1 Informed consent Bernard Lo, M.D. August 11 and 12, 2010.
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Transcript of 1 Informed consent Bernard Lo, M.D. August 11 and 12, 2010.
1
Informed consent
Bernard Lo, M.D.
August 11 and 12, 2010
Neonatal blood samples
Screen for birth defects Required by law Parental consent not required
Later used for research on Preterm birth Environmental levels of pesticides Gene-environment interactions (smoking,
folic acid, cleft palate)2
Questions for audience
Do regulations permit research be
carried out on leftover neonatal spots
without consent? Yes /No / Unsure
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Questions for audience
Should regulations permit research be
carried out on leftover neonatal spots
without consent? Yes /No / Unsure
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Neonatal blood samples
Parents in Texas sued over storage of
samples for for research without
consent
2002 Texas law allows opt-out
5.3 million samples from before 2002
destroyed
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Use of neonatal blood spots for research
Permitted under federal regulations
Ethically contested
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Outline for today
What does informed and voluntary
consent require?
How can consent be improved?
What are exceptions to consent? Why are some exceptions in regulations
ethically problematic?
Why is consent needed?
Research compared to clinical care Risks and benefits uncertain Risk/benefit balance less favorable Purpose is not to benefit participants
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Rationale for informed consent
Respect for values and choices of
subjects
Deter research with unacceptable risks
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Questions for audience
After signing consent forms, do most
participants understand key features of
study?
Do IRB modifications improve
consent?
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1. HIV prevention trial
RCT of diaphragm + gel vs. diaphragm
+ placebo in women in Africa at risk for
HIV infection Both arms receive free condoms
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What must researchers disclose?
Nature and purpose of research
Research procedures, risks, benefits Unforeseeable risks
Participation voluntary, may
discontinue
IRB template
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Why is informed consent difficult?
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Why is informed consent difficult?
Participants commonly misunderstand Not understand how RCT differs from
clinical care Believe that study interventions are
• Standard therapy
• Best treatment for condition
• No additional risks
• For their personal benefit
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Why is informed consent difficult?
Participants commonly misunderstand Basic features of trial design
• May be in control group• Randomization• Therapeutic options restricted by study design
rather than individualized for them
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Why is informed consent difficult?
Vulnerable participants Low health literacy, low literacy Poverty, few options
Cultural context No informed consent in clinical care No acknowledgement of medical
uncertainty
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How can informed consent be enhanced?
Empirical studies Spend more time talking to participants Questions and feedback Shorter, simpler consent forms Multimedia -- mixed evidence
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How can informed consent be enhanced?
Practical suggestions Take point of view of participant Use simple language that 8th grader can
understand Explain how RCT differs from clinical care Invite questions
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How can informed consent be enhanced?
Focus on comprehension by
participant, not consent forms Administer questionnaire to ensure
appreciation of key aspects of study
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What is essential for participants to comprehend?
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What is essential for participants to comprehend?
Could still get HIV
Don’t know whether intervention works
May not get active intervention
Keep using condoms every time
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What is essential for participants to comprehend?
May refuse to participate
May withdraw from study
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Why is voluntary consent difficult?
Hard to say no to persons in power Defer to husband or father Relationship to investigator
• Student
• Employee
Undue monetary influence
Research participants who may lack decision-making capacity
Persons receiving CPR, ICU care
Severe dementia
Severe psychiatric illness
Young children
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Concerns about participants who lack decision-making capacity
Not appreciate risks
Not able to refuse
Might be subjected to risks that
competent persons would refuse
Options if lack decision-making capacity
Exclude from trials But lack evidence safety and effectiveness
of treatments
Additional protections
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Additional protections if lack decision-making capacity
Formal assessment of decision-making
capacity
Permission from surrogate
Assent of participant
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Additional protections for vulnerable partcipants
Closer monitoring for adverse effects
Subject advocate who can withdraw
participant from study
IRB include persons familiar with the
condition that impairs capacity
Research advance directives
Questions for audience
Without consent, may researcher
Use EMR to study whether patients
have worse outcomes if admitted over
weekend?
Use leftover cancer tissue to identify
prognostic markers?
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Ethical rationale for no consent
Very low risk No physical risks Confidentiality the main risk Cannot be breached if not identifiable
Benefits of research >> risks
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Ethical rationale for no consent
No one would or should object if asked Cancer tissue would be discarded Leftover tubes of blood
Impracticable to get consent Could not carry out important study
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Consent not required
1. Not human subjects research No IRB review
2. Exempt from human subjects
regulations
3. Qualifies for waiver
What is human subjects research?
Interact with person OR
Use identifiable private information Not human subjects research if data and
materials cannot be identified Examples of tissue from cancer surgery
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1. Not human subjects research
De-identified data and materials
Coded data and materials, researcher
cannot access keys to code
None of 18 HIPAA identifiers Code may be retained by database or
biobank
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2. Exempt from federal regulations
Most survey and interview research Unless subjects can be identified and
responses could put respondents at risk• Not if ask about illegal activities, sensitive or
private topics
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2. Exempt from federal regulations
Existing data or materials Publicly available Existing data or specimens if researcher
records information in manner than subjects cannot be identified
• Can look at medical records
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Studies that require identifiers
Link specimens with clinical records
Prognostic markers in cancer HER2/neu overexpression = poor prognosis Trastuzumab effective only in patients who
overexpress HER2/neu
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3. Waiver of consent
Minimal risk
Not adversely affect rights and welfare
Could not be practicably carried out
IRB may allow identifiable data to be
used without consent Use identifiers to link different databases
Research with cancer specimens
Not human subjects research if Completely de-identified Coded and researcher has no access to key Can determine prevalence of marker
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Neonatal spots
Not human subjects research if Completely de-identified Coded and researcher has no access to key
Waiver of consent Can link spots to medical records
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Neonatal spots
Permissible in regulations
Approved by IRBs
But still problematic
New standard is to offer opt-out for
research
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Questions for audience
Do regulations permit whole genome
sequencing on de-identified materials? Yes /No / Unsure
Should regulations permit whole
genome sequencing on de-identified
materials? Yes /No / Unsure
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Re-identification in whole genomic sequencing
Reference samples in forensic
databases DOJ has 8.3 million profiles STRs at 13 locations Full genome sequence yields DOJ
identifiers
Whole genome sequence an overt identifier?
Need access to DOJ database
Is access to DOJ identifiers more
secure than access to SSN?
May need to rethink concept of “de-
identified” samples
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Concerns about whole genome sequencing
Subject may consider information very
private and sensitive
Privacy concerns access to
information about self May not want others to access Even if identity not explicitly known
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Concerns about whole genome sequencing
Some donors may object When giving blanket consent for research,
donors did not consider this If donors had been told, would they object?
Respect donors who have strong
objections
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Questions for audience
Genetics of criminal behavior Match DOJ database with neonatal blood
spots without consent
Do regulations permit this? Yes /No / Unsure
Should regulations permit this? Yes /No / Unsure
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Objections to certain research on existing samples
Genetics of criminal and antisocial
behavior Stigmatize vulnerable populations Undermine individual responsibility
Human evolution
Derivation of embryonic stem cells
from IVF embryos50
Options
Sensitive research only with express
consent IRB determination of “sensitive”
More specific consent at donation
Re-consent participants? Make research much more difficult
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Take home message
Consent is important but challenging
Important exceptions to consent
permitted in federal regulations But some exceptions ethically contested Ethical standards may be stricter than
regulatory requirements Ultimate researcher is repsonsible
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