug Administration codified in 21 CFR 50. If an institutional review board determines that a clinical trial constitutes "minimal risk," there are important practical implications: the institutional review board may then allow a waiver or alteration of the informed consent process; the study may be carried out in certain vulnerable populations; or the study may be reviewed by institutional review boards using an expedited process. However, it is unclear how institutional review boards should assess the risk levels of pragmatic clinical trials. Such trials typically compare existing, widely used medical therapies or interventions in the setting of routine clinical practice. Some of the therapies may be considered risky of themselves but the study comparing them may or may not add to that pre-existing level of risk. In this article, we examine the common interpretations of research regulations regarding minimal-risk classifications and suggest that they are marked by a high degree of variability and confusion, which in turn may ultimately harm patients by delaying or hindering potentially beneficial research. We advocate for a clear differentiation between the risks associated with a given therapy and the incremental risk incurred during research evaluating those therapies as a basic principle for evaluating the risk of a pragmatic clinical trial. We then examine two pragmatic clinical trials and consider how various factors including clinical equipoise, practice variation, research methods such as cluster randomization, and patients' perspectives may contribute to current and evolving concepts of minimal-risk determinations, and how this understanding in turn affects the design and conduct of pragmatic clinical trials.
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Affiliation(s)
- John D Lantos
- Children's Mercy Bioethics Center, Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, MO, USA
| | - David Wendler
- National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Edward Septimus
- Department of Internal Medicine, Texas A&M Health Science Center, Houston, TX, USA Clinical Services Group, Hospital Corporation of America, Nashville, TN, USA
| | - Sarita Wahba
- Patient-Centered Outcomes Research Institute, Washington, DC, USA
| | - Rosemary Madigan
- Perelman School of Medicine, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Geraldine Bliss
- Research Support Committee, Phelan-McDermid Syndrome Foundation, Venice, FL, USA
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Constand M, Tanel N, Ryan SE. PAeDS-MoRe: A framework for the development and review of research assent protocols involving children and adolescents. RESEARCH ETHICS REVIEW 2014. [DOI: 10.1177/1747016114523772] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We systematically reviewed contemporary literature to create an evidence-informed framework for research studies involving children and adolescents who can assent to participate. We searched seven citation indices to locate peer-reviewed research published in English language journals between 2000 and 2012. After screening 1,231 titles and abstracts for relevance, we assessed levels of evidence, extracted information, and analysed content from 87 articles. Most articles narrowly focused on paediatric assent barriers and facilitators for decision-making about research participation. No articles provided a single, comprehensive ethical framework to guide the development and review of research assent protocols. We developed a 6-step framework that provides guidance to: prepare the child for the assent process; assess the child’s readiness to engage in decision making; discuss the elements of informed consent to the greatest extent possible; seek an initial assent decision; monitor and affirm assent; and respect the child’s role as a research participant. The PAeDS-MoRe framework also supports the creation of process models that address the unique, developmental needs of paediatric sub-groups, and guides the operationalization of jurisdictional requirements for ethical research involving children who are unable to provide free, informed and ongoing consent.
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Affiliation(s)
| | - Nadia Tanel
- Holland Bloorview Kids Rehabilitation Hospital, Canada
| | - Stephen E Ryan
- Holland Bloorview Kids Rehabilitation Hospital and Department of Occupational Science and Occupational Therapy, University of Toronto, Canada
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Giesbertz NAA, Bredenoord AL, van Delden JJM. Clarifying assent in pediatric research. Eur J Hum Genet 2014; 22:266-9. [PMID: 23756442 PMCID: PMC3895639 DOI: 10.1038/ejhg.2013.119] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 04/22/2013] [Accepted: 05/01/2013] [Indexed: 01/14/2023] Open
Abstract
Assent is a relatively young term in research ethics, but became an often mentioned ethical requirement in current pediatric research guidelines. Also, the European Society of Human Genetics considers assent an important condition for the inclusion of children in biobanks. However, although many emphasize the importance of assent, few explain how they understand the concept and few have elaborated on the underlying grounds. In this paper, we will discuss the different underlying ethical principles of assent. In the first category, assent appears to be derived from informed consent. This understanding is grounded in respect for autonomy and protection against harm. We conclude that this interpretation of assent is not of added value as a majority of children cannot be considered competent to make autonomous decisions. In addition, other safeguards are more appropriate to protect children against harm. The grounds from the second category can be classified as engagement grounds. These grounds do justice to the specifics of childhood and are of added value. Furthermore, we argue that it follows that both the content and the process of assent should be adjusted to the individual child. This can be referred to as personalized assent. Personalized assent is an appeal to the moral responsibility and integrity of the researcher.
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Affiliation(s)
- Noor A A Giesbertz
- Department of Medical Humanities, Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Annelien L Bredenoord
- Department of Medical Humanities, Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johannes J M van Delden
- Department of Medical Humanities, Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
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Blehar MC, Spong C, Grady C, Goldkind SF, Sahin L, Clayton JA. Enrolling pregnant women: issues in clinical research. Womens Health Issues 2013; 23:e39-45. [PMID: 23312713 DOI: 10.1016/j.whi.2012.10.003] [Citation(s) in RCA: 165] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 09/17/2012] [Accepted: 10/29/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite the fact that many pregnant women are affected by a range of serious health conditions and take medications for these conditions, there is widespread reticence to include them in clinical intervention research. Hence, their clinical care is typically not informed by evidence derived from pregnant populations. METHOD In October 2010, the National Institutes of Health Office of Research on Women's Health convened a workshop to address ethical, regulatory, and scientific issues raised by the enrollment of pregnant women in clinical research. This report summarizes three areas that emerged from that meeting as important next steps to be taken to promote ethically responsible and scientifically sound research during pregnancy. FINDINGS The three areas are: 1) Reclassify pregnant women from their current status in regulations as a "vulnerable" population to a scientifically "complex" population and change the presumption of exclusion to one of inclusion; 2) examine the institutional review boards' (IRB) gatekeeper role in interpreting regulations governing pregnancy research and identify steps to facilitate IRB approval of ethically informed pregnancy research; and 3) develop a pregnancy-focused research agenda that addresses pressing clinical needs, identifies opportunities to gather information from existing resources and studies, and encourages important new research areas. CONCLUSION Research is needed to address the therapeutic needs of pregnant women and to study pregnancy as it may shed light on a pregnant woman's later health and the health of her child.
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Affiliation(s)
- Mary C Blehar
- Office of Research on Women's Health, National Institutes of Health, Bethesda, Maryland 20892-5484, USA.
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Wilfond BS. Quality improvement ethics: lessons from the SUPPORT study. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2013; 13:14-19. [PMID: 24256524 PMCID: PMC4077328 DOI: 10.1080/15265161.2013.851582] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The Office of Human Research Protections was not justified in issuing findings against the SUPPORT Institutions. Our community can learn from the evolving healthcare transformation into learning health systems by thinking about the novel ethical issues about standard of care research raised by the SUPPORT with the same spirit of quality improvement. The current regulatory framework and the concept of foreseeable research risks is insufficient to advance the debate about the ethics of randomization of standard clinical interventions. This article uses the example of the Wisconsin cystic fibrosis randomized clinical trial for newborn screening trial to explore the distinctions between risks of research and clinical care and waivers of informed consent for randomization. Collaborative exploration of these complex policy issues is needed and further deliberation, community engagement, and social science research will be critical to advance novel approaches for informed consent.
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Burris S, Moss K. U. S. Health Researchers Review their Ethics Review Boards: A Qualitative Study. J Empir Res Hum Res Ethics 2012; 1:39-58. [PMID: 19385877 DOI: 10.1525/jer.2006.1.2.39] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
VIRTUALLY ALL RESEARCH INVOLVING HUMAN subjects in the United States must be reviewed by an institutional review board, a form of research ethics review board. This article reports the results of qualitative research on how investigators regard this regulatory regime. Interviews were conducted with forty investigators conducting health-related research. Most respondents shared the regulations' goals, but doubted that the regulations, as implemented, promoted these goals efficiently, effectively and fairly. The interviews suggest that efforts to raise researchers' ethical consciousness have been, over time, quite successful, but that implementation of the regulations remains problematic. Research aimed at better defining the problem to be solved b y the r egulatory sy stem, and at a ssessing the effectiveness of the regulatory tools for solving properly defined problems, could guide a more productive debate about human subject protection.
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Affiliation(s)
- Scott Burris
- James E. Beasley School of Law Temple University
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Abstract
Children have been identified as uniquely vulnerable clinical research subjects since the early 1970s. This article reviews the historical underpinnings of this designation, the current regulatory framework for pediatric and neonatal research, and common problems in pediatric research oversight. It also presents 3 areas of pediatric and neonatal research (genomic screening, healthy children donating stem cells, and therapeutic hypothermia for neonates with hypoxic-ischemic encephalopathy) that highlight contemporary challenges in pediatric research ethics, including balancing risk and benefit, informed consent and assent, and clinical equipoise.
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Affiliation(s)
- Naomi Laventhal
- Department of Pediatrics and Communicable Diseases, Division of Neonatal-Perinatal Medicine, University of Michigan School of Medicine, 8-621 C&W Mott Hospital, 1540 E. Hospital Drive, SPC 4254, Ann Arbor, MI 48109-4254, Phone: 734-763-4109, Fax: 734-763-7728,
| | - Beth Tarini
- Department of Pediatrics and Communicable Diseases, Child Health Evaluation and Research Unit, University of Michigan School of Medicine, 300 North Ingalls 6C11, Ann Arbor, Michigan 48109-5456, Phone: 734-615-8153, Fax: 734-264-2599,
| | - John Lantos
- Children’s Mercy Bioethics Center, Children’s Mercy Hospital, 2401 Gilham Rd., Kansas, City, MO 64108, Phone: 816-701-5283, Fax: 816-701-5286,
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Silberman G, Kahn KL. Burdens on research imposed by institutional review boards: the state of the evidence and its implications for regulatory reform. Milbank Q 2011; 89:599-627. [PMID: 22188349 PMCID: PMC3250635 DOI: 10.1111/j.1468-0009.2011.00644.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
CONTEXT Federal regulations mandate independent review and approval by an "institutional review board" (IRB) before studies that involve human research subjects may begin. Although many researchers strongly support the need for IRB review, they also contend that it is burdensome when it imposes costs that do not add to the protections afforded to research participants and that this burden threatens the viability of research. The U.S. Department of Health and Human Services recently announced its intention to reform the regulations governing IRB review. METHODS We used a search of the PubMed database, supplemented by a bibliographic review, to identify all existing primary data on the costs of IRB review. "Costs" were broadly defined to include both expenditures of time or money and constraints imposed on the scope of the research. Burdensome costs were limited to those that did not contribute to greater protections for the participants. FINDINGS Evidence from a total of fifty-two studies shows that IRBs operate at different levels of efficiency; that waiting to obtain IRB approval has, in some instances, delayed project initiation; that IRBs presented with identical protocols sometimes asked for different and even competing revisions; and that some decisions made (and positions held) by IRBs are not in accord with federal policy guidance. CONCLUSIONS While the evidence is sufficient to conclude that there is burden associated with IRB review, it is too limited to allow for valid estimates of its magnitude or to serve as the basis for formulating policies on IRB reform. The single exception is multicenter research, for which we found that review by several local IRBs is likely to be burdensome. No mechanism currently exists at the national level to gather systematic evidence on the intersection between research and IRB review. This gap is of concern in light of the changing nature of research and the increasingly important role that research is envisioned to play in improving the overall quality of health care.
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Affiliation(s)
- George Silberman
- RAND Corporation, Cancer Policy Group, LLC, Santa Monica, CA 90407, USA.
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Abbott L, Grady C. A systematic review of the empirical literature evaluating IRBs: what we know and what we still need to learn. J Empir Res Hum Res Ethics 2011; 6:3-19. [PMID: 21460582 DOI: 10.1525/jer.2011.6.1.3] [Citation(s) in RCA: 159] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Institutional review boards (IRBs) are integral to the U.S. system of protection of human research participants. Evaluation of IRBs, although difficult, is essential. To date, no systematic review of IRB studies has been published. We conducted a systematic review of empirical studies of U.S. IRBs to determine what is known about the function of IRBs and to identify gaps in knowledge. A structured search in PubMed identified forty-three empirical studies evaluating U.S. IRBs. Studies were included if they reported an empirical investigation of the structure, process, outcomes, effectiveness, or variation of U.S. IRBs. The authors reviewed each study to extract information about study objectives, sample and methods, study results, and conclusions. Empirical evidence collected in forty-three published studies shows that for review of a wide range of types of research, U.S. IRBs differ in their application of the federal regulations, in the time they take to review studies, and in the decisions made. Existing studies show evidence of variation in multicenter review, inconsistent or ambiguous interpretation of the federal regulations, and inefficiencies in review. Despite recognition of a need to evaluate effectiveness of IRB review, no identified published study included an evaluation of IRB effectiveness. Multiple studies evaluating the structure, process, and outcome of IRB review in the United States have documented inconsistencies and inefficiencies. Efforts should be made to address these concerns. Additional research is needed to understand how IRBs accomplish their objectives, what issues they find important, what quality IRB review is, and how effective IRBs are at protecting human research participants.
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Affiliation(s)
- Lura Abbott
- Department of Bioethics, National Institutes of Health, Clinical Center, Building 10/1C118, Bethesda, MD 20892, USA
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Pritchard IA. How Do IRB Members Make Decisions? A Review and Research Agenda. J Empir Res Hum Res Ethics 2011; 6:31-46. [DOI: 10.1525/jer.2011.6.2.31] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Many factors have been found to influence the nature and quality of the human research ethics review process. These are reviewed along with discussion of ways in which normal psychological characteristics and group decision-making processes may affect the decisions of institutional review board (IRB) members when reviewing proposed research activities, and may contribute to the acknowledged variability of IRB responses to identical research proposals. Three salient features of human judgment and decision-making illuminated by the existing psychological research literature are used to illustrate this idea: Research findings related to (a) risk perception and acceptance, (b) the standards people use to make decisions, and (c) some nonrational influences on group decision-making suggest how psychological characteristics may affect some outcomes of convened IRB meetings. Recognizing such influences may enable the improvement of IRB decision-making.
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Ménoni V, Lucas N, Leforestier JF, Doz F, Chatellier G, Jacqz-Aigain E, Giraud C, Tréluyer JM, Chappuy H. Readability of the written study information in pediatric research in France. PLoS One 2011; 6:e18484. [PMID: 21494689 PMCID: PMC3071832 DOI: 10.1371/journal.pone.0018484] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Accepted: 03/09/2011] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The aim was to evaluate the readability of research information leaflets (RIL) for minors asked to participate in biomedical research studies and to assess the factors influencing this readability. METHODS AND FINDINGS All the pediatric protocols from three French pediatric clinical research units were included (N = 104). Three criteria were used to evaluate readability: length of the text, Flesch's readability score and presence of illustrations. We compared the readability of RIL to texts specifically written for children (school textbooks, school exams or extracts from literary works). We assessed the effect of protocol characteristics on readability. The RIL had a median length of 608 words [350 words, 25(th) percentile; 1005 words, 75(th) percentile], corresponding to two pages. The readability of the RIL, with a median Flesch score of 40 [30; 47], was much poorer than that of pediatric reference texts, with a Flesch score of 67 [60; 73]. A small proportion of RIL (13/91; 14%) were illustrated. The RIL were longer (p<0.001), more readable (p<0.001) and more likely to be illustrated (p<0.009) for industrial than for institutional sponsors. CONCLUSION Researchers should routinely compute the reading ease of study information sheets and make greater efforts to improve the readability of written documents for potential participants.
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Affiliation(s)
- Véronique Ménoni
- Unité de Recherche Clinique Paris Centre, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
- Laboratoire d'Ethique Médicale, Université Paris Descartes, Paris, France
- CIC P0901 Mère Enfant, Inserm, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Noël Lucas
- CIC E4 Inserm, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Jean-François Leforestier
- CIC E4 Inserm, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - François Doz
- Service de pédiatrie, Institut Curie, Université Paris Descartes, Paris, France
| | - Gilles Chatellier
- CIC E4 Inserm, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Evelyne Jacqz-Aigain
- Centre d'Investigation Clinique Inserm 9202, Hôpital Robert Debré, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Carole Giraud
- Unité de Recherche Clinique Paris Centre, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
- CIC P0901 Mère Enfant, Inserm, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Université Paris Descartes, Paris, France
- EA3620, Université Paris Descartes, Paris, France
| | - Jean-Marc Tréluyer
- Unité de Recherche Clinique Paris Centre, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
- CIC P0901 Mère Enfant, Inserm, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Université Paris Descartes, Paris, France
- Pharmacologie, Groupe Hospitalier Broca Cochin Hôtel Dieu, Assistance Publique Hôpitaux de Paris, Paris, France
- EA3620, Université Paris Descartes, Paris, France
| | - Hélène Chappuy
- Unité de Recherche Clinique Paris Centre, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
- Laboratoire d'Ethique Médicale, Université Paris Descartes, Paris, France
- EA3620, Université Paris Descartes, Paris, France
- Service d'Urgences Pédiatriques, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
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Horner J, Minifie FD. Research ethics I: Responsible conduct of research (RCR)--historical and contemporary issues pertaining to human and animal experimentation. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2011; 54:S303-S329. [PMID: 21081677 DOI: 10.1044/1092-4388(2010/09-0265)] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
PURPOSE In this series of articles--Research Ethics I, Research Ethics II, and Research Ethics III--the authors provide a comprehensive review of the 9 core domains for the responsible conduct of research (RCR) as articulated by the Office of Research Integrity. In Research Ethics I, they present a historical overview of the evolution of RCR in the United States then examine the evolution of human and animal experimentation from the birth of scientific medicine through World War II to the present day. METHOD They relied on authoritative documents, both historical and contemporary, insightful commentary, and empirical research in order to identify current issues and controversies of potential interest to both faculty and students. CONCLUSIONS The authors have written this article from a historical perspective because they think all readers interested in RCR should appreciate how the history of science and all the good--and harm--it has produced can inform how researchers practice responsible research in the 21st century and beyond.
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Affiliation(s)
- Jennifer Horner
- College of Health Sciences and Professions, Ohio University, W380 Grover Center, Athens, OH 45701, USA.
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Kelly B, Mackay-Lyons MJ. Ethics of involving children in health-related research: applying a decision-making framework to a clinical trial. Physiother Can 2010; 62:338-46. [PMID: 21886373 DOI: 10.3138/physio.62.4.338] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE This paper explores ethical issues related to the involvement of children in health-related research through the application of a conceptual model (the Miller and Kenny framework) to a current clinical trial on casting protocols for equinus gait of children with cerebral palsy (CP). SUMMARY OF KEY POINTS The direct involvement of children in health-related research is important for maintaining and improving standards of paediatric clinical care. Ethical considerations around investigations involving this highly vulnerable population are complex, however, requiring the involvement of many levels of decision makers-government, research ethics boards (REBs), health care providers, parents, and children. The Miller and Kenny framework is useful in distinguishing these levels and heightening awareness of the complexities of the issues around engaging children in research. Considerations include the role of parents/caregivers in decision making, individual assessment of the child's decisional capacities, close attention to the child's context and life experience, provision of developmentally appropriate information about the research study, and careful assessment of dissent prior to withdrawing the child from the study. RECOMMENDATIONS Physical therapists involved in paediatric clinical practice and/or research must be knowledgeable about ethical principles, policies, and REB requirements. The Miller and Kenny framework is a helpful guide to clarify decision-making roles around children's participation in research.
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Affiliation(s)
- Barbara Kelly
- Barbara Kelly, BScPT, MSc (Rehab Research): Physiotherapist, IWK Health Centre, Halifax, Nova Scotia; Instructor, School of Physiotherapy, Dalhousie University, Halifax, Nova Scotia
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25
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Birnie KA, Noel M, Chambers CT, von Baeyer CL, Fernandez CV. The Cold Pressor Task: Is it an Ethically Acceptable Pain Research Method in Children? J Pediatr Psychol 2010; 36:1071-81. [DOI: 10.1093/jpepsy/jsq092] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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26
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Davidson A, Babl FE. A primer for clinical researchers in the emergency department: part I: ethical and regulatory background. Emerg Med Australas 2010; 22:399-406. [PMID: 20726870 DOI: 10.1111/j.1742-6723.2010.01320.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Research is an important part of emergency medicine and provides the scientific underpinning for optimal patient care. Although increasing numbers of emergency physicians participate in research activities, formal research training is currently neither part of emergency physician training in Australia nor easily available for clinicians interested in clinical research. In a two-part series, which is targeted at part-time clinical researchers in the ED, we set out and explain the key elements for conducting high-quality and ethical research. In Part I, we describe important underlying ethical principles for research in humans and explain key regulatory processes and documents pertaining to good clinical research practice in Australia. The ethics of research in children as a particularly vulnerable group will also be addressed. Part II will address important elements of research science and conduct.
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Affiliation(s)
- Andrew Davidson
- Department of Anesthesia and Pain Mangement, Royal Children's Hospital, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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27
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Spriggs M. Ethical Difficulties With Consent in Research Involving Children: Findings From Key Informant Interviews. ACTA ACUST UNITED AC 2010. [DOI: 10.1080/21507711003754526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
The ethics of clinical research is based on several well-known guidelines and documents. The guidelines vary between countries, but the principles of respect for persons, beneficence, and justice are constant. These principles are reflected in requirements to obtain free and informed consent, to minimize risk or harm, and to not overly burden or disadvantage particular populations. For research to be ethical, it must also be of such a standard, and be conducted in such a manner that it will generate knew and useful knowledge. Children have limited capacity for understanding and may be more open to coercion. Therefore, they are regarded as a particularly vulnerable population, and specific clauses regarding children are incorporated into many guidelines. A key concept in these clauses is the degree of risk acceptable for children involved in research. While it is generally agreed that children require particular attention because of their vulnerability, there is also increasing concern that children in general should not be disadvantaged by lack of knowledge due to reduced research activity. Finally, an increasingly active area of research in children involves genetics and biobanking. Research in these areas raises new and challenging ethical issues.
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Affiliation(s)
- Andrew J Davidson
- Department of Anesthesia and Pain Management, The Royal Children's Hospital, Murdoch Children's Research Institute, Parkville, Victoria, Australia.
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29
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DunnGalvin A, Chang WC, Laubach S, Steele PH, Dubois AEJ, Burks AW, Hourihane JO. Profiling families enrolled in food allergy immunotherapy studies. Pediatrics 2009; 124:e503-9. [PMID: 19706573 DOI: 10.1542/peds.2008-3642] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Little is known about specific psychological factors that affect parents' decisions to take part in clinical studies. We examined factors, related to health-related quality of life (HRQoL), that may influence parents' decision to allow their children to participate in research on clinical food allergy. METHODS Parents of children with food allergies were offered investigational oral immunotherapy (OIT) in a regular outpatient clinic. Forty parents (group A) declined, and 25 parents (group B) agreed to take part. Both groups agreed to complete the Food Allergy Quality of Life-Parent Form and the Food Allergy Independent Measure. RESULTS Children were aged between 1 and 12 years (mean: 6.5 years). Groups A and B displayed a similar and typical distribution for gender, age, number of foods, severity and number of symptoms, and socioeconomic variables. Parents who chose to enroll their children in the OIT trial reported a similar impact of food allergy on the HRQoL of their children as parents of children who did not volunteer for the study. Participating parents perceived a significantly higher likelihood (odds ratio: 6.753) of their child having a severe reaction and dying if food is ingested. By using this model, the likelihood of taking part in immunotherapy could be predicted accurately in 90% of cases. CONCLUSIONS Parents who had higher anxiety about negative outcomes from accidental ingestion were more likely to consent to experimental therapy for their child. This finding has ethical implications for investigators and supports the need to create mechanisms to avoid unintended coercion in vulnerable groups.
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Affiliation(s)
- Audrey DunnGalvin
- Department of Pediatrics and Child Health, University College, Cork, Ireland.
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30
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Taylor HA. Inclusion of women, minorities, and children in clinical trials: opinions of research ethics board administrators. J Empir Res Hum Res Ethics 2009; 4:65-73. [PMID: 19480593 DOI: 10.1525/jer.2009.4.2.65] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
IN AN ATTEMPT TO ENCOURAGE INCLUSION of women, minorities, and children in clinical trials, the U.S. National Institutes of Health (NIH) requires investigators conducting NIH-sponsored research to adequately address NIH inclusion guidelines concerning recruitment of women, minorities, and children. A survey of U.S. Research Ethics Board (REB) administrators at institutions receiving NIH funding indicated awareness and implementation of the inclusion guidelines. According to the administrators, investigators and REBs address inclusion in more than half of the relevant protocols. About half of the REB administrators consider the guidelines partly responsible for increased attention to inclusion, but only about a quarter believe that there is greater inclusion as a result.
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Affiliation(s)
- Holly A Taylor
- School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA.
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31
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Abstract
Little is known about how children and parents make decisions regarding pediatric research. To provide data, we surveyed children aged 7 to 14 years who were enrolled in clinical research or receiving clinical care for cancer or asthma at one of 7 sites, and a parent or guardian. The present manuscript reports data on the respondents' attitudes and experiences regarding the child's involvement in making clinical care and research decisions. Of 117 parent-child pairs invited to participate, 81 completed the survey (response rate=69.2%). Pediatric respondents reported that their decisions regarding research enrollment were influenced primarily by a desire to benefit themselves, and to help others. In the research group, 90.5% of pediatric respondents believed they should be involved in making research enrollment decisions, whereas only 61.5% of the adult respondents believed children should be involved in making these decisions. These findings highlight the potential for disagreement within families regarding children's involvement in making decisions about research enrollment. Investigators should be aware of and find ways to address these disagreements when soliciting assent from children.
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Reed JL, Huppert JS. Predictors of adolescent participation in sexually transmitted infection research: brief report. J Adolesc Health 2008; 43:195-7. [PMID: 18639795 PMCID: PMC2708072 DOI: 10.1016/j.jadohealth.2008.01.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2007] [Revised: 12/20/2007] [Accepted: 01/08/2008] [Indexed: 11/19/2022]
Abstract
We examined the effect of an institutional requirement for parental consent on adolescents' enrollment in a research study involving sexually transmitted infections. Fewer adolescents enrolled when parental consent was required compared with those who enrolled after this requirement was waived (79% vs. 94%, p = .01). Of the adolescents, 100% requested confidential test results. We conclude that requiring parental consent decreases participation in STI research.
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Affiliation(s)
- Jennifer L. Reed
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jill S. Huppert
- Division of Adolescent Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Address correspondence to: Jill Huppert, M.D., M.P.H., Division of Adolescent Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue ML 4000, Cincinnati, OH 45229. E-mail address:
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Abstract
Clinical research has led to great advances in cancer therapy for children, and a greater proportion of children than adults with cancer participate in clinical trials. Despite this success, there remain important ethical challenges in conducting this research. There are challenges in obtaining informed consent and assent when children are research subjects; challenges arising from study design issues in phase III, II, or I clinical trials; and challenges related to the development of new classes of drugs, especially molecularly targeted therapies. It is important for researchers and clinicians to understand these challenges so that progress in cancer treatment is achieved in a sound ethical and regulatory fashion.
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Affiliation(s)
- Stacey L Berg
- Texas Children's Cancer Center, 6621 Fannin Street, MC3-3320, Houston, Texas 77030, USA.
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34
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Abstract
Physician-investigators are required to obtain informed consent from adult participants in their studies. Inclusion of children in research legally requires informed permission of a child's parent or guardian. It is increasingly recognized that a child need not assume a passive role when included in research, but that his or her active involvement should be sought, as expressed by the child's assent to partake in clinical research. This article briefly explores the history of assent and the central role of assessing a child's understanding of research and preference for participating in decisions related to their care, as necessary components of meaningful assent.
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Affiliation(s)
- Yoram Unguru
- Division of Hematology/Oncology, Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, DC 20010-2970, USA.
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35
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Backhus LE, Zoloth L. Today's research, tomorrows cures: the ethical implications of oncofertility. Cancer Treat Res 2008; 138:163-79. [PMID: 18080664 DOI: 10.1007/978-0-387-72293-1_12] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
Social networking web sites are popular among adolescents and may represent a new venue for conducting adolescent health research. Conducting research by using social networking web sites raises several concerns, including the social value of this research, fair subject selection, confidentiality, privacy, and informed consent. Addressing each of these concerns, we offer an ethical framework to promote informed and appropriate decisions.
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Affiliation(s)
- Megan A Moreno
- Department of Pediatrics, Section of Adolescent Medicine, University of Washington and Children's Hospital and Regional Medical Center, Seattle, Washington 98105, USA.
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Research knowledge among the participants in the Treatment for Adolescents With Depression Study (TADS). J Am Acad Child Adolesc Psychiatry 2007; 46:1642-50. [PMID: 18030086 DOI: 10.1097/chi.0b013e318153f8c7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We examined the extent to which parents and adolescents participating in the Treatment for Adolescents With Depression Study (TADS) understood key aspects of the study. METHOD TADS was a clinical trial comparing the effectiveness of fluoxetine, cognitive-behavioral therapy (CBT), their combination, and placebo in 439 adolescents (12-17 years old) with major depressive disorder. Six weeks after starting treatment, adolescents and their parents were asked to complete a questionnaire about critical elements of the trial. RESULTS Completion rate was 67.2% for adolescents (N = 295) and 73.6% for parents (N = 323). More than 90% of the completers knew of the main purpose of the trial, possible assignment to placebo, and their right to withdraw participation at any time. However, about one third overall (and 49% in the CBT group) described TADS as "education" rather than "research." Of 12 questions, the mean number of correct answers was 10.3 (SD 1.7) among adolescents and 11.2 (SD 1.2) among parents (p <.0001). The most frequently stated reason for TADS participation was the pursuit of high-quality care. CONCLUSIONS Most parents and adolescents were well-informed research participants. Difficulties in appreciating the research nature of the trial, however, emerged, especially among participants assigned to psychotherapy. Parents were overall better informed than adolescents.
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Reed JL, Thistlethwaite JM, Huppert JS. STI research: recruiting an unbiased sample. J Adolesc Health 2007; 41:14-8. [PMID: 17577529 PMCID: PMC1976264 DOI: 10.1016/j.jadohealth.2007.02.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2006] [Revised: 02/02/2007] [Accepted: 02/09/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE Although minors may legally consent for clinical care of sexually transmitted infections (STI) in all states, research participation often requires parental consent. We examined whether age, race, and parental barriers differed between those adolescents who accepted versus refused enrollment in a minimal risk STI research study. METHODS A cross-sectional sample (age 13-21 years, sexually active females, presenting to an Emergency Department) was approached to participate in an STI study. Participation required an interview regarding symptoms and sexual history, a vaginal swab and urine sample for STI testing, and parental consent for those under age 18 years. Demographics, enrollment, and reasons for ineligibility or refusal were recorded. RESULTS Of 466 females approached, 240 (52%) met eligibility criteria, and 139 (58%) of those eligible refused enrollment. Reasons for refusal included: 32 (23%) lack of parental confidentiality or consent, 65 (47%) no reason, 23 (17%) time constraints, and 19 (13%) other reasons. Parental barriers were only cited by those under age 18. Reasons for refusal did not differ by race. In unadjusted and adjusted analyses, enrollees were more likely to be black and age > or = 18 than nonenrollees. An interaction between age and race is shown in stratified logistic regression analyses: The association of age > or = 18 with enrollment was highly significant for white/other females (odds ratio [OR] 12.5, 95% confidence interval [CI] 3.0-52.7) but not for Black females (OR 1.5, 95% CI .77-3.0). CONCLUSIONS Requiring parental consent appears to preclude participation in minimal risk STI research, especially for younger non-black females.
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Affiliation(s)
- Jennifer L Reed
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA.
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Bagley SJ, Reynolds WW, Nelson RM. Is a "wage-payment" model for research participation appropriate for children? Pediatrics 2007; 119:46-51. [PMID: 17200270 DOI: 10.1542/peds.2006-1813] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Our goal was to evaluate the applicability of a "wage-payment" model to inducements for children to participate in research. SUBJECTS AND METHODS We interviewed 42 children and adolescents between the ages of 4 and 16 years who had diabetes, asthma, seizures, or no chronic medical condition. The interview explored hypothetical participation decisions for up to 4 research scenarios. To evaluate factors that would influence children and adolescents' decision-making for research participation, we probed for the impact of monetary and other incentives. The interviews were transcribed and coded for specific themes related to money or other rewards and incentives. RESULTS Older children, mainly those >9 years of age, showed an appreciation for the role and value of money through (a) an accurate concept of the material value of money in society or (b) asking for a realistic amount of money in exchange for their research participation. Younger children, primarily those <9 years of age, showed an inability to appreciate the role and value of money by: (a) asking for excessive monetary amounts that bore no relationship to the sum warranted by participation; (b) having no concept of what that money could buy; (c) not comprehending the meaning of a wage as earning a reward for working; or (d) justifying proposed amounts with reasons unrelated to the time and effort involved. CONCLUSIONS An age-appropriate token of appreciation as an inducement for research participation is appropriate for the younger child who is <9 years old, because they generally have an inadequate understanding of the value of money and, therefore, the meaning of a wage. A wage-payment model for compensating older children (>9 years of age) and adolescents for the time and effort of research participation is appropriate because they generally understand the meaning and value of a wage.
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Affiliation(s)
- Stephen J Bagley
- College of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
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Joffe S, Fernandez CV, Pentz RD, Ungar DR, Mathew NA, Turner CW, Alessandri AJ, Woodman CL, Singer DA, Kodish E. Involving children with cancer in decision-making about research participation. J Pediatr 2006; 149:862-868. [PMID: 17137908 DOI: 10.1016/j.jpeds.2006.08.027] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2005] [Revised: 07/05/2006] [Accepted: 08/11/2006] [Indexed: 10/23/2022]
Affiliation(s)
- Steven Joffe
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
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Abstract
Obtaining assent is an important part of research involving children, both from an ethical and regulatory perspective. Current practice for documenting assent is derived largely from documentation of informed consent for adults as there is little guidance in federal regulations. We propose a new approach to documenting assent.
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Affiliation(s)
- David Ungar
- Division of Pediatric Hematology/Oncology, Penn State Children's Hospital, Hershey, PA 17033, USA.
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Kimberly MB, Hoehn KS, Feudtner C, Nelson RM, Schreiner M. Variation in standards of research compensation and child assent practices: a comparison of 69 institutional review board-approved informed permission and assent forms for 3 multicenter pediatric clinical trials. Pediatrics 2006; 117:1706-11. [PMID: 16651328 DOI: 10.1542/peds.2005-1233] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To systematically compare standards for compensation and child participant assent in informed permission, assent, and consent forms (IP-A-CFs) approved by 55 local institutional review boards (IRBs) reviewing 3 standardized multicenter research protocols. METHOD Sixty-nine principal investigators participating in any of 3 national, multicenter clinical trials submitted standardized research protocols for their trials to their local IRBs for approval. Copies of the subsequently IRB-approved IP-A-CFs were then forwarded to an academic clinical research organization. This collection of IRB-approved forms allowed for a quasiexperimental retrospective evaluation of the variation in informed permission, assent, and consent standards operationalized by the local IRBs. RESULTS Standards for compensation and child participant assent varied substantially across 69 IRB-approved IP-A-CFs. Among the 48 IP-A-CFs offering compensation, monetary compensation was offered by 33 as reimbursement for travel, parking, or food expenses, whereas monetary or material compensation was offered by 22 for subject inconvenience and by 13 for subject time. Compensation ranged widely within and across studies (study 1, $180-1425; study 2, $0-500; and study 3, $0-100). Regarding child participant assent, among the 57 IP-A-CFs that included a form of assent documentation, 33 included a line for assent on the informed permission or consent form, whereas 35 included a separate form written in simplified language. Of the IP-A-CFs that stipulated the documentation of assent, 31 specified > or =1 age ranges for obtaining assent. Informed permission or consent forms were addressed either to parents or child participants. CONCLUSION In response to identical clinical trial protocols, local IRBs generate IP-A-CFs that vary considerably regarding compensation and child participant assent.
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Affiliation(s)
- Michael B Kimberly
- Pediatric Generalist Research Group, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
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Affiliation(s)
- Alexander A Kon
- Department of Pediatrics, University of California, Davis, Sacramento, California, CA, USA.
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Abstract
PURPOSE This article provides the physical therapist (PT) researcher with valuable information regarding the issues of assent by reviewing the history, regulations, and issues surrounding the protection of children participating in research. KEY POINTS To conduct ethical research, knowledge about the history, regulations, and issues surrounding the protection of children in research is important. While most of the research done by PTs is non-invasive and low risk, it is still important for a researcher to be aware of the full spectrum of risk involved with research. An important topic for PTs involves the related concepts of parental permission and child assent. Those children, who are capable of understanding a research study, need to know what is involved in the study and have the choice to participate or to decline to participate. SUMMARY/CLINICAL IMPLICATIONS PTs should be encouraged to be involved in research to advance the profession and contribute to evidence-based practice. Due to this, PTs are becoming more involved in the process of obtaining assent from a child, and therefore need to be aware of the unique aspects of this process.
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Parsons SK, Saiki-Craighill S, Mayer DK, Sullivan AM, Jeruss S, Terrin N, Tighiouart H, Nakagawa K, Iwata Y, Hara J, Grier HE, Block S. Telling children and adolescents about their cancer diagnosis: cross-cultural comparisons between pediatric oncologists in the US and Japan. Psychooncology 2006; 16:60-8. [PMID: 16874746 DOI: 10.1002/pon.1048] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
PURPOSE Over the last 50 years, direct communication about cancer with adults has shifted from an approach of not telling to one of telling. Less is known about communication practices with children. The purpose of this study is to (1) describe patterns of communication at diagnosis between pediatric oncologists and children with cancer and (2) compare cultural differences in these practices in the US and Japan. METHODS This 2003 survey, developed in English and translated into Japanese was mailed to members of the American Society of Pediatric Hematology/Oncology and the two Japanese Societies of Pediatric Hematology and Oncology; there were 350 US and 362 Japanese respondents. Descriptive statistics and logistic regressions were performed. RESULTS US physicians had a consistent pattern of telling children (65% always told the child; less than 1% rarely or never told). Japanese physicians had greater variability in their patterns of telling (with only 9.5% always telling, 34.5% rarely or never telling). Direct communication with the child was influenced by personal attitudes, patient factors, and work culture in both countries. Many more variables emerged as influencing Japanese physicians' communication practices than for US physicians. US physicians were influenced by their own sense of responsibility for telling, while Japanese physicians were more influenced by personal attitudes, patient factors, and work culture. CONCLUSIONS US and Japanese physicians differed when communicating directly with the child about his or her cancer. The impact of these practices on children and their parents should be explored and the parent and child's perspectives elicited. This information will help facilitate culturally sensitive patient and family centered communication.
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Affiliation(s)
- Susan K Parsons
- Center on Child and Family Outcomes, Institute for Clinical Research and Health Policy Studies, Tufts-New England Medical Center, Boston, MA 02111, USA.
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Abstract
OBJECTIVE To examine whether and how institutional review boards (IRBs) are using their web-sites to provide guidance to investigators conducting pediatric research. STUDY DESIGN We studied guidance on pediatric research from IRB web-sites at the 25 US medical schools, plus affiliated hospitals, research centers, and public health schools, and the top National Institutes of Health-funded (>5 million dollars) children's hospitals with separate IRBs. We also included 1 IRB that was not otherwise eligible because other IRBs use its web-based research ethics training program. Our final study population was 39 IRB web-sites. RESULTS IRB web-sites generally provide basic information about pediatric research. However, few IRBs discuss important ethical issues on which the regulations are silent. Moreover, some IRBs provide incorrect advice about the regulations. More detailed IRB guidance may help pediatric investigators think through ethical issues and protect children in clinical research. Helpful approaches we identified include checklists and "points to consider," concrete examples to illustrate regulatory requirements, and discussion of areas of controversy. CONCLUSION Few IRBs present the kind of detailed guidance that investigators might need to ensure ethically designed protocols. IRBs should revise their web-sites to ensure that they provide accurate, comprehensive, and sufficiently detailed guidance.
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Affiliation(s)
- Leslie E Wolf
- Program in Medical Ethics, Center for AIDS Prevention Studies, San Francisco, CA 94143, USA.
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