2. health ethics intro
-
Upload
mesfin-tafa -
Category
Healthcare
-
view
40 -
download
2
Transcript of 2. health ethics intro
04/15/20231
Introduction
04/15/20232
04/15/20233
What is the right thing to do?
How should we do our research in a
responsible way towards the
participants ?
How do we avoid, minimize or balance
any kind of risk/harm to the study
subject as the result of the research?
What makes an effective councelor?
04/15/2023
Definitions and concepts
4
What is ethics?
Principles of Biomedical Ethics
Regulations in Research Ethics
Research Ethics Committee
Ethical review in Ethiopia
04/15/20235
Ethics: Greek word ethos - custom or
culture
A branch of philosophy that deals with
moral principles
Right way of doing; based on basic
human values; respect for human
dignity.
04/15/2023
Ethics
6
It is a set of principles that tells as whether we do right or wrong.
Ethics provide guidelines for acceptable behavior.
Gives a philosophical account of justified behavior and belief.
Systematic study of morality Influenced by various factors
04/15/20237
Morality: It is beliefs and standards of good and bad, right and wrong, that people actually do and should follow in a society.what people do and believe.A science concerned with the
distinction between right and wrong.
04/15/20238
Medical Research: “research involving
intervention in the integrity of a person,
human embryo or human fetus for the
purpose of increasing knowledge of the causes,
symptoms, diagnosis, treatment and prevention
of diseases or the nature of disease in general”
Medical research act, Helsinki, April 1999.
04/15/20239
Bioethics: "the application of theories,
principles, and general ethical rules to
the particular problems of therapeutic
practice and of biomedical and biological
research.“
Biomedical Ethics: the systematic study of
value questions that arise in health care
delivery and in biomedicine.
04/15/202310
“Specific bioethical issues attention
needed:-
Euthanasia, new reproductive technologies,
cloning, human experimentation, genetic
engineering, abortion, informed consent, AIDS,
organ donation and transplantation, and
managed care and other concerns in the
allocation of health care resources.”
04/15/2023
Historical Back Ground
11
There have been historical cases of unethical
research that have been contributed to how we
work with participants today.
These studies led to the creation of the Belmont
Report and the Institutional Review Board (IRB)
which were formed to protect human subjects
involved in research.
04/15/2023
Some example
12
The unethical Nazi experiment (WWII)
The Tuskegee Syphilis study (1932-1972)
The Willow brook study (1963-1966): New york
The Jewish Chronic Disease Hospital Study 1963:NY
The Stanley Milgram's experiment (after WWII)
The Laud Humphrey's "Tearoom Sex“ study (1960s)
Humphrey’s PhD.
04/15/2023
NAZI Experiments
13
The history of research ethics begins with the
tragic history of research abuse by Nazi
doctors during World War II.
A total of 16 German physicians practiced
unethical medical experiments on Jews,
gypsies, and political prisoners.
04/15/2023
NAZI Experiments
14
In 1947, out of this horror, came the Nuremberg Code and other international codes of ethics written to protect research participants.
Under this code, the physicians were convicted for crimes against humanity. This also led to standards in research requiring that subjects participate voluntarily and are informed of the risks of the research.
04/15/2023
Nazi experiments
15
The Nazi experiments fell into three basic categories
1. Medico-Military Research;
2. Miscellaneous, Ad Hoc
Experiments; and,
3. Racially Motivated Experiments
04/15/2023
1. Medico-Military Research
16
Includes the following;a. Freezing Experimentsb. High Altitude Experimentsc. Sea Water Experimentsd. Sulfanilamide Experimentse. Tuberculosis Experiments:
04/15/2023
1 Medico-Military Research
17
A. High Altitude Experiments: To determine the best means of rescuing pilots from the risks of high altitude when they abandoned craft (with or without oxygen equipment) and were subjected to low atmospheric pressures. Used a decompression chamber to simulate high altitude conditions. Dissect several of the victims' brains, while they were still alive, to demonstrate that high altitude sickness was a result of the formation of tiny air bubbles in the blood vessels of the subarachnoid part of the brain.
04/15/202318
B. Freezing Experiments: Prisoners were immersed into tanks of ice water for hours at a time, often shivering to death, to discover how long German pilots downed by enemy fire could survive the frozen waters of the North Sea. 300 prisoners were victimsC. Sea Water Experiments: Tests on the potability of sea water were conducted at Dachau on 90 Gypsy prisoners. The subjects were given unaltered sea water and sea water whose taste was camouflaged as their sole source of fluid.
04/15/2023
Medico-Military …..
19
D. Sulfanilamide(C6H8N2O2S) Experiments
Wartime wounds were recreated and inflicted on
healthy Jews designated to be treated by the new
drug.
Wounds deliberately inflicted on the experimental
subjects were infected with bacteria such as
streptococcus, gas gangrene and tetanus.
Circulation of blood was interrupted by tying off
blood vessels at both ends of the wound to create a
condition similar to that of a battlefield wound.
04/15/2023
Medico-Military …..
20
E. Tuberculosis Experiments: To determine whether there were any natural immunities to Tuberculosis (TB) and to develop a vaccination serum against TB. To disprove the popular belief that TB was an infectious disease. "inferior organism of the Jews.” Injected live tubercle bacilli into the subjects' lungs to immunize against TB. And also removed the lymph glands from the arms of twenty Jewish children.
04/15/2023
2. Miscellaneous, Ad Hoc Experiments
21
Conducted unspeakable varieties of
torture that carried no pretense of
scientific inquiry. E.g
a. Poison Experiments: IV injection of
phenol gasoline and cyanide on
Russian prisoners.
To see how fast the subjects die.
04/15/2023
Miscellaneous…..
22
b. Wound Experiments: the cause of death
of most soldiers on the battlefield was
hemorrhage, to develop a blood coagulant to
be administered to the German troops before
they went off to war.
Tested coagulant by observing the rate of
blood drops that would ooze from freshly cut
amputation stumps of living and conscious
prisoners at the Dachau crematorium.Shoot
Russian prisoners in the spleen whenever to
take extra blood to test.
04/15/2023
3.Racially Motivated Experiments
23
Towards Jewisha. Artificial Insemination
Experiments:b. Sterilization Experiments:
c. Twin Experimentsd. Jewish Skeleton Collection:
04/15/202324
A. Artificial Insemination Experiments
04/15/2023
Racially …..
25
B. Sterilization Experiments:
Thousands of prisoners had their genitals
mutilated.
Injections of caustic substances into their
cervix or uterus, producing horrible pain,
inflamed ovaries, bursting spasms in the
stomach, and bleeding.Young men had their testicles subjected to
large doses of radiation and were subsequently castrated to ascertain the pathological change in their testes.
04/15/202326
C. Twin Experiments: Jewish twins kept alive to be used in Josef Mengele's medical experiments. These children from Auschwitz were liberated by the Red Army in January, 1945.
D. Jewish Skeleton Collection: wished to acquire a large collection of Jewish skulls and skeletons to form a museum dedicated to the extinct Jewish race.
04/15/2023
Tuskegee Syphilis Study(Bad Blood) (1932)
27
Syphilis is a venereal disease spread during sexual intercourse.
It can also be passed from mother to child during pregnancy. It is caused Treponema Pallidum.
It has three clinical stages 1. primary 2. Secondary 3. Tertiary
04/15/2023
Tuskegee Syphilis Study(Bad Blood) (1932)
28
A 40-year project administered by the US PHS in Macon County, Tuskegee, Alabama
Purpose: Evaluate the natural history of untreated Syphilis, in humans Population.
The American Government promised 400Afro-American men free treatment for “bad blood” which had become an epidemic in the county.
The study sample was made up of poor, African American men who were told that they had "bad blood".
04/15/202329
The treatment was never given to the men and was in fact withheld.
These men did not receive standard treatment for syphilis even when penicillin was available later during the study.
Were not informed of the research design and it's risks to them.
The investigators were government physicians, respected men of science, who published their reports of the study in medical journals.
04/15/202330
The government doctors who participated in this study failed to obtain informed consent from the subjects.
Invasive procedures like lumbar puncture was used to get data on alive subjects.
The information for the experiment was to be collected from autopsies of the men, and they were deliberately left to degenerate under the ravages of tertiary syphilis.
04/15/202331
04/15/202332
04/15/2023
Tuskegee ….
33
The study's unethical features did not come to light until 1972 when Jean Heller who broke the story.
By this time, over one hundred of the infected men died and others suffered from serious syphilis related conditions.
www.tuskegee.edu/bioethics
04/15/202334Bil Clinton...Apologize the remaining victims- 1997
04/15/202335
04/15/2023
Willowbrook Hepatitis Study 1963‐1966
36
Would YOU like to be injected with Hepatitis?
04/15/2023
Willowbrook Hepatitis Study 1963‐1966
37
New YorkMentally defective children deliberately
infected by hepatitis virus .”Designed to : Gain an understanding of
the natural history of infectious hepatitis.
– Test the effects of gamma globulin to prevent or
ameliorate the disease.During the study the school closed door to all
sections except the “hepatitis section”
04/15/2023
The Jewish Chronic Disease Hospital Study 1963 -New York
38
To develop information on the nature of the human transplant rejection process.
These studies involved the injection of live cancer cells into patients who were hospitalized with various chronic debilitating diseases.
Researchers said that consent had been given orally, but was not documented.
Patients were not told that they would receive cancer cells.
04/15/2023
Individual Assignment1 (10%)
39
1. The Stanley Milgram's experiment
(after WWII)
2. The Laud Humphrey's "Tearoom Sex“
study (1960s) Humphrey’s Phd
Font size 12pt,Times new roman, 1.5 Line spacing, Max 1 page
04/15/2023
Research Ethics:
40
Why Research Ethics?Research is itself ‘ethical’However: Tuskegee, Nazi experiment
etc.More generally: patients are vulnerable –Sick –Care or science? –Dependency and pressure / seduction
04/15/2023
Research Ethics
41
Research ethics: involves the application of fundamental ethical principles to a variety of topics involving scientific research. These include the design and implementation of research involving human experimentation, animal experimentation, various aspects of academic scandal, including scientific misconduct (such as fraud, fabrication of data and plagiarism)
04/15/202342
Principles of Biomedical Ethics
04/15/2023
Principles Biomedical ethics
43
The basic ethical principles: are those general judgments that serve as a basic justification for ethical evaluations of human actions.
They are considered universal regardless of geographic, economic, legal and political boundaries.
Researchers are obliged to assure that these principles are followed while conducting research involving human participants.
04/15/2023
Principles….
44
Ethical guidelines assist both investigators and ethical review committees in acting responsibly.
Epidemiological studies in the past were widely regarded as not raising any significant ethical issues and were commonly carried out without approval of an ethical review committee.
04/15/2023
Ethical Principles
45
Four basic ethical principles
1. Respect for persons
2. Beneficence: the act of doing good
3. Non-maleficence: not doing harm
4. Justice: fairness or moral rightness
(Based on Belmont Report, 1979)
04/15/2023
1. Respect for person’s:
46
Respect for persons; autonomy, informed choice and confidentiality. i. Autonomy: right of self determinationAn autonomous person is one who is
capable of deliberation about personal goals and of acting under the direction of such deliberation.
To respect autonomy is, therefore, to give weight to the considered opinions and choices of the individual, while refraining from obstructing his/her actions.
04/15/2023
Respect for person’s ….
47
Respect for persons demands the voluntary participation of the research participant with adequate information
It refers to the investigator to respect each participant as a person capable of making an informed decision regarding participation in the research study.
04/15/2023
Respect for person’s ….
48
ii. Informed consent : Voluntary participationInformed: everything should be revealed to
the study subject or the surrogate; No fact should be concealed
They should be told about the purpose of the research, procedures and interventions like randomization, placebo, prior animal research, possible therapeutic benefits, potential risks etc. Who pays for undesired outcomes? Researchers? Insurance? Subjects?
Do not give more hope than is justified.The possibility to withdraw from the
experiment/interview at any time.
04/15/2023
Informed consent
49
04/15/2023
Respect for persons…..
50
Non disclosure for scientific Reason:Deception is unacceptable! Even if
disclosure might result in refusal of consent
But it is not always necessary to reveal every detail if there is a risk of invalidating the research. General rather than particular disclosure is sufficient and ethical. E.g. randomization to experimental and control groups)
04/15/2023
Respect of …
51
Surrogacy:In case of competent individual, decisions
should be made by the person. When the person is not competent (minors, mentally handicapped), decisions are made by a surrogate (legally authorized representative for the subjects)
Such a study is justified only if mentally competent adults are not suitable subjects. (E.g. pediatric drugs, psychiatric medications)
04/15/2023
Respect for ..
52
Surrogates may use one of the following 3 principles to arrive to a decision
1. Substitute judgment principle: if the surrogate knows what the subject wants or would want in the situation2. Best interest principle: possible ‘best interest’ of the person; works in the absence of risk. 3. Rational choice principle: consideration of the good and evil consequences for the others as well as the subjects
04/15/2023
Elements of Written Consent
53
PurposeProceduresVoluntary ParticipationHow the information will be usedHow to opt out at any pointHow to contact the researcherSignatures
04/15/2023
Respect…
54
iii. Confidentiality: The use of information for any purpose other than that to which participants consented is unethical to the participants.The privacy of individual participant
needs to be kept through out the investigation by the researcher(s).
To protect participants from possible harm at the revelation of information
04/15/2023
2. Beneficence and Non-maleficence
55
Do not harmMaximize possible benefits and
minimize possible harms.Direct benefit to subjectOverall benefits to society “do no harm” : The Hippocratic oath: a
fundamental principle of medical ethics
04/15/2023
B. Beneficence and Nonmaleficence
56
Risks:The following need to be noted with regard to risks:To Whom
Research participant: Is the risk limited only to the research participant?
Community: Does the risk extend to the community?
04/15/2023
Beneficence and Nonmaleficence
57
Types Physical: any damage to any of the organs, e.g., handicapped
Social: offence by the society, e.g., stigma
Psychological: a feeling of discomfort, e.g., stress
Economic: loss of earning capacity, e.g., loosing job because of getting involved in a research which the employer does not like.
04/15/2023
Beneficence and Nonmaleficence
58
Magnitude: The degree of severity of the risk, i.e., mild, moderate or severe
Duration : How long the risk lasts, i.e., the risk may be (For the period of the study only or Extended further after the study is complete)
Population exposed: are vulnerable groups, such as Children, pregnant women, prisoners, mentally handicapped, elderly enrolled to participate ?
04/15/2023
Beneficence and Nonmaleficence
59
Benefits:Beneficiaries Research participants, Community, Country
Forms of benefits Monetary, i.e., financial Health care Capacity building: research facility
and manpower development
04/15/2023
Beneficence and Nonmaleficence
60
Magnitude of benefitsCompensation, i.e., to compensate
the time participants spent for the study, the expenses they covered for the meal and transport
Undue Inducements, i.e., to provide benefits for participation more than they earn and more than they deserve. This might coerce !
Duration of benefits Short term, i.e., only for the study period
Long term. i.e., extends beyond the study period
04/15/2023
C. Justice
61
The underlying principle of justice is to treat
each person in accordance with what is
morally right and proper, i.e., fairness in
distribution: distributive justice
There must be equitable distribution of both
the burdens and benefits of participation in
research.
04/15/2023
Justice…
62
Fair distribution of benefits– Equal shares– Equal individual need– Equal individual effort– Equal societal contribution– Equal merit
04/15/202363
Individual vs community interest has to be considered in the principle of justice. The research might compromise the interest of the individual, while benefiting the community or vice versa. This might create an ethical dilemma.
In this case, it is up to the Ethics Committee to pass a fair decision considering the cons and pros of the research both on the individual research participant and the community.
04/15/2023
Components of justice
64
Local participation right from the inception to preparation of the proposalInvolvement of the community in the planning and implementation of the studyFair research participant selectionJustified use of placebo and randomization
04/15/2023
Components of justice…
65
Standard care for research participantsCompensation of research participantsClear procedures for results disseminationMemorandum of understanding pertaining to authorship, intellectual property rightPost trial responsibilitiesPermission for sample transport
04/15/2023
Balance between the principles
66
Any risk needs to be justified by humanitarian goods to be obtained from the research that directly promote the welfare and dignity of the person.
It is humanitarian goods and not scientific knowledge that supply justification for the risks.
In human research knowledge is not self justifying. Nothing can justify research that disregards the dignity of human subjects.
The decision on the ethical correctedness of a given piece of research cannot always be delineated with absolute clarity.
04/15/202367
Balanced emphasis is given to the
following points;
Protecting the subject from harm:
“when in doubt do what is safest for the
subject”
Social concerns: humanitarian good
for the society and community who are
not in the research study
Freedom of choice: subjects have the
right to choose what is most
convenient, provided with enough
information, even if it involves risk.
04/15/2023
Regulations in Research Ethics
68
International The Nuremberg Code of human rights
(1947)The Helsinki Declaration(since 1964 till now)
By WMA Council for international organization of
Medical Sciences (CIOMS) 2001International guidelines for Biomedical
Research involving human subject 1982The WHO and ICH (International Conference
on Harmonization) 1995Guidelines for good clinical practice-by WHO-For trials and pharmatical products The
Belmont Report(1979)..others
04/15/2023
Nuremberg Code:1947
69
Ten (10) principles1. Informed consent.
2. Experiment should be useful and
necessary.
3. Human experiments should be based
on previous animal experiments.
4. Physical and mental suffering should
be avoided.
5. Death and disability should not be
the expected outcomes.
04/15/2023
Nuremberg Code…
70
6. Degree of risk should not exceed the humanitarian importance of solving a problem.7. Human subjects :‐protected against even remote possibilities of harm.8. Human subjects are free to end an experiment at any time.9. Only qualified scientists should conduct medical research.10.Must be prepared to end experiment at any stage.
04/15/2023
Declaration of Helsinki-1964
71
(revised 75,83,89,96,2000,2002,2004,2008)HighlightsWell being of the subject takes
precedence over science and society.Respect for persons & protection of
subjects health & rights.Vulnerable populations require special
protection.Procedures must be detailed in a
protocol & submitted to an ethical review committee, including the monitoring of information
04/15/2023
Declaration of Helsinki-1964
72
Assessment of risks and benefits to the subjects or others before conducting the research.
– Informed consent is a must.– Informed consent must be Documented.In 2000 – art.16 , Every medical research project involving human subjects should be preceded by careful assessment of predictable risks and burdens in comparison with foreseeable benefits to the subject or to others. This does not preclude the participation of healthy volunteers in medical research.
04/15/2023
Belmont report: 1979
73
US response, 1979
Belmont Report…
04/15/202374
The basic ethical principles were addressed
Protect humans from exploitationSpecial protection for most
vulnerable (children, pregnant women, prisoners)
04/15/2023
National Regulations
75
The Constitution of the Federal Republic of Ethiopia,
Relevant laws (Civil Code and Penal Code)
ESTC Health department, National Health Research Ethics Review Guidelines,
Relevant International conventions to which Ethiopia is a party
04/15/202376
04/15/2023
National regulations….
77
All health researches involving human participants must be subjected to independent ethics review and thus must be conducted by a health research ethics review committee.
In Ethiopia Health research ethics review committee (HRERC) are established at three levels :
National (NERC)Regional(RERC) Institutional (IERC)
04/15/2023
Research Ethics Committee
78
Evaluates Research Proposals Based on Criteria
Approves or disapproves the research Objectives:1. Safeguard the study participants from
any harm related research 2. Assure that individual benefit and civil
rights are being respected.
04/15/2023
Research Ethics Committee
79
Specific objectives which include the following:To safe guard research participants from any risk,
To evaluate ongoing and post research implications on the participants and the community at large, and
To make sure that research participants are participating in the study with written informed consent.
04/15/2023
IRB (Institutional Review Board)
80
Definition : An independent body constituted of medical ,scientific , and non scientific members whose responsibility is to ensure the protection of the rights, safety and well being of human subjects by; reviewing, approving, and providing continuing review of protocols, amendments of the methods ,material to be used in obtaining and documenting informed consent of the human subject.
Contains at least 5 members of varying background.
04/15/2023
IRB…
81
Law requires hospitals, educational and research institutions have an institutional review board (IRB).
The IRB reviews and approves or disapproves of the proposed research in its institutions in terms of risk benefit analysis.
The boards are not infallible but provide ethical safeguards in research.
04/15/2023
IRB..
82
This goals is accomplished by having the IRB assure that the following requirements are satisfied:
1. Risk to subjects are minimized2. Risk to subjects are reasonable in
relation to anticipated benefits,3. Selection of subjects is equitable, i.e.
fair4. Informed consent is sought form each
subject or his/her legally authorized representative,
5. Informed consent is appropriately documented,
6. When appropriate, the research plan makes provisions for monitoring data collection,
04/15/2023
IRB
83
7. Privacy and confidentiality of research
subjects is appropriately protected, and
8. When some or all of the subjects are
likely to be vulnerable to coercion or
undue influence, additional safeguards
have been included.The IRB has to approve that these requirements are followed before they approve a research study and must review these documents on, at the least, an annual basis.
04/15/2023
Ethical review in Ethiopia
84
Applications first submitted to the
appropriate Regional or Institutional
Ethical Review Committee.
RERC/IERC reviews, gives comments and
where necessary forwards to the
National Ethical Review Committee.
04/15/2023
Ethical review in Ethiopia
85
National Ethical Review Committee reviews –
• All clinical trials• Research on very sensitive issues• Multi-centre collaborative research• Research financed/carried out by
external donors• Research to be carried out by a
national agency with bilateral or multilateral collaboration
• Research to be conducted in more than one region
04/15/2023
Thank you!
86