SCHS Topic7 research ethics

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Saudi Commission for Health Specialties, Part 1 of the series of lectures I gave for the PEER (Professionalism and Ethics Education for Residents) Project sponsored and organized by the Saudi Commission for Health Specialties (SCHS).

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  • At the end of World War II, the International Military Tribunal prosecuted Nazi war criminals, including Nazi doctors who performed experiments on concentration-camp prisoners. The tribunal’s decision includes what is now called the Nuremberg Code, a 10-point statement outlining permissible medical experimentation on human participants.Other provisions require the minimization of risk and harm, a favorable risk/benefit ratio, qualified researchers using appropriate research designs, and freedom for the participant to withdraw at any time.
  • In 1972, the public became aware of the Tuskegee study, which took place in the southern United States from 1932 to 1972. More than 400 men with latent syphilis were followed for the natural course of the disease rather than receiving treatment.As a result, in 1974 the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research was established. In 1978, the commission submitted its report titled, The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research. Those principles—respect for persons, beneficence and justice—are accepted as the 3 fundamental principles for the ethical conduct of research involving human participants.
  • In 1993, CIOMS issued the International Ethical Guidelines for Biomedical Research Involving Human Subjects, with the purpose to indicate how the ethical principles of the Declaration of Helsinki can be applied effectively, particularly in developing countries. • informed consent• research in developing countries• protection of vulnerable populations• distribution of the burdens and benefits• role of ethics committees
  • SCHS Topic7 research ethics

    1. 1. Asst. Prof., Dept. of Medical Ethics King Fahad Medical City – Faculty of Medicine King Saud Bin Abdul-Aziz University for Health Sciences Dr. Ghaiath M. A. Hussein Professionalism and Ethics Education for Residents (PEER) Ethical Issues in Research
    2. 2. Outline • Introduction • What is research ethics? • Historical background: How did research ethics develop? • Ethical principals of research: What makes research ethical?
    3. 3. Outline of presentation What are the ethical issues in research? – Benefit/harm analysis – Vulnerability (Risk-Vulnerability Matrix) – Informed Consent – Fairness and equity in research participation – Privacy and confidentiality – Conflict of Interests (COI) – Research ethical review – Clinical trials – Special topics in research ethics Ethical issues after the conduct of research: ethics of results presentation & publication
    4. 4. • What is research? • Where does research fit in the knowledge Management Cycle (KMC) • Where are we in terms of research? INTRODUCTION
    5. 5. What is Research?  “Research” is defined as an undertaking intended to extend knowledge through a disciplined inquiry or systematic investigation.  A determination that research is the intended purpose of the undertaking, is key for differentiating activities that require ethics review by an ethics review and those that do not.  Systematic methodological scientific approach for basic facts around a certain problem in order to find solutions based on these facts.
    6. 6. : www.worldmapper.org
    7. 7. Research in Context...the KMC Generation Dissemination SynthesisUtilization Assessment Research Statistics
    8. 8. “Good” research: Good Science & Good Ethics “Good” Evidence: near-top to hierarchy of Evidence Evidence-Based Healthcare: Better practice that is based on best evidence Better health status Better Ethics is Better Health
    9. 9. What Makes a Good Research? Good science Good Ethics •Problem selection •SMART objectives •Proper methodology •Proper analysis •Fair subject selection •Favorable Risk-Benefit Ratio •Independent Review •Informed Consent
    10. 10. Criteria of “Good” Science Research • Systematic: The research developed, implemented and reported in a systematic manner. • Methodolic: Adopt & use skillfully the research methods, materials ,approaches in order to ensure reliability of the results & findings. • Scientific: The research should be scientifically sound through utilizing scientific approaches , tools and techniques.
    11. 11. Criteria for Good Ethics: What Makes Research Ethical? 1. Social or Scientific Value: – Improve health and wellbeing – Increase the knowledge 2. Scientific Validity – Acceptable methods including analysis techniques to produce valid data (Test the objectives)
    12. 12. Criteria for Good Ethics: Cont. What Makes Research Ethical? 3. Fair Subject Selection: – Stigmatized and vulnerable are not targeted – Rich not favored for the benefit of research – Clear inclusion and exclusion criteria according to the objectives. – Clear Strategies for recruitment 4. Favorable Risk-Benefit Ratio
    13. 13. 5. Independent Review: – Review of the Design, the proposed subject selection and risk-benefit ratio. 6. Informed Consent 7. Respect for the potential and enrolled subjects: – Privacy and confidentiality – Informing about the new discovered risks or benefits – Informing about the results – Maintaining the welfare of the subjects. Criteria for Good Ethics: What Makes Research Ethical?
    14. 14. What’s Research Ethics?  It is the field of ethics that systematically analyze the ethical and legal questions raised by research involving human subjects.  Its main focus is to ensure that the study participants are protected and, ultimately,  that clinical research is conducted in a way that serves the needs of such participants and of society as a whole. It works when and only when it is applied before the research is conducted
    15. 15. HISTORICAL BACKGROUND BORN IN SCANDAL… THE EVOLUTION OF RESEARCH ETHICS Saudi Commision for Health Specialties
    16. 16. Eighteenth and Nineteenth Century • James Lind “scurvy study in sailors - Salisbury • Edward Jenner cowpox vaccine test • 1897 Giuseppe Sanarelli yellow fever test 1900 Walter Reed established several [first ever] “safeguards” • Self-experimentation • Only adults would be enrolled in research • Written informed consent • Reimbursement (inducement)
    17. 17. History of Research Ethics Pre-World War II • Research standards left up to the discretion of the individual researcher World War II • Experiments conducted on inmates of Nazi concentration camps • 1945-1949 - Trials in Nuremberg, Germany– physicians convicted of crimes against humanity
    18. 18. Nazi Doctors’ Experimentation
    19. 19. International Research Guidelines Nuremberg Code (1947) - As a result of WWII Nazi experiments - First international code in research ethics • Voluntary consent absolutely essential (restricting research with infants, children, developmentally challenged, etc.) • Risk/Benefit Analysis essential to ethics review • Scientific Soundness is important to ethics review
    20. 20. The Nuremberg Code (1947) The first provision of the code requires that “the voluntary informed consent of the human subject is absolutely essential.” The code provides other details implied by such a requirement: • Capacity to consent • Freedom from coercion • Comprehension of the risks and benefits involved • Experiment to be conducted by highest qualified persons The code on the web: http://ohsr.od.nih.gov/nuremberg.php3 Saudi Commision for Health Specialties
    21. 21. The Declaration of Helsinki (DOH)  The World Medical Association created the Declaration of Helsinki in 1964 and amended in: Tokyo (1975), Venice (1983), Hong Kong (1989), South Africa (1996), Edinburgh (2000), Washington (2002), and Tokyo (2004)  “The well-being of the subject should take precedence over the interests of science and society”
    22. 22. The Declaration of Helsinki (DOH) Cont.  Consent should be in writing  Use caution if participant is in dependent relationship with researcher  Limited use of placebo  Greater access to benefit
    23. 23. World Medical Association WMA (1964)  Respect for Persons – people are not a means to an end; researchers have duty to protect life, health, privacy and dignity of research participants  Standard of care must be best available, even for control group  Proxy consent and assent for vulnerable populations Saudi Commision for Health Specialties
    24. 24.  More than 400 African- American men with latent syphilis were followed for the natural course of the disease rather than receiving treatment.  Continued after penicillin available  40 wives infected, 19 children born with congenital syphilis TUSKEGEE SYPHILIS STUDY, ALABAMA ( 1932 – 1972 )
    25. 25. Willowbrook Study, New York 1956-1972, NYU  800 Children Willowbrook State School for the Mentally Retarded  Researchers injected students with mild form of hepatitis
    26. 26. The Belmont Report (1979)  In 1972, the public became aware of the Tuskegee study, which took place in the southern United States from 1932 to 1972.  In 1974 the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research was established.  In 1978, the commission submitted its report titled, The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research. Those principles respect for persons, beneficence and justice are accepted as the 3 fundamental principles for the ethical conduct of research involving human participants.
    27. 27. Council for International Organizations of Medical Science (CIOMS) Guidelines (1993) • Informed consent • Research in developing countries • Protection of vulnerable populations • Distribution of the burdens and benefits • Role of ethics committees
    28. 28. Is it over?... Torvan trial in Kano, Nigeria  Kano Trovan clinical trials in 1996, on pediatric age group, during the worst ever meningococcal meningitis.  Lack of proper Governmental authorization and informed consent during the studies publicized in 2000, by Washington Post.  Court trial and release of investigation panel reports stalled in Nigeria.  Suit for 5.8 billion USD moved to the USA and report leaked there too.  Settlement out of court being discussed.
    29. 29. Ethical Principles of Research What makes research ethical?
    30. 30. What Makes the Research Ethical? 1- Social or Scientific Value: • Improve health and wellbeing • Increase the knowledge 2- Scientific Validity • Acceptable methods including analysis techniques to produce • Valid data (Test the objectives)
    31. 31. 3- Justice and Inclusiveness: • Stigmatized and vulnerable are not targeted • Rich not favored for the benefit of research • Clear inclusion and exclusion criteria according to the objectives. • Clear Strategies for recruitment 4- Favorable Risk-Benefit Ratio: • Identification and Minimization the risk • Enhancement of the potential benefit • Risk to the subject are appropriate to the benefits to the subject and society. What Makes the Research Ethical? Cont.
    32. 32. What Makes the Research Ethical? Cont. 5- Independent Review: • Review of the Design, the proposed subject selection and risk-benefit ratio. 6- Free and Informed Consent: • Provision of Information • Voluntarily and Consists with the values
    33. 33. 7- Respect for the potential and enrolled subjects and Respect for Vulnerable Persons : • Right to withdrawal • Privacy and confidentiality • Informing about the new discovered risks or benefits • Maintaining the welfare of the subjects. What Makes the Research Ethical? Cont.
    34. 34. WHAT ARE THE ETHICAL ISSUES IN RESEARCH? •Benefit/harm analysis •Vulnerability (Risk-Vulnerability Matrix) •Informed Consent •Fairness and equity in research participation •Privacy and confidentiality •Conflict of Interests (COI)
    35. 35. Benefits • Benefits to research subjects • Benefits to society • Specific new, effective intervention • Knowledge which some time in the future may lead to effective interventions
    36. 36. Benefits to Research Subjects Direct Benefit – Arising from the intervention being studied – Information that can influence care, e.g., diagnostic Collateral “indirect” Benefit – Arising from being a subject, even if one does not receive the experimental intervention – Extra supervision from being in the research study (?) – Access to medical care not available for economic reasons – Unplanned or unanticipated benefits
    37. 37. Benefits to Research Subjects  Inspirational  Aspirational • Benefit to society (arises from the results of the study)  Payments or incentives – benefits? Any level of research risk could be offset by such gains if they were significant enough
    38. 38. Benefits to Research Subjects No benefits from the research – Phase I trials testing maximum tolerated dose – Non-therapeutic research procedures • Mechanism of disease
    39. 39. Risk/Harm • Risk: – Means any harm or injury that affect the subject or the participant under study. • Risk: – “ A state of uncertainty where some of the possibilities involve a loss, catastrophe, or other undesirable outcome. ”
    40. 40. Types of risks Physical risks: 1. Cold: Nazi Experiments with ice tanks 2. Pressure: Nazi experiments in high altitude 3. Heat: Heat stroke; Burn; Exhaustion 4. Noise: High noise may lead to impairment or loss of hearing 5. Light: Dim light may affect the vision
    41. 41. Nazi Experiments
    42. 42. High Altitude Experiments
    43. 43. Types of Risk…Cont. Medical Risks: 1. Therapeutics: (Tuskegee expirement) 2. Preventive: (Trials of polio vaccine) 3. Diagnostic: • Irradiation: - Teratogenic effect to the fetus. - Carcinogenic effect. • Samplings: - Biopsies: tissues that contain genetic information about the participant. - Surgical hazards. - Too risky procedures (under anesthesia)
    44. 44. The Forgotten Risks  Social Risks: Stigma (e.g. research on HIV-AIDS, STDs).  Emotional Risks: On families when their children were chosen for trial of new vaccine; research in war.  Psychological Risks: Questionnaires with sensitive questions to participants in sensitive positions, as to ask poor people about there nutrition and houses.
    45. 45. Risk to the Society  Manipulating environmental factors (Pathogenic organisms and toxic chemicals).  Economic risk  Legal risks: Vulnerable groups, e.g., prisoners, children, pregnant women.
    46. 46. Categorization of Risk Risk is categorized by severity into: 1. Minimal Risk: As routine blood sample , throat swabs, vaginal swabs, sputum exams 2. Above Minimal Risk: That can be minimized, and within the toleration of the participant. 3. Too Risky: The most dangerous type, and the Researcher should not be allowed to conduct a research that endangers the life of the participants e.g. live cancer cells , live virus
    47. 47. Minimal Risk The probability and magnitude of harm or discomfort anticipated in the research are not greater in and of themselves than those ordinarily encountered in daily life or during routine performance of physical or psychological examination or tests
    48. 48. Clinical Equipoise • Clinical equipoise means a genuine uncertainty on the part of the expert medical community about the comparative therapeutic merits of each arm of a clinical trial. • The tenet of clinical equipoise provides a clear moral foundation to the requirement that the health care of subjects not be disadvantaged by research participants.
    49. 49. Minimization of Risk  Adequate facilities ,procedures and personnel for dealing with emergencies .  Arrangement made for monitoring and detecting adverse out comes .  All trials should be reviewed by a Data Safety Monitoring Board (DSMB).  All potential toxins, mutagens or teratogens used should be justified.  The National Committee for Atomic Energy should complete risk assessment for the use of the radiation and radioactive substances .
    50. 50. Minimization of Risk For Drugs: - Registration, its trade name, chemical name and pharmacological class . - Recommended dose, form of administration in the study. - Known or possible interaction with other drugs, side effects and adverse reactions. - Placebo should be justified.
    51. 51. Minimization of Risk Social Risks: - The research should have potential to enhance the future health of the society . For vulnerable groups : - Additional safeguards needed to protect there rights and welfare . For recruitment materials: - (posters, newspapers, T.V, videos ……). Should be acceptable if submitted.
    52. 52. Minimization of Risk For Psychological Risks : • Sensitive questions for sensitive group like those with AID, STDs, T.B, can be questioned through 3rd person or ask the help of psychologists . Economic Risks : • Traveling cost can be solved out. • Absentees issues should also be solved out.
    53. 53. Minimization of Risk Legal : - The risk should be reasonable in relation to the anticipated benefits to the subjects or society. - Privacy of subject should be adequately protected. - For tissue samples containing genetics information the subject should have option to withdraw at any time.
    54. 54. Vulnerability (Risk-Vulnerability Matrix) Saudi Commision for Health Specialties
    55. 55. Definition  Vulnerable: “Vulnerable persons are those who are relatively (or absolutely) incapable of  protecting their own interests. More formally, they may have I insufficient power, intelligence, education, resources strength, or other needed attributes to protect their own interests.” (CIOMS, 2002) Saudi Commision for Health Specialties
    56. 56. Who is Vulnerable? Making use of this definition… let’s brainstorm! www.amanet-trust.org
    57. 57. Who is Vulnerable? 1. WOMEN  Women in the reproductory age group are usually excluded in drug/vaccine studies where the possible effects on fetus are not known.  As justice to women, their health conditions should be addressed through involving them in research.  Types of research that benefit women directly include, obstetrics and gynecology, sexually transmitted infections, vitamin studies etc.
    58. 58. Who is Vulnerable? 2. PREGNANT WOMEN  Should be awarded special protection because of additional health concerns during pregnancy and the risk of damage to the fetus.  Pregnant women must be excluded from research unless the purpose is to meet the health needs of the mother, and  The fetus will be placed at risk only to the minimum extent necessary to meet such needs or  The risk to the fetus is minimal
    59. 59. Who is Vulnerable? 3. CHILDREN  Particularly vulnerable group. The major ethical issue for involving children is that parents are the primary decisions makers for their minor children.  There must be no undue inducement to participate for parent, guardian or child, although reimbursement of expenses is allowed.  A “small gift” to the child after completion of the research is however acceptable.
    60. 60. Requirements for involving in Research  The purpose of the research is to obtain knowledge relevant to the health needs of children  A parent or legal representative of each child should give permission;  The agreement (assent) of each child has been obtained to the extent of the child`s capabilities; and  A child`s refusal to participate or continue in the research should be respected.
    61. 61. Assessment of Risk in children  Minimal Risk- risk in relation to normal experience of average, healthy normal children – daily life/routine physical psychological exams  Minimal Risk varies with age but not social status, illness or circumstances  Consultation with experts – pediatricians , social workers etc
    62. 62. Who is Vulnerable? 4. MENTALLY ILL / MENTALLY HANDICAPPED PERSONS  Is he/she capable of self-determination?  Respect for the immature and the incapacitated may require protecting them as they mature or while they are incapacitated (Belmont Report)  It is usually that informed consent will be provided by a surrogate/ legal representative of that person.  The golden rule for involving mentally ill or handicapped people is that ; The objections of these subjects to involvement should be honored, unless the research entails pro-providing them a therapy unavailable elsewhere.
    63. 63. Who is Vulnerable? 5. THE ELDERLY  Old age alone does not render a person incapable of consenting to health research.  In the absence of any indication to the contrary, elderly patients are generally assumed to be competent to consent to research.  However, consideration should be given to the possibility of mental deterioration, the ability to comprehend, and the dependence and vulnerability of the elderly
    64. 64. Who is Vulnerable? 6. PRISONERS  Prisons are organizational structures exacerbate vulnerability of the incarcerated individuals.  They have limited economic power, inadequate protection of human rights, limited availability of health care and treatment options.  The prison structure makes the incarcerated prisoners confined, stressed, crowded, psychologically devastated with symptoms such as psychosis, severe depression, and complete social withdrawal.
    65. 65. Who is Vulnerable? 7. CAPTIVE/DISPLACED/RETURNING POPULATIONS  Have constrained movements and choices  Refugees, those in police custody, and displaced population,  Hospitalized patients, students, institutionalized persons and military personnel.  Readily available for research activities for extended periods, enhancing their attractiveness to research enterprise.  Researchers should always have to be sure if participant’s decision making capacity is not compromised.
    66. 66. How to Decide?  Nature and degree of risk  The condition of the particular population involved and,  The nature and level of the anticipated benefits.  Relevant risks and benefits must be thoroughly arrayed in documents and procedures used in the informed consent process
    67. 67. Assessment of Risk-Vulnerability Research Risk depends on both Level of Invasiveness (physical, psychological or emotional) and Vulnerability of participants. Vulnerability is generally a pre-existing condition, in that it exists regardless of whether the research is conducted or not. It can be inherent or situational.
    68. 68. Tri-Council Policy Statement Ethics Review (Cont.) Invasiveness: consider the physical, psychological, emotional and legal harms that could be caused by or exacerbated by the research. Group Invasiveness Vulnerability Low Medium High Low Exp. Exp. Full Medium Exp. Full Full High Full Full Full
    69. 69. Risk/Vulnerability Matrix
    70. 70. Conclusion  Vulnerability is considered to offer better protection, not to stop research on the vulnerable  Vulnerable groups should not be denied their right to participate in relevant research  The risk assessment varies with the degree of vulnerability
    71. 71. Informed Consent
    72. 72. Definition  “Autonomous authorization of a medical intervention…by individual patients/participants“ (Beauchamp and Faden, 2004)  It's the practical expression of patient's autonomy, and the respect for him/her personality
    73. 73. Components of FIC: 1. "Disclosure" refers to the provision of relevant information by the clinician and its comprehension by the patient. 2. "Capacity" refers to the patient's ability to understand the relevant information and to appreciate those consequences of his or her decision that might reasonably be foreseen. 3. "Voluntariness" refers to the patient's right to come to a decision freely, without force, coercion or manipulation.
    74. 74. Disclosure VoluntarinessCapacity
    75. 75. 1. Disclosure This refers to the process during which physicians provide information about the proposed research to the participant.
    76. 76. Eight Required Elements [45 CFR 46.116(a) & 21 CFR 50.25] 1. Statement that study in research and information on purposes / duration / procedures / experimental procedures 2. Reasonably foreseeable risks or discomforts 3. Reasonably expected benefits 4. Alternative procedures
    77. 77. Eight Required Elements Cont. [45 CFR 46.116(a) & 21 CFR 50.25] 5. How confidentiality will be maintained 6. Information on compensation for injuries (unless minimal risk) 7. Contact persons for information on research, injury, subject’s rights 8. Voluntary participation, no penalty or loss of benefits for refusal or withdrawal
    78. 78. Six Additional Elements 1. Statement that there may be risks which are unforeseeable 2. Under what circumstances investigator could terminate subject’s participation 3. Additional costs to subjects 4. Consequences of subject’s withdrawal from research 5. Statement that will be told of new findings 6. Approximate number of subjects in study
    79. 79. Forms of Consent Normally, should be provided by participants themselves. • Deferred consent: is where the subject is entered into a research study and consent is gained from surrogates after a specified period of time for continuation of the subject’s inclusion in the trial. • Prospective informed consent : represents an attempt to canvass support in advance from a population considered at risk of developing a serious illness. • Surrogate consent (SDM): ideally a substituted judgment made by a person responsible for health care decision-making for a particular patient under the relevant legislation
    80. 80. Waiver of Informed Consent REC must find and document that the following criteria have been satisfied:  Poses no more than Minimal risk research  Waiver or alteration will not adversely affect the rights and welfare of the subjects  Research could not practicably be carried out without the waiver or alteration  Does not involve a therapeutic intervention  Subjects will be provided with additional pertinent information All of the above must apply
    81. 81. Documentation of Informed Consent  Written consent document  Language understandable to the subject or the subject’s Legally Authorized Representative (LAR)  Signed by subject or subject’s LAR  Copy SHALL be given to subject  Opportunity to read before signing
    82. 82. Principles for Providing Information the Participant:  Make it clear; avoid jargon  Use language appropriate to the patient's level of understanding in a language of their fluency  Pause and observe patients for their reactions  Invite questions from the patient and check for understanding
    83. 83. Principles for Providing Information the Participant: Cont.  Invite the patient to share fears, concerns, hopes and expectations  Watch for patients' emotional response: verbal and non-verbal  Show empathy and compassion  Summarize the imparted information  Provide contact information (and other resources)
    84. 84. 2. Capacity: Refers to the presence of a group/set of functional abilities a person needs to possess in order to make a specific decisions (Griso and Applebaum, 1998). These include:  To UNDERSTAND the relevant information  To APPRECIATE the relatively foreseeable consequences of the various available options available.
    85. 85. 3. Voluntariness: • Refers to a participant’s right to make participation decisions free of any undue influence. Influences include: • Physical restraint or sedation • Coercion involves the use of explicit or implicit threat to ensure that the treatment is accepted • Manipulation involves the deliberate distortion or omission of information in an attempt to induce the subject’s participation
    86. 86. Voluntariness • Free of undue influence • Persuasion: appeals to reason • Manipulation • Coercision: explicit or implicit threats • Force: restraint or sedation
    87. 87. MANIPULATION • Distortion of facts or omission • Non-coercive alternation of choices • Undue financial payment • Undue influence, government funding only at grade eight for hpv
    88. 88. Practical Challenges to a "Fully Informed Consent" • Diagnostic uncertainty • Complexity of medical information • Linguistic and cultural differences • Overworked health personnel • Paternalistic approach in doctor-patient relationship in developing countries, including Sudan.
    89. 89. Informed Consent from Children • Written Parental/Guardian consent only required for those below the “legal age” • Assumption : best interests of the child should be regarded • Both parents of the child should sign or just one? • Institutionalised children? • Children without any recognisable legal guardian?
    90. 90. Assent After the age of seven and below legal consenting age (which is different for different countries depending on regulations) those who are competent to understand the opinion of the child should be respected “A child’s affirmative agreement to participate in research. Mere failure to object should not be construed as assent” Silence Assent
    91. 91. Assent Waiver of parental consent may be granted in adolescent research in certain circumstances i.e. drug abuse, sexual behaviour etc. Assent documents may include – age appropriate information sheets and forms where applicable
    92. 92. PRIVACY AND CONFIDENTIALITY
    93. 93. Privacy The right to be left alone and to keep personal information inaccessible to others (the condition of limited access to a person) Saudi Commision for Health Specialties
    94. 94. Privacy  Relates primarily to Process of clinical examination and collecting data Often Challenging in Natural Environment Can inconvenience research participants Can encounter participants in public Procedures and processes can compromise privacy Some institutions and cultures not accustomed to privacy, or do not value it
    95. 95. Infringements of privacy • Infringements is justified under certain circumstances; if: 1. Necessary for research conduct 2. Doesn’t create harm to participants 3. There is societal benefit
    96. 96. Confidentiality - The duty to respect the research participant’s confidence that the researcher/doctor will not disclose the information he/she received as part of research of health care. - How someone will deal with the information that was disclosed to him in confidence - Failure to keep private information is an infringements of confidentiality - Deliberate - Accidental
    97. 97. Measures to respect confidentiality • Avoid identifiable data • Encode the collected data • Limit access to data • Keep in password-protected PC • Destroy the original copies after analysis, or publication • Training of research team on confidentiality • Release information without identification To each of the previous conditions, there are ethically-acceptable exceptions
    98. 98. Breaking Confidentiality • Court order • Communicable diseases • Vulnerable person abuse/neglect • Driving/flying/machine safety • Dangerous patients
    99. 99. Unanticipated Problems: Examples • STDs research – placement of clinic. Sign on door. • Waiting with others, who knows you?
    100. 100. Important Considerations: • Retention of data after the study is complete • Secondary uses and linkage of data (i.e. databases) • How much personal information is actually necessary for the study?
    101. 101. CONFLICTS OF INTEREST (COI)
    102. 102. What is an interest? • An interest may be defined as a commitment, goal, or value held by an individual or an institution. • Examples include a research project to be completed, gaining status through promotion or recognition, and protecting the environment. Interests are pursued in the setting of social interactions.
    103. 103. What is COI? • COI exists when two or more contradictory interests relate to an activity by an individual or an institution. • Conflicts of interest are “situations in which financial or other personal considerations may compromise, or have the appearance of compromising, an investigator’s judgement in conducting or reporting research.” AAMC, 1990
    104. 104. What is COI? Cont. • “A conflict of interest in research exists when the individual has interests in the outcome of the research that may lead to a personal advantage and that might therefore, in actuality or appearance compromise the integrity of the research.” NAS, Integrity in Scientific Research
    105. 105. Levels of COI • Researchers • The REB should assess the likelihood that the researcher’s judgment may be influenced, or appear to be influenced, by private or personal interests, and assess the seriousness of any harm that is likely to result from such influence or from the mere appearance of undue influence (TCPS, 200)
    106. 106. Levels of COI Conflicts of Interest by REB Members • It is of the highest importance that members of the REB avoid real or apparent conflicts of interest . • For example: when their own research projects are under review by their REB or • when they have been in direct academic conflict or collaboration with the researcher whose proposal is under review.
    107. 107. Levels of COI Institutional Conflicts of Interest • Situations may arise where the parent organization has a strong interest in seeing a project approved before all ethical questions are resolved. • The REB must act independently from the parent organization. • Institutions must respect the autonomy of the REB and ensure that the REB has the appropriate financial and administrative independence to fulfill its primary duties.
    108. 108. What comprises COI? • Stock ownership • Paid employment Board membership • Patent applications (pending or actual) • Research grants (from whatever source) • Travel grants and honoraria for speaking or participation at meetings
    109. 109. What comprises COI? Cont. • Gifts Membership of lobbying organizations • Relationship with the National Research Ethics Review Committee, or with possible reviewers of the paper • Relationship with organizations and funding bodies Membership of a government advisory board
    110. 110. Is it always bad? COIs may result in: 1. Loss of objectivity 2. Reordering of priorities towards applied research 3. Degradation of the nature of science as an open and collegial enterprise 4. Exploitation of trainees 5. Transfer of time and interest to Commercial ventures
    111. 111. • In May 2004, the pharmaceutical giant Pfizer agreed to pay $430 million to settle a lawsuit by a former employee turned whistle-blower, who was joined in the lawsuit by the U.S. federal government and 11 state governments. • The lawsuit exposes various marketing practices by the company Warner-Lambert – later bought by Pfizer.
    112. 112. • Leading academic researchers were paid to deliver promotional lectures at educational events and to publish favorable reports on the off-label use of its epilepsy drug, Neurontonin. L. Kowalczyk “Pfizer Drug Strategy Probed: States Question Marketing Tactics for Neurontin,” Boston Globe, October 18, 2002, Saudi Commision for Health Specialties
    113. 113. Conflicts Can Occur at all Levels of Research • In reviews/awarding of grant • In ethics review of grant • In recruitment of participants • In analysis of data • In presentation of data
    114. 114. The Case of Nancy Oliveiri • In 1996, Olivieri found that the drug she was researching (deferiprone, active iron-chelating agent ) at the Hospital for Sick Children in Toronto was showing unexpected potential risks to some patients in the trials. • The drug company sponsoring her research abruptly terminated the trials and issued warnings of legal action against Olivieri should she inform her patients at the Hospital for Sick Children of the risks, or publish her findings.
    115. 115. The Case of Nancy Oliveiri Cont. • The manufacturer (Apotex) issued more legal warnings to deter Dr Olivieri from communicating this second unexpected risk of L1 to anyone. • However, she published her findings in the New England Journal of Medicine and
    116. 116. The Case of Nancy Oliveiri Cont. • She was subsequently dismissed from her position as Director of the Hospital for Sick Children Program of Hemoglobinopathies. • Apotex was planning to donate USD 100 Million to the University of Toronto
    117. 117. The Case of Nancy Oliveiri • After more than seven years of legal battle, an independent committee of inquiry into the matter vindicated Olivieri and concluded that neither the university nor the hospital offered her appropriate support in her conflict with the drug company. • Olivieri was reinstated to her position at the Hospital for Sick Children and her actions have also been vindicated by several other independent reports.
    118. 118. The other side of the story • Deferiprone is the only effective orally active iron- chelating agent licensed for the treatment of patients with thalassaemia major and other disorders of transfusional iron overload. • It is the only alternative to deferoxamine—a drug that has to be given by daily subcutaneous infusions and fails in many patients worldwide because of the lack of compliance, high cost, toxicity, or hypersensitivity.
    119. 119. The other side of the story • No other clinicians using the drug had found evidence for long-term liver damage and her interpretation of the data was immediately questioned in letters to the New England Journal of Medicine. • Four of her patients in whom liver fibrosis had been suggested also had hepatitis C and all five had iron overload—both causes of liver fibrosis.
    120. 120. LET’S DEBATE…! What do you think? OR ?
    121. 121. Practical Steps to resolve • Disclosure / transparency • Stringent analysis of COI, • Review of contracts between funders and researchers • Close external monitoring • Blinding of study, when possible • Restrict review of colleague’s work • Peer review of manuscripts
    122. 122. ETHICAL REVIEW OF RESEARCH
    123. 123. What is Ethical Review? • It is a process by which research proposals are reviewed for their compliance and accordance with the national/international ethical principles & guidelines for research involving human subjects.
    124. 124. Research Requiring Ethics Review All research involving living human subjects by collecting identifiable information or materials including:  Research with human remains, cadavers, tissues, biological fluids, embryos and fetuses.  Interviews, surveys and questionnaires.  Secondary data analysis of data from living human subjects.
    125. 125. Research exempt from Ethics Review:  Research about living individuals in the public arena or artists, based exclusively on publicly available information.  Participant observation of public demonstrations, political rallies and public meetings.  Quality assurance studies, performance reviews or normal educational testing.
    126. 126. DISCUSSION… Q & A

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