The longstanding ethical framework for protecting human volunteers in medical research needs to be replaced because it is outdated and can impede efforts to improve health care quality, assert leaders in bioethics, medicine, and health policy in two companion articles in a Hastings Center Report special report, “Ethical Oversight of Learning Health Care Systems.”
Seven commentaries in the publication, written by leaders with national responsibility for ethical oversight of medical research and efforts to improve health care quality, find areas of agreement and offer critiques.
“The challenge is to design oversight that adequately protects patients without impeding the kinds of data collection activities we need to improve health care quality, reduce disparities, and bring down our rate of medical errors,” says Mildred Z. Solomon, President of The Hastings Center and a co-guest editor of the report. (See video of Dr. Solomon on the importance of this debate.) By inviting these commentaries, the editors aimed “to provoke a national conversation,” wrote Solomon and co-guest editor Ann C. Bonham, Chief Scientific Officer at the American Association of Medical Colleges, in an accompanying editorial.
For nearly four decades, protection of human participants in medical research has been based on the premise that there is a clear line between medical research and medical treatment. But, the two feature articles argue, that distinction has become blurred now that health care systems across the country are beginning to collect data from patients when they come in for treatment or follow-up. The Institute of Medicine has recommended that health care organizations do this kind of research, calling on them to become “learning health care systems.”
In particular, the articles challenge the prevailing view that participating in medical research is inherently riskier and provides less benefit than receiving medical care. They point out that more than half of medical treatments lack evidence of effectiveness, putting patients at risk of harm. On the other hand, some kinds of clinical research are no riskier than clinical care and are potentially more beneficial; an example is comparative effectiveness research to find out which of two or more widely used interventions for a particular condition works best for which patients.
“Relying on this faulty research-practice distinction as the criterion that triggers ethical oversight has resulted in two major problems,” the authors write. First, it has led to “delays, confusion, and frustrations in the regulatory environment” when institutional review boards, which are responsible for the ethical oversight of research with human subjects, have difficulty distinguishing between research and clinical practice. Second, it has “resulted in a morally questionable public policy in which many patients are either underprotected from clinical practice risks (when exposed to interventions of unproven effectiveness or to risks of medical error) or overprotected from learning activities that are of low risk . . . and that stand to contribute to improving health care safety, effectiveness, and value.”
The authors call for a new ethical framework that “is commensurate with the risk and burden in both realms.” Their second article outlines such a framework for determining the type and level of oversight needed for a learning health care system. The basic structure consists of seven obligations: 1) to respect the rights and dignity of patients; 2) to respect the clinical judgment of clinicians; 3) to provide optimal care to each patient; 4) to avoid imposing nonclinical risks and burdens on patients; 5) to reduce health inequalities among populations; 6) to conduct responsible activities that foster learning from clinical care and clinical information; and 7) to contribute to the common purpose of improving the quality and value of clinical care and the health system. The first six obligations would be the responsibility of researchers, clinicians, health care systems administrators, payers, and purchasers. The seventh obligation would be borne by patients.
Authors of the feature articles are Nancy E. Kass, deputy director for public health in the Johns Hopkins Berman Institute of Bioethics; Ruth R. Faden, director of the Johns Hopkins Berman Institute of Bioethics; Steven N. Goodman, associate dean for clinical and translational research at the Stanford University School of Medicine; Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins; Sean Tunis, founder, president, and chief executive officer of the Center for Medical Technology Policy in Baltimore; and Tom L. Beauchamp, a professor of philosophy at Georgetown University and a senior research scholar at the Kennedy Institute of Ethics. Beauchamp was a chief architect of the Belmont Report, which established the existing research ethics framework in the United States.
The commentaries on the articles find common cause with the need to update clinical oversight for learning health care systems, but offer important critiques of the proposed framework. In particular, some hold that the research-treatment distinction is still useful and are concerned that the obligation for patients to participate in quality improvement efforts would exempt too many studies from voluntary informed consent and IRB protections.
The commentaries are written by Emily Largent, a PhD candidate in Harvard University’s health policy program; Franklin Miller, who works in the department of bioethics at the National Institutes of Health; Steven Joffe, a pediatric hematologist/oncologist at the Dana-Farber Cancer Institute, Children’s Hospital Boston and Harvard Medical School; Jerry Menikoff, director of the Office for Human Research Protections; Christine Grady, chief of the Department of Bioethics at the National Institutes of Health Clinical Center; David Wendler, head of the Unit on Vulnerable Populations in the Department of Bioethics at the National Institutes of Health Clinical Center; Joe Selby, executive director of the Patient- Centered Outcomes Research Institute; Harlan Krumholz, director of the Robert Wood Johnson Clinical Scholars Program at Yale University School of Medicine; Tom Puglisi, chief officer and director of the Office of Research Oversight in the Department of Veterans Affairs; and Joel Kupersmith, chief research and development officer of the Veterans’ Health Administration.