Skip to main content

Ethical Issues

  • Chapter
  • First Online:
Fundamentals of Clinical Trials

Abstract

People have debated the ethics of clinical trials for as long as trials have been conducted. The arguments have changed over the years and perhaps become more sophisticated, but many of them involve issues such as the physician’s obligations to the individual patient versus societal good, clinical equipoise, study design considerations such as randomization and the choice of control group, including use of placebo, informed consent, conduct of trials in underdeveloped areas, conflict of interest, participant confidentiality and sharing of data and specimens, and publication bias.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 54.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Emanuel EJ, Wendler D, Grady C. What makes clinical research ethical? JAMA 2000;283:2701–2711.

    Article  Google Scholar 

  2. Emanuel EJ, Grady C, Crouch RA, et al. (eds.). The Oxford Textbook of Clinical Research Ethics. Oxford: Oxford University Press, 2008.

    Google Scholar 

  3. The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research; The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, April 18, 1979. http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.htm.

  4. The Nuremberg Code. http://www.hhs.gov/ohrp/references/nurcode.htm.

  5. World Medical Association Declaration of Helsinki. http://www.wma.net/e/policy/b3.htm.

  6. Council for International Organizations of Medical Sciences (CIOMS). http://www.cioms.ch/frame_guidelines_nov_2002.htm.

  7. The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med 1989;321:406–412.

    Article  Google Scholar 

  8. Elliott C. Guinea-pigging. New Yorker. January 7, 2008.

    Google Scholar 

  9. Jonsen AR, Miller FG. Research with healthy volunteers. In Emanuel EJ, Grady C, Crouch RA, et al. (eds.). The Oxford Textbook of Clinical Research Ethics. Oxford: Oxford University Press, 2008, pp. 481–487.

    Google Scholar 

  10. Dickert N, Grady C. Incentives for research particpants. In Emanuel EJ, Grady C, Crouch RA, et al. (eds.). The Oxford Textbook of Clinical Research Ethics. Oxford: Oxford University Press, 2008, pp. 386–396.

    Google Scholar 

  11. Savulescu J, Spriggs M. The hexamethonium asthma study and the death of a normal volunteer in research. J Med Ethics 2002;28:3–4.

    Article  Google Scholar 

  12. Suntharalingam G, Perry MR, Ward S, et al. Cytokine storm in a phase 1 trial of the anti-CD28 monoclonal antibody TGN1412. N Engl J Med 2006;355:1018–1028.

    Article  Google Scholar 

  13. St. Clair EW. The calm after the cytokine storm: lessons from the TGN1412 trial (Commentaries). J Clin Invest 2008;118:1344–1347 (correction J Clin Invest 2008;118:2365).

    Article  Google Scholar 

  14. Agrawal M, Emanuel E. Ethics of phase 1 oncology studies: reexamining the arguments and data. JAMA 2003;290:1075–1082.

    Article  Google Scholar 

  15. Joffe S, Miller FG. Bench to bedside: mapping the moral terrain of clinical research. Hastings Cent Rep 2008;38:30–42.

    Article  Google Scholar 

  16. Freedman B. Equipoise and the ethics of clinical research. N Engl J Med 1987;317:141–145.

    Article  Google Scholar 

  17. Shaw LW, Chalmers TC. Ethics in cooperative clinical trials. Ann NY Acad Sci 1970;169:487–495.

    Article  Google Scholar 

  18. Byar DP, Simon RM, Friedewald WT, et al. Randomized clinical trials: perspectives on some recent ideas. N Engl J Med 1976;295:74–80.

    Article  Google Scholar 

  19. Spodick DH. The randomized controlled clinical trial:scientific and ethical basis. Am J Med 1982;73:420–425.

    Article  Google Scholar 

  20. Royall RM, Bartlett RH, Cornell RG, et al. Ethics and statistics in randomized clinical trials. Stat Sci 1991;6:52–88.

    Article  MATH  Google Scholar 

  21. Dawson L, Zarin DA, Emanuel EJ, et al. Considering usual medical care in clinical trial design. PLoS Med 2009;6(9):e1000111. Epub 2009 Sep 29.

    Article  Google Scholar 

  22. Holm S, Harris J. The standard of care in multinational research. In Emanuel EJ, Grady C, Crouch RA, et al. (eds.). The Oxford Textbook of Clinical Research Ethics. Oxford: Oxford University Press, 2008.

    Google Scholar 

  23. Temple RJ, Meyer R. Continued need for placebo in many cases, even when there is effective therapy. Arch Intern Med 2003;163:371–373.

    Google Scholar 

  24. Freedman B, Weijer C, Glass KC. Placebo orthodoxy in clinical research I: empirical and methodological myths. J Law Med Ethics 1996;24:243–251.

    Article  Google Scholar 

  25. Freedman B, Glass KC, Weijer C. Placebo orthodoxy in clinical research II: ethical, legal, and regulatory myths. J Law Med Ethics 1996;24:252–259.

    Article  Google Scholar 

  26. Rothman KJ, Michels KB. The continuing unethical use of placebo controls. N Engl J Med 1994;331:394–398.

    Article  Google Scholar 

  27. Rothman KJ, Michels KB. Update on unethical use of placebos in randomised trials. Bioethics 2003;17:188–204.

    Article  Google Scholar 

  28. O’Shea JC, Hafley GE, Greenberg S, et al. Platelet glycoprotein IIb/IIIa integrin blockade with eptifibatide in coronary stent intervention: the ESPRIT trial: a randomized controlled trial. JAMA 2001;285:2468–2473.

    Article  Google Scholar 

  29. Mann H, London AJ, Mann J. Equipoise in the Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Trial (ESPRIT): a critical appraisal. Clin Trials 2005;2:233–241.

    Article  Google Scholar 

  30. Tcheng J. Comment on Mann et al. Clin Trials 2005;2:242–243.

    Google Scholar 

  31. International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use: ICH Harmonised Tripartite Guideline: Choice of Control Group and Related Issues in Clinical Trials E10 (July 2000). http://www.ich.org/cache/compo/276-254-1.html.

    Google Scholar 

  32. Miller FG. The ethics of placebo-controlled trials. In Emanuel EJ, Grady C, Crouch RA, et al. (eds.). The Oxford Textbook of Clinical Research Ethics. Oxford: Oxford University Press, 2008, pp. 261–272.

    Google Scholar 

  33. Levinsky NG. Sounding Board. Nonfinancial conflicts of interest in research. N Engl J Med 2002;347:759–761.

    Article  Google Scholar 

  34. Weinfurt KP, Hall MA, King NMP, et al. Sounding Board: disclosure of financial relationships to participants in clinical research. N Engl J Med 2009;361:916–921.

    Article  Google Scholar 

  35. Code of Federal Regulations, Title 45, Part 46. http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.htm.

  36. Code of Federal Regulations, Title 21. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm.

  37. Cassileth BR, Zupkis RV, Sutton-Smith K, et al. Informed consent – why are its goals imperfectly realized? N Engl J Med 1980;302:896–900.

    Article  Google Scholar 

  38. Grunder TM. On the readability of surgical consent forms. N Engl J Med 1980;302:900–902.

    Article  Google Scholar 

  39. Howard JM, DeMets D, the BHAT Research Group. How informed is informed consent? The BHAT experience. Control Clin Trials 1981;2:287–303.

    Article  Google Scholar 

  40. Henderson GE, Churchill LR, Davis AM, et al. Clinical trials and medical care: defining the therapeutic misconception. PLoS Med 2007; 4:e324.

    Article  Google Scholar 

  41. U.S. Food and Drug Administration. Exception from informed consent requirements for emergency research. http://www.fda.gov/RegulatoryInformation/Guidances/ucm127625.htm.

  42. Federal Register, volume 61, October 2, 1996, 45 CFR Part 46, pages 5131–5133; Department of Health and Human Services, Waiver of Informed Consent Requirements in Certain Emergency Research. http://www.hhs.gov/ohrp/documents/100296.pdf.

  43. Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (amended 2005). http://www.pre.ethics.gc.ca/policy-politique/tcps-eptc/docs/TCPS%20October%202005_E.pdf.

  44. European Medicines Agency ICH Topic E6 (R1) Guideline for Good Clinical Practice, January 1997 (corrected July 2002). http://www.ema.europa.eu/docs/en_GB/document_library/Scientific_guidline/2009/09/WC500002874.pdf.

  45. Bottinger BW, Arntz H-R, Chamberlain DA, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med 2008;359:2651–2662.

    Article  Google Scholar 

  46. Burton TM. Despite heart attack deaths, PolyHeme still being tested on trauma patients. Wall St J February 22, 2006.

    Google Scholar 

  47. Kipnis K, King NMP, Nelson RM. Trials and errors: barriers to oversight of research conducted under the emergency research consent waiver. IRB 2006;28:16–19.

    Google Scholar 

  48. Karlawish JHT. Sounding Board: Research involving cognitively impaired adults. N Engl J Med 2003;348:1389–1392.

    Article  Google Scholar 

  49. Rosenstein DL, Miller FG. Research involving those at risk for impaired decision-making capacity. In Emanuel EJ, Grady C, Crouch RA, et al. (eds.). The Oxford Textbook of Clinical Research Ethics. Oxford: Oxford University Press, 2008, pp. 437–445.

    Google Scholar 

  50. Steinbrook R. How best to ventilate? Trial design and patient safety in studies of the acute respiratory distress syndrome. N Engl J Med 2003;348:1393–1401.

    Article  Google Scholar 

  51. Silverman HJ, Luce JM, Schwartz J. Protecting subjects with decisional impairment in research: the need for a multifaceted approach. Am J Respir Crit Care Med 2004;169:10–14.

    Article  Google Scholar 

  52. Love RR, Duc NB, Allred DC, et al. Oophorectomy and tamoxifen adjuvant therapy in premenopausal Vietnamese and Chinese women with operable breast cancer. J Clin Oncol 2002;20:2559–2566.

    Article  Google Scholar 

  53. Vickers A, Goyal N, Harland R, Rees R. Do certain countries produce only positive results? A systematic review of controlled trials. Control Clin Trials 1998;19:159–166.

    Article  Google Scholar 

  54. O’Shea JC, Califf RM. International differences in cardiovascular clinical trials. Am Heart J 2001;141:875–880.

    Article  Google Scholar 

  55. London AL. Responsiveness to host community health needs. In Emanuel EJ, Grady C, Crouch RA, et al. (eds.). The Oxford Textbook of Clinical Research Ethics. Oxford: Oxford University Press, 2008, pp. 737–744.

    Google Scholar 

  56. Lind SE. Finder’s fees for research subjects. N Engl J Med 1990; 323:192–195.

    Article  Google Scholar 

  57. The Alpha-Tocopherol Beta Carotene Prevention Study Group. The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. N Engl J Med 1994;330:1029–1035.

    Article  Google Scholar 

  58. Miller AB, Buring J, Williams OD. Stopping the carotene and retinal efficacy trial: the viewpoint of the safety and endpoint monitoring committee. In DeMets DL, Furberg CD, Friedman LM. (eds.). Data Monitoring in Clinical Trials: A Case Studies Approach. New York: Springer, 2006, pp. 220–227.

    Chapter  Google Scholar 

  59. The Age-Related Eye Disease Study Research Group. Design Paper: The Age-Related Eye Disease Study (AREDS): design implications. AREDS report no. 1. Control Clin Trials 1999;20:573–600.

    Article  Google Scholar 

  60. Age-Related Eye Disease Study Research Group. A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss. AREDS report no. 8. Arch Ophthalmol 2001;119:1417–1436 (correction Arch Ophthalmol 2008;126:1251).

    Article  Google Scholar 

  61. Tegeler CH, Furberg CD. Lessons from warfarin trials in atrial fibrillation: missing the window of opportunity. In DeMets DL, Furberg CD, Friedman LM (eds.). Data Monitoring in Clinical Trials: A Case Studies Approach. New York: Springer, 2006, pp. 312–319.

    Chapter  Google Scholar 

  62. Hulley S, Grady D, Bush T, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS). JAMA 1998;280:605–613.

    Article  Google Scholar 

  63. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA 2002;288:321–333.

    Article  Google Scholar 

  64. Hulley SB, Grady D, Vittinghoff E, Williams OD. Consideration of early stopping and other challenges in monitoring the Heart and Estrogen/Progestin Replacement Study. In DeMets DL, Furberg CD, Friedman LM (eds.). Data Monitoring in Clinical Trials: A Case Studies Approach. New York: Springer, 2006, pp. 236–247.

    Chapter  Google Scholar 

  65. Wittes J, Barrett-Connor E, Braunwald E, et al. Monitoirng the randomized trials of the Women’s Health Initiative: the experience of the Data and Safety Monitoring Board. Clin Trials 2007;4:218–234.

    Article  Google Scholar 

  66. Peppercorn J, Buss WG, Fost N, Godley PA. The dilemma of data-safety monitoring: provision of significant new data to research participants. Lancet 2008;371:527–529.

    Article  Google Scholar 

  67. Black HR, Elliott WJ, Grandits G, et al. Principal results of the Controlled Onset Verapamil Investigation of Cardiovascular End Points (CONVINCE) trial. JAMA 2003;289:2073–2082.

    Article  Google Scholar 

  68. Psaty BM, Rennie D. Stopping medical research to save money: a broken pact with researchers and patients (editorial). JAMA 2003;289: 2128–2131.

    Google Scholar 

  69. Marcus AD. Paying to keep your drug trial alive. Wall Street J April 10, 2007.

    Google Scholar 

  70. Health Insurance Portability and Accountability Act (HIPAA). http://privacyruleandresearch.nih.gov/.

  71. NIH Data Sharing Policy and Implementation Guidance (updated March 5, 2003). http://grants.nih.gov/grants/policy/data_sharing/data_sharing_guidance.htm.

  72. Policy for Sharing of Data Obtained in NIH Supported or Conducted Genome-Wide Association Studies. http://grants.nih.gov/grants/guide/notice-files/NOT-OD-07-088.html.

  73. Zarin DA, Tse T. Moving toward transparency of clinical trials. Science 2008;319:1340–1342.

    Article  Google Scholar 

  74. Wilson D, Meier B. Doctor falsified study on injured G.I.’s, Army says. The New York Times. May 12, 2009.

    Google Scholar 

  75. Scott J. Withdrawal of a paper (editorial). J Bone Joint Surg Br 2009;91:285–286.

    Article  Google Scholar 

  76. Fisher B, Anderson S, Redmond CK, et al. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1995;333:1456–1461.

    Article  Google Scholar 

  77. Angell M, Kassirer JP. Setting the record straight in the breast cancer trials (editorial). N Engl J Med 1994;330:1448–1450.

    Article  Google Scholar 

  78. Turner EH, Matthews AM, Linardatos E, et al. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med 2008;358:252–260.

    Article  Google Scholar 

  79. Heres S, Davis J, Maino K, et al. Why olanzapine beats risperidone, risperidone beats quetiapine, and quetiapine beats olanzapine: an exploratory analysis of head-to-head comparison studies of second-generation antipsychotics. Am J Psychiatry 2006;163:185–194.

    Article  Google Scholar 

  80. International Committee of Medical Journal Editors. Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Writing and Editing for Biomedical Publication (Updated October 2008). http://www.icmje.org/.

    Google Scholar 

  81. Clinical Trials Registration in ClinicalTrials.gov (Public Law 110-85): Competing Applications and Non-Competing Progress Reports. http://grants.nih.gov/grants/guide/notice-files/NOT-OD-08-023.html.

  82. Federal Register: May 21, 2008 (Volume 73, Number 99). http://edocket.access.gpo.gov/2008/E8-11042.htm.

  83. Steinbrook R. Gag clauses in clinical-trial agreements (perspective). N Engl J Med 2005;352:2160–2162.

    Article  Google Scholar 

  84. Drazen JM, Van Der Weyden MB, Sahni P, et al. Editorial. Uniform format for disclosure of competing interests in ICMJE journals. www.nejm.org October 13, 2009 (10.1056/NEJMe0909052).

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Lawrence M. Friedman .

Rights and permissions

Reprints and permissions

Copyright information

© 2010 Springer New York

About this chapter

Cite this chapter

Friedman, L.M., Furberg, C.D., DeMets, D.L. (2010). Ethical Issues. In: Fundamentals of Clinical Trials. Springer, New York, NY. https://doi.org/10.1007/978-1-4419-1586-3_2

Download citation

Publish with us

Policies and ethics