Good Research, Bad Choices? Mary Coombs
Jan 02, 2016
What Makes Something Research Rather Than Treatment?
Subject welfare isn’t primary goal: “risks to subjects must be reasonable in
relation to anticipated benefits, if any, to subjects and the importance of the knowledge that may reasonably be expected to result”
What Makes Something Research Rather Than Treatment?
Decisions are based on protocol in first instance
Not on contextual best interests of this person
What Makes Something Research Rather Than Treatment?
Usually requires testing and procedures beyond those needed for treatment
What Makes Something Research Rather Than Treatment?
Usually/ ideally is RCT Neither subject nor researcher know if
is getting treatment A or treatment B
Proposed: “The main purpose of a clinical trial is to benefit future patients rather than the patients in the trial”
Do you think this is true?
Proposed: “The main purpose of a clinical trial is to benefit future patients rather than the patients in the trial”
What did doctors at a (Boston-based) academic institution think?
Proposed: “The main purpose of a clinical trial is to benefit future patients rather than the patients in the trial”
What did doctors at a (Boston-based) academic institution think?
Yes: 45.9%Unsure: 29.5%No: 24.6%
This misunderstanding is common enough to have a name:
Therapeutic MisconceptionTherapeutic Misconception
Law and Ethics of Treatment
Option B: Reasonable Experimental TreatmentMore Detailed Informed Consent needed
Law and Ethics of Treatment
Option C: Unreasonable Experimental TreatmentNot permitted“Consent” Irrelevant
Law and Ethics of Treatment
There is Potential Tort Liability if 1) there is a bad outcome and2) there was
a. Unreasonable Experimental Treatment or
b. Insufficient Informed Consent or
c. Execution of Treatment fell below standard of care
How Can Research Study be a “Bad Choice”? Phase One Trial
Consider:Risk to subjectBenefit to subjectBenefit to knowledge/future patients
How Can it be a “Bad Choice”? Phase One Trial
Risk to subject Significant: more toxic dose than
previously given to humans
How Can it be a “Bad Choice”? Phase One Trial
Benefit to subject? Minor in fact Protocol not designed to test efficacy
How Can it be a “Bad Choice”? Phase One Trial
Benefit to knowledge/future patients? Subjects say are doing to find a cure for
themselves Are either altruistic or misunderstand the
“free rider” option
Downsides of being a Subject: Other Clinical Trials
Apart from Randomization Rigidity of protocol Risks/Inconveniences of Additional
Testing Not told of interim results
Upsides of being a Subject: Other Clinical Trials
Apart from Randomization Access to better quality care than P
might otherwise obtain Academic medical center trials Effect of limits on health insurance
Upsides of being a Subject: Other Clinical Trials
Apart from Randomization Possible Access to Drug/Treatment not
otherwise available If new drug If (some) doctors won’t provide off-label If new technique not available outside trial
setting
Upsides/Downsides of being a Subject:Randomization
Must be “clinical equipoise” What might be differences between
standard and new treatment?
Possible Differences [to be tested by study]
Effectiveness Expected Mild-to-Moderate Side
Effects Level of Risk of Serious Side Effects Convenience Cost
Possible Outcomes [after study]
New treatment is clearly as good or better on all dimensions
Standard treatment is clearly as good or better on all dimensions
Two treatments are in equipoise: incommensurable (known) differences
Clinician decisions [after study]
New treatment is clearly as good or better on all dimensions: USE NEW
Standard treatment is clearly as good or better on all dimensions: USE STANDARD
Clinician decisions [after study]
Two treatments are in equipoise: incommensurable (known) differences Choose what is best given specifics of
this patient Engage patient to help choose given
subjective preferences E.g. risk vs. efficacy E.g. cost vs mild/moderate likely side
effects
Clinician decisions [before study](if new treatment available outside study
Two treatments are in equipoise: incommensurable (unknown) differencesChoose what is best given specifics of this patientEngage patient in choice given subjective preferences
E.g. risk vs. efficacyE.g. cost vs mild/moderate likely side effects
Is informed consent the answer to the “bad choices/good study” dilemma?
Are people free to be altruistic?Are people free to make “bad choices”?Should we be skeptical that bad choices are freely made and fully informed?
Does Informed Consent Form Matter?
written documentation matters Research form is more important
than treatment form Research form is easier to prepare
than treatment form Liability: “I always tell people; I
must have told Ms. X”
What might a subject want to know?
That is a research study Potential future benefits of research study Intervention being studied Alternative [standard care? placebo?] Are there third alternatives available? Risks of Standard Care Risks of Proposed New Treatment
What might a subject want to know?
Benefits of Standard Care Benefits of New Treatment Risks/discomforts inherent in
participation Obligations of being a subject What happens if leave study
prematurely
What might a subject want to know?
What recompense ($$) for participating?
What consequence if things go wrong? Who pays for what?
Facts about person offering to enroll me might be relevant to determining his/her motivations
Are these all in the standard forms?
Research study/ purposes/benefits: yes
Treatment being tested and randomized alternative: yes
Availability of third alternatives? Sometimes Often doesn’t include option of study
treatment outside research study
Are these all in the standard forms?
Risks/discomforts inherent in study Generally included Tests may be referred to as “routine” This may be understood as “risk-free”
rather than common outside the research protocol
Are these all in the standard forms?
Obligations/effect of leaving prematurely? Usually covered Doesn’t indicate that won’t be told of
interim results
Why might a subject want to know – and a researcher not want to reveal this??
Results show new treatment more efficaciousConfidence interval overlaps null hypothesisCompare researcher interest and patient interest
Are these all in the standard forms?
Risk/benefit of standard and alternative? Yes, but boiler-plate COST study of laparoscopic surgery for
colon cancer Form language: “it is possible that the
new technique may change the way the tumor grows back after surgery if it does”
Vs. Benefits of “smaller incisions and faster recovery”
Are these all in the standard forms?
Financial Issues Payment to P for time/inconvenience? Y Coverage of Medical Costs during trial?
Y Compensation for damages from trial?
Usually not included/not covered Incentives to Researcher/Doctor to
Include P in trial? No