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Irb.2011
 

Irb.2011

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Duties of the IRB

Duties of the IRB

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  • There have been many uplifting and morally upright chapters written in the history of the State of Alabama. However, one of them was not the infamous Tuskegee Syphilis Experiment which took place in East Alabama town of Tuskegee with the full knowledge of the government of the United States and at least the acquiescence of the State of Alabama. As you will remember from your history, beginning in 1932 and continuing until 1972, a 600 black men, 399 of whom were identified as being infected with syphilis and 201 without, who rather than being treated, were instead surreptitiously monitored to see what the long term consequences would be. In the 1970s, the truth, as it always does, began to out and the consequences of this very bad idea were many and far-reaching. By the end of the study, only 74 of the test subjects were still alive. Twenty-eight of the men had died directly of syphilis, 100 were dead of related complications, 40 of their wives had been infected, and 19 of their children had been born with congenital syphilis. As part of a settlement of a class action lawsuit subsequently filed by NAACP, nine million dollars and the promise of free medical treatment were given to surviving participants and surviving family members who had been infected as a consequence of the study. The Tuskegee experiment represents an abuse of power by physicians in the face of illiterate minority patients. One attorney who represented the patients and their survivors commented on the illiteracy of the patients' descendants, which he discovered while attempting to identify potential beneficiaries of the legal settlement: Perhaps the most distressing thing [attorneys] Gray and Carter encountered was the lack of social and economic mobility among the heirs. “There were more people who had to execute document by making marks than I'll ever see the rest of my life,” Carter recalled. “It didn't matter whether they had gone to Cleveland or stayed right here, so many of them were illiterate and uneducated .”
  • One good consequence of the Experiment was the push within the then Department of Health, Education and Welfare (HEW) to study the ethical principles involved in such human experimentation and to issue guidelines applicable to all institutions proposing perform such research. A blue ribbon commission was established by HEW and was directed to consider:           the boundaries between biomedical and behavioral research and the accepted and routine practice of medicine,           the role of assessment of risk-benefit criteria in the determination of the appropriateness of research involving human subjects,           appropriate guidelines for the selection of human subjects for participation in such research and           the nature and definition of informed consent in various research settings.   The report was finished on April 18, 1979 and gets its name from the Belmont Conference Center where the document was drafted. Belmont, which at one time belonged to the Smithsonian Institution, is located in Elkridge, Maryland, close to Baltimore.
  • The Tuskegee Experiment was not the first widely publicized abuse of human subjects to draw widespread attention and to beg corrective action. In the wake of atrocious tales of human experimentation by the infamous Dr. Mengele for Hitler in World War II, the Nuremberg Code was written to set standards for the judging of the ex post facto conduct of physicians and scientists in the war. The Nuremberg Code, though a retrospective, nevertheless became the “prototype” for several later codes that had a prospective application. The Nuremberg Code divided the field into three broad areas of scope: boundaries between practice and research; basic ethical principle; and practice. Building upon the Nuremberg foundation, the World Medical Associated in 1964 drafted the Declaration of Helsinki. Named for the meeting place, Helsinki, Finland, the Declaration established informed consent as the ethical standard in research while allowing for “surrogate” consent in appropriate cases. The Declaration also enunciated the principle that research should only be performed when it is “necessary to promote the health of the population represented.” The Helsinki Declaration laid the foundation for the establishment by the Belmont Report of Institutional Review Boards. The Belmont Report builds upon this base and continues it placing the general principles more in utilitarian categories.
  • In 1991, fourteen federal agencies joined HHS in adopting the uniform set of guidelines for human research and the protection of human subjects. This today is known as the “Common Rule,” and is the standard for all agencies and institutions performing such research. Boundaries between practice and research - According to Belmont, “practice” refers to interventions designed to “enhance the well-being” of the individual while “research” applies to the process to test an hypothesis, permit the drawing of conclusions therefrom and thus contribute to generalizable knowledge. This definition needs to be borne in mind as the place of the research has changed over the years. Research is no longer carried on only in teaching institutions and academic medical facilities. One author estimates that there are as many as 19,000,000 individuals participating in research in a given year. The Heart of our consideration herein is the second portion of Belmont as informed by Nuremberg – ethical principles. These principle, though specifically applicable to research involving human subjects sounds very much like basic human rights statements – and so they are. Belmont renders three basic principles: respect for persons, beneficence and justice.
  • Respect for persons is an eagle with two wings. First that persons should be treated as autonomous agents and second that persons with diminished capability for autonomy must be protected by society. Autonomous persons have the right to have their opinion consulted in matters that relate to themselves. To make a fair judgment about such decisions, they must be given accurate information and must not be pressured into making decisions. One of the first things our IRB looks at in an IRB submittal is the “informed consent.” Is there one? Is it really “informed,” does it give enough information, and is it understandable to the group under consideration. A further aspect of this is the requirement that this consent be periodically tested to make sure the subject still understands and still consents.
  • Beneficence requires the investigator to not only make sure there is continuing knowing consent, but to look out for the broader good of the subject. The investigator starts with a borrowing from Hippocrates and “does no harm” and then move past this to attempting to maximize the benefit to the individual subject. In other words, this principle requires the investigator not stop at merely doing no harm because as the research progresses, what is considered “harm” can change based on facts learned. A thorny ethical controversy involves questions of whether it is a valid subject of beneficent research where there is little or minimal risk to the subject balanced against substantial benefit to generalizable knowledge or even to identifiable groups.
  • The Principle of Justice applies to the allocation of risk and benefit the subjects and to the expected served populations. To explain, it can be said that there are several formulations for distributing the benefits and burdens of research: to each person an equal share, to each person according to his or her need, to each person according to societal contributions past and future or to each person according to merit. An example of the justice principle is the question of how the researcher goes about selecting the subjects for the research. Are these welfare patients, from a particular socio-economic or ethic background, confined populations such as prisoners? If so, the selection process of the subjects would give me pause as an IRB chair. The reverse application of the principle is true for the recipients of the benefit of the research. Is it going to benefit only a member of one of these groups or is it going to exclude systematically members of one of these or other groups?
  • As these principles work themselves out in the mechanics of application, there must be an informed consent, a detailed analysis of the risk to benefit ratio and an analysis of the criteria for selection of the subjects of the research. There are occasions when the revelation of the subject of the research would invalidate the outcome. In that case informed consent requires three things: 1) incomplete disclosure must really be necessary, 2) there would be no undisclosed risks that are more tan minimal to the subject and 30 there is an adequate plan for debriefing subjects after the conclusion of the project. The laying out of the risk to benefit ratio concerns itself with probabilities and “magnitude” of possible harm and anticipated benefits. Harm, of course can be more than merely physical, consideration must also be given to psychological, legal, social and economic elements of the possible risk. These must then be balanced. To a great extent, the “balancing” is subjective but should be governed by a full knowledge of the ethical principles which underlie research itself. The selection of subjects is accomplished principally according to the justice of the matter. This obtains on a social and an individual level. Individually, researchers should be fair with the subjects, telling the truth to them and not offering inflated goals or promises. Neither should promises or recruitment statements be used to encourage or discourage particular subjects.
  • Special care must be taken with confined or disadvantaged populations so as not to continue the over-burdening of such populations. In recruiting especially prisoners, special attention must be given to whether or not the “volunteers” are really volunteers. The same can apply to service men and women. If they are allowed to perceive that they get a special benefit such as light duty or excuse from exercises because they participate, one should look carefully at the justice of such promises.
  • Questions?
  • See “Closed Pods” - downloads on Slideshare © http://www.slideshare.net/jwible

Irb.2011 Irb.2011 Presentation Transcript

  • Brief Duties of IRBs Alabama Department of Public Health IRB March 2, 2011 ADPH, 2011
  • Researchers Ethics
    • The Tuskegee Experiment – “Bad Blood”
    • Tuskegee by the numbers:
      • 600 men in the study
      • 399 infected with syphilis and untreated
      • 201 without syphilis
      • 100 dead of causes “related to” syphilis
      • 74 men survived
      • 40 wives contracted syphilis
      • 19 children born with congenital syphilis
      • 9,000,000 dollars paid out in direct damages
      • 1 good result – The Belmont Commission
    ADPH, 2011
  • The Belmont Commission Studied:
    • The boundaries between biomedical and behavioral research and the accepted and routine practice of medicine,
    • The role of assessment of risk-benefit criteria in the determination of the appropriateness of research involving human subjects,
    • Appropriate guidelines for the selection of human subjects for participation in such research and
    • The nature and definition of informed consent in various research settings
    ADPH, 2011
  • Other International Works
    • Nuremberg Code – ex post facto guidance to judge WWII Nazi war criminals
      • Boundaries between research and practice
      • Ethical research
      • Ethical practice
    • Declaration of Helsinki (1964)
      • Informed consent as the ethical standard
      • “ Surrogate” consent defined and allowed
      • Research should only be performed when “necessary to promote the health of the population represented”
      • Laid the foundation for the establishment of IRBs
    ADPH, 2011
  • The “Common Rule” (Based on the Belmont Report)
    • Established boundaries between research and practice
    • Defined ethical practice based on three principles to include:
      • Respect for persons
      • Beneficence
      • Justice
    ADPH, 2011
  • Common Rule
    • The Common Rule is a federal policy regarding Human Subjects Protection that applies to 17 Federal agencies and offices. It does not apply to federal agencies that have not signed the agreement (e.g., Department of Labor, etc.) The main elements of the Common Rule include: Requirements for assuring compliance by research institutions
    • Requirements for researchers' obtaining and documenting informed consent
    • Requirements for Institutional Review Board (IRB) membership, function, operations, review of research, and record keeping.
    ADPH, 2011
  • Common Rule
    • The Common Rule includes additional protections for certain vulnerable research subjects. Subpart B provides additional protections for pregnant women, in vitro fertilization, and fetuses
    • Subpart C contains additional protections for prisoners
    • Subpart D does the same for children.
    • DHHS Regulations are provided in 45 CFR, Part 46. http://www.access.gpo.gov/nara/cfr/waisidx_99/45cfr46_99.html
    • FDA Regulations are detailed in 21 CFR, Part 50, and 21 CFR, Part 56.You can review these at http://www.access.gpo.gov/cgi-in/cfrassemble.cgi?title=199945
    ADPH, 2011
  • Common Rule
    • An institution with a DHHS approved Federal Wide Assurance typically agrees to apply DHHS regulations to all research regardless of the funding source, including research that is internally funded and collaborative research across institutions
    ADPH, 2011
  • The Common Rule
    • DHHS Regulations are provided in 45 CFR, Part 46.
    ADPH, 2011
  • Human Research
    • Research in humans differs from other research in that the subject has decision-making power and must be treated with respect. The long history, even in the name of science of one group of humans exploiting another has made it necessary to establish elaborate rules and procedures to protect human participants in research.
    ADPH, 2011
  • Ethical Principles
    • The primary responsibility of physicians is the best care and research is secondary.
    • Research is important to improve health care
    • Investigators should be aware of the ethical, legal and regulatory requirements for research on humans.
    • Research on humans must be scientifically sound and carried out by qualified persons.
    • It must be voluntary and informed, with consent and ability to withdraw documented.
    ADPH, 2011
  • Ethical Principles (continued)
    • Vulnerable populations may require surrogate consent.
    • The research protocol must have been scrutinized and approved by an ethics committee for risks and benefits with minimization of the former and maximization of the latter.
    • Investigators must monitor their research and report problems.
    • The population studied should have a reasonable chance of benefiting from the results.
    • Reporting and publication should adhere to the facts.
    • A limitation was placed on jointly providing clinical care and research.
    • Placebo use was strictly limited. Investigators should try to compare standard of care with the new agent.
    ADPH, 2011
  • Respect for Persons
    • People are treated as autonomous agents
    • Protection for those of diminished capacity
    • Informed consent defined
    • Period reviews of status of subjects required
    ADPH, 2011
  • Beneficence
    • Look out for the “broader good” of the subject
    • Do no harm
    • Balance the risks against the benefits
    ADPH, 2011
  • Justice
    • Applies the allocation of risk or burden to benefit to the subject and to the proposed benefited population
      • Are these welfare patients,
      • from a particular socio-economic or ethic background,
      • confined populations such as prisoners
    • Formulations for distributing benefits and burdens:
      • to each person an equal share,
      • to each person according to his or her need,
      • to each person according to societal contributions past and future
      • to each person according to (perceived) merit
    ADPH, 2011
  • Application
    • Informed, knowing consent
    • Detailed risk analysis with varied elements
      • Physical and psychological,
      • legal,
      • social
      • economic
    • Detailed and fair subject selection criteria
    ADPH, 2011
  • Special or Confined Populations
    • Are they really “volunteers?”
    • Soldiers or service people
    • Prisoners
    • Health Department or Medicaid patients
    ADPH, 2011
  • Definitions
    • Research A systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge . 45 CFR 46.102(d)
    • Human Subject A living individual about whom an investigator (whether professional or student) conducting research obtains data through intervention or interaction with the individual, or identifiable private information. 45 CFR 46.102(f)
    ADPH, 2011
  • Definitions
    • Interaction - includes communication or interpersonal contact between investigator and subject.
    • Private Information - information about behavior that occurs in a context in which an individual can reasonably expect that no observation or recording is taking place, as well as information that has been provided for specific purposes by an individual and which the individual can reasonably expect will not be made public.
    • Definition of Human Research
      • Data from living individuals
      • Biological material from living individuals
      • Interaction or intervention with a living individual
      • Use of a non-FDA approved, drug, device or biological
    ADPH, 2011
  • Mission of IRB
    • IRBs are impaneled to protect the rights and welfare of human subjects and support the institution's research mission. By requiring local review the Federal Government requires local responsibility that is both institutional and individual.
    • Researchers must respect and protect the rights and welfare of individuals recruited for, or participating in, research conducted by or under the auspices of the Institution. By institution is meant any entity that is sanctioned by the Federal Government to conduct research. The IRB is constituted to be the agency within the institution that reviews and approves research involving humans.
    ADPH, 2011
  • Mission - Personnel
    • IRBs have a full time administrative core to handle the applications, keep abreast of the changing rules, and monitor the approved protocols.
    • IRB members consist of faculty and non-affiliated non-scientists who in the aggregate possess a broad range of expertise and interests corresponding to the research proposed.
    ADPH, 2011
  • Requirement for an IRB
    • Research institutions have a contract, called an assurance, with the Federal government outlining their collective obligations and responsibilities to protect human subjects. These multiple project assurances require ethical review of all human research under defined rules.
    • Review by the institutional IRB(s) is required for research on humans when the conduct or recruitment of the research involves institutional resources, property, or facilities, regardless of funding source, when the research is conducted by or under the direction of any employee, student, or agent of the institution: in connection with her/his institutional responsibilities using any property or facility of the institution when the research involves the use of an institution's non-public information to identify or contact potential subjects
    ADPH, 2011
  • Mission – Local Control
    • The Common Rule adopted the principle of local control of research oversight because:
    • It would enhance education of the research community & the public
    • It would provide greater familiarity with the actual conditions surrounding the conduct of the research
    • It would enhance the ability to work closely with scientists to assure the protection of the rights and welfare of the subjects
    • It would assure that the application of policies is fair to investigators
    • Any study involving research on human beings must go through the IRB. However, there are certain exceptions based on the intent of the research or on the characteristics of the study.
    ADPH, 2011
  • Mission – Exemptions from Review
    • Hospitals are required to carry out programs of quality assurance that involves research into clinical practices in the institution. These are usually designed to improve the care locally and there is no intent to generate generalizable knowledge. That is not considered research.
    • On the other hand, a program evaluation/quality assurance program becomes research when the intent of the project is to answer a research question or create generalizable knowledge that will be shared outside of the program being assessed, such as journal articles, professional presentations, etc. Frequently the findings precipitate the interest in publishing.
    ADPH, 2011
  • Mission – IRB Exemptions
    • In general, a Study is exempt from IRB Review if it is Research in commonly accepted educational settings involving normal educational practice (Think “course evaluations”)
    • Surveys
    • Interviews or Questionnaires
    • Observation of public behavior, unless subjects can be identified, directly or through identifiers linked to the subjects; and any disclosure of the human subjects' responses outside of the research could reasonably place the subjects at risk of criminal liability or be damaging to the subjects' financial standing, employability, or reputation
    ADPH, 2011
  • Mission - Exemptions
    • Collection or study of existing data, documents, records, pathological specimens or diagnostic specimens, if:
      • The sources are publicly available, or
      • If the information is recorded in such a manner that subjects cannot be identified directly or through identifiers linked to the subject
    • Due to HIPAA: Medical record reviews are no longer exempt except or public health or quality improvement purposes
    ADPH, 2011
  • Questions?
  • For A Copy of the Presentation
    • See “Closed Pods” - downloads on Slideshare ©
    • http://www.slideshare.net/jwible
    Slideshare 7 ©