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Papastefan ST, De Boer C, Zeineddin S, Hu A, Harris CJ, Wall JK, Hunter CJ, Lautz TB, Goldstein SD. Innovation versus Experimentation: An Application of Ethical Frameworks to the Acceptance of Fluorescence-Guided Pediatric Surgery. J Pediatr Surg 2023; 58:1609-1612. [PMID: 37330376 DOI: 10.1016/j.jpedsurg.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/26/2023] [Accepted: 05/14/2023] [Indexed: 06/19/2023]
Abstract
Innovation is essential to the advancement of the field of pediatric surgery. The natural skepticism toward new technologies in pediatrics leads to frequent confusion of surgical innovation and research. Using fluorescence-guided surgery as an archetype for this ethical discussion, we apply existing conceptual frameworks of surgical innovation to understand the distinction between innovation and experimentation, acknowledging the spectrum and "grey zone" in between. In this review, we discuss the role of Institutional Review Boards in evaluating surgical practice innovations, and the aspects of certain surgical innovations that are distinct from experimentation, including a thorough understanding of the risk profile, preexisting use in humans, and adaptation from related fields. Examining fluorescence-guided surgery through these existing frameworks as well as the concept of equipoise, we conclude that new applications of indocyanine green do not constitute human subjects research. Most importantly, this example gives practitioners a lens through which they may appraise potential surgical innovations to allow for a sensible and efficient improvement of the field of pediatric surgery. LEVEL OF EVIDENCE: V.
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Affiliation(s)
- Steven T Papastefan
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Christopher De Boer
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Suhail Zeineddin
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Andrew Hu
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Courtney J Harris
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - James K Wall
- Division of Pediatric Surgery, Lucile Packard Children's Hospital, Stanford, CA, USA
| | - Catherine J Hunter
- Division of Pediatric Surgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Timothy B Lautz
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Seth D Goldstein
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Wiersma M, Kerridge I, Lipworth W. Clinical innovation ethics frameworks: A systematic narrative review. Health Policy 2023; 129:104706. [PMID: 36639310 DOI: 10.1016/j.healthpol.2023.104706] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/27/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023]
Abstract
BACKGROUND It is common for doctors to engage in clinical innovation-i.e. to use novel interventions that differ from standard practice, and that have not yet been shown to be safe or effective according to the usual standards of evidence-based medicine-in the belief that this will benefit their patients. Clinical innovation is currently poorly defined and lacks cohesive oversight mechanisms. METHODS A systematic narrative review, with the aim of identifying areas of similarity and divergence in innovation ethics frameworks developed across different medical specialties. RESULTS 47 articles were included in the review. Few ethical issues raised by the ethics frameworks appear to be unique to distinct areas of practice. While variations exist in the oversight mechanisms suggested, these are again not specific to areas of practice, but rather reflect either cautious or more permissive attitudes towards clinical innovation. CONCLUSIONS There is considerable overlap amongst ethics frameworks developed for use in diverse areas of practice. This reflects a tendency to treat innovative interventions in each area of practice as "exceptional" and a failure to develop "higher order" frameworks such as those that have been developed for research. Those involved in the oversight of clinical innovation need to aim for a balance between exceptionalism and harmonisation.
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Affiliation(s)
- Miriam Wiersma
- Faculty of Medicine and Health, Sydney School of Public Health, Sydney Health Ethics, Rm 134, Edward Ford Building A27, The University of Sydney, NSW 2006, Australia.
| | - Ian Kerridge
- Faculty of Medicine and Health, Sydney School of Public Health, Sydney Health Ethics, Rm 134, Edward Ford Building A27, The University of Sydney, NSW 2006, Australia; Haematology Department, Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065, Australia; Department of Philosophy, Macquarie University, Macquarie Park, NSW 2109, Australia
| | - Wendy Lipworth
- Faculty of Medicine and Health, Sydney School of Public Health, Sydney Health Ethics, Rm 134, Edward Ford Building A27, The University of Sydney, NSW 2006, Australia; Department of Philosophy, Macquarie University, Macquarie Park, NSW 2109, Australia
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Endo K, Morishima K, Koizumi M, Sasanuma H, Sakuma Y, Lefor AK, Sata N. Lateral retroperitoneal adrenalectomy: Comparison of introduction and education periods of a new surgical procedure in a teaching hospital. A retrospective case series study. International Journal of Surgery Open 2022. [DOI: 10.1016/j.ijso.2022.100550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Cousins S, Richards HS, Zahra J, Robertson H, Mathews JA, Avery KNL, Elliott D, Blencowe NS, Main B, Hinchliffe R, Clarke A, Blazeby J. Healthcare organization policy recommendations for the governance of surgical innovation: review of NHS policies. Br J Surg 2022; 109:1004-1012. [PMID: 36084337 PMCID: PMC10364689 DOI: 10.1093/bjs/znac223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/15/2022] [Accepted: 05/30/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND The governance for introducing innovative surgical procedures/devices differs from the research requirements needed for new drugs. New invasive procedures/devices may be offered to patients outside of research protocols with local organization oversight alone. Such institutional arrangements exist in many countries and written policies provide guidance for their use, but little is known about their scope or standards. METHODS One hundred and fifty acute NHS trusts in England and seven health boards in Wales were systematically approached for information about their policies. A modified framework approach was used to analyse when policies considered new procedures/devices to be within local organization remit and/or requiring research ethics committee (REC) approval. RESULTS Of 113 policies obtained, 109 and 34 described when local organization and REC approval was required, respectively. Procedures/devices being used for the first time in the organization (n = 69) or by a clinician (n = 67) were commonly within local remit, and only 36 stated that evidence was required. Others stated limited evidence as a rationale for needing REC approval (n = 13). External guidance categorizing procedures as 'research only' was the most common reason for gaining REC approval (n = 15). Procedures/devices with uncertain outcomes (n = 28), requiring additional training (n = 26), and not previously used (n = 6) were within the remit of policies, while others recommended REC application in these situations (n = 5, 2 and 7, respectively). CONCLUSION This study on NHS policies for surgical innovation shows variability in the introduction of procedures/devices in terms of local oversight and/or need for REC approval. Current NHS standards allow untested innovations to occur without the safety of research oversight and thus a standard approach is urgently needed.
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Affiliation(s)
- Sian Cousins
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hollie S Richards
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jez Zahra
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Harry Robertson
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Johnny A Mathews
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kerry N L Avery
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Daisy Elliott
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Natalie S Blencowe
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Barry Main
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Robert Hinchliffe
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
- North Bristol NHS Trust, Bristol, UK
| | - Adrian Clarke
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Jane Blazeby
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
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Jopling JK, Visser BC. Mastering the thousand tiny details: Routine use of video to optimize performance in sport and in surgery. ANZ J Surg 2021; 91:1981-1986. [PMID: 34309995 DOI: 10.1111/ans.17076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 06/20/2021] [Accepted: 07/06/2021] [Indexed: 12/31/2022]
Affiliation(s)
- Jeffrey K Jopling
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Brendan C Visser
- Department of Surgery, Stanford University, Stanford, California, USA
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Angelos P. Double-edged sword of surgical innovation: ethical issues of early and late adoption of novel techniques. Br J Surg 2021; 108:107-108. [PMID: 33711150 DOI: 10.1093/bjs/znaa162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/08/2020] [Indexed: 11/12/2022]
Affiliation(s)
- P Angelos
- Department of Surgery, MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA
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Jain M, Duh Q, Hirose R, Sosa JA, Suh I. A model for the institutional adoption of innovative surgical techniques. Surgery 2020; 168:238-43. [DOI: 10.1016/j.surg.2020.03.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/08/2020] [Accepted: 03/14/2020] [Indexed: 11/21/2022]
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Bokey L, Zhang M, Fingerhut A, Dent OF, Chapuis PH. Trans-anal total mesorectal excision - reflections on the introduction of a new procedure. Colorectal Dis 2020; 22:739-744. [PMID: 32533809 DOI: 10.1111/codi.15190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/24/2020] [Indexed: 02/08/2023]
Affiliation(s)
- L Bokey
- Department of Colorectal Surgery and Department of Surgery, Liverpool Hospital, Liverpool, New South Wales, Australia.,School of Medicine, Western Sydney University, Penrith, New South Wales, Australia
| | - M Zhang
- Department of Anatomy, University of Otago, Otago, New Zealand
| | - A Fingerhut
- Department of Surgery, Medical University of Graz, Graz, Austria.,Department of General Surgery, Shanghai Minimally Invasive Surgery Centre, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - O F Dent
- School of Medicine, Western Sydney University, Penrith, New South Wales, Australia
| | - P H Chapuis
- School of Medicine, Western Sydney University, Penrith, New South Wales, Australia
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Larsen SG, Pfeffer F, Kørner H. Author response to: Comments on: Norwegian moratorium on transanal total mesorectal excision. Br J Surg 2019; 106:1855. [PMID: 31747073 DOI: 10.1002/bjs.11374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 08/29/2019] [Indexed: 11/10/2022]
Affiliation(s)
- S G Larsen
- Department of Gastroenterological Surgery, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - F Pfeffer
- Department of Gastroenterological Surgery, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - H Kørner
- Department of Gastroenterological Surgery, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
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Affiliation(s)
- Guy J Maddern
- The University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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