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Genomic research and data-mining technology: implications for personal privacy and informed consent.

This essay examines issues involving personal privacy and informed consent that arise at the intersection of information and communication technology (ICT) and population genomics research. I begin by briefly examining the ethical, legal, and social implications (ELSI) program requirements that were established to guide researchers working on the Human Genome Project (HGP). Next I consider a case illustration involving deCODE Genetics, a privately owned genetic company in Iceland, which raises some ethical concerns that are not clearly addressed in the current ELSI guidelines. The deCODE case also illustrates some ways in which an ICT technique known as data mining has both aided and posed special challenges for researchers working in the field of population genomics. On the one hand, data-mining tools have greatly assisted researchers in mapping the human genome and in identifying certain "disease genes" common in specific populations (which, in turn, has accelerated the process of finding cures for diseases tha affect those populations). On the other hand, this technology has significantly threatened the privacy of research subjects participating in population genomics studies, who may, unwittingly, contribute to the construction of new groups (based on arbitrary and non-obvious patterns and statistical correlations) that put those subjects at risk for discrimination and stigmatization. In the final section of this paper I examine some ways in which the use of data mining in the context of population genomics research poses a critical challenge for the principle of informed consent, which traditionally has played a central role in protecting the privacy interests of research subjects participating in epidemiological studies.

Computational Biology↗

Heart transplantation without informed consent: discussion of a case.

OBJECTIVE: To discuss informed consent to heart transplantation in the case of an intensive care unit (ICU) patient: relatives' informed consent was refused by the patient himself whose cognitive ability appeared to be reasonable for the purpose. SETTING: ICU of a university teaching hospital. PATIENT: A 62-year-old man who underwent myocardial revascularization had in the immediate post-operative hemodynamic instability, continuous serious arrhythmias, ventilatory support, fentanyl infusion. Heart transplantation could be the only chance for his survival. INVENTION: Heart transplantation. RESULTS: Despite patient's refusal, we decided to hold the relative's consent as valid, and transplantation was accordingly performed, to the subsequent satisfaction of the patient. CONCLUSIONS: Our decision was based on two beliefs: (1) the severity of the patient's clinical condition may have impaired his cognitive abilities; (2) the very same conditions may mask impairment and certainly make reliable assessment of cognition and judgment impossible. This being so, the preservation of life assumes priority.

Cardiac Output, Low↗

Clinician-parent communication during informed consent for pediatric leukemia trials.

OBJECTIVE: To address the need to describe informed consent in pediatric settings and to identify barriers to parent understanding, this study assessed how aspects of clinician-parent communication during the informed consent conference (ICC) relate to parent understanding of informed consent and parent perception of the impact of the ICC on their anxiety and control. METHODS: Parents of 127 children with newly diagnosed leukemia who were eligible for clinical trials were the participants. The study used comprehensive methods including both observational and self-report assessment methods. RESULTS: Structural equation modeling demonstrated that parent race and socioeconomic status (SES) were powerful predictors of clinician-parent communication, parent anxiety and control as a result of the ICC, and parent understanding. Clinician information giving and partnership building predicted parent participation during the ICC. CONCLUSIONS: These findings may be used to design interventions that increase the effectiveness of the ICC by identifying specific elements of the conference that influence parent affect and understanding.

Adolescent↗

Informed consent in clinical research: policies and practices in Singapore.

The policies and practices for obtaining informed consent from research subjects in clinical research play a vital role in determining a nation's success as a center for clinical research. The difficulty lies in the fact that while on the one hand, informed consent is a necessary pre-condition for ethical clinical research, a scrupulous observance of the guidelines for informed consent could, on the other hand, cripple medical research. Crippling of ethical medical research can be adverse to public interest, and consequently, unethical. Hence, a fine balance must be struck in the application of the guidelines for obtaining informed consent. This, in turn, would depend on the constitution and skill of research ethics committees who are appointed to consider and approve clinical research proposals. The discussion below addresses the above difficulty with recommendations that could further enhance Singapore's image as a regional clinical trial hub.

Clinical Trials as Topic↗

Informed consent: considerations in aesthetic and reconstructive surgery of the breast.

A definite standard of care exists for establishing informed consent. The plastic surgeon has an obligation to meet these requirements with each patient undergoing surgery. The difficulties of adequately informing have been described and suggestions made for supplementing the consultation with a variety of adjuncts. The goal is to inform and use whatever methods are effective in achieving this goal. Establishing valid informed consent will not prevent all medical liability claims. Despite the most conscientious efforts to inform, some claims will still occur alleging "lack of informed consent." The surgeon must then prove that sufficient information was provided. However, many patients who feel that the surgeon made every effort to inform and felt that the surgeon was honest, conscientious, concerned, and thorough will be less inclined to generate claims even in the face of unsatisfactory results or untoward complications. Informed consent is the patient's right and the surgeon's obligation. The medicolegal benefits from fully informing are tangible and one of the most effective methods to reduce claims and modify risk.

Breast↗

Informed consent for upper gastrointestinal endoscopy.

The process of informed consent is an ethical, legal, and medical necessity for endoscopists before performing upper endoscopy. The basics of informed consent include the nature, benefits, risks, and alternatives of the procedure being performed. A simple, straightforward application of the process is essential to appropriate care by endoscopists in everyday clinical practice.

Disclosure↗

Informed consent for patient transfers to a Veterans Affairs medical center.

OBJECTIVE: To evaluate whether informed consent was obtained prior to transfers of patients from a community hospital to a Veterans Affairs medical center. DESIGN: Cross-sectional study. SETTING: A Department of Veterans Affairs medical center. PARTICIPANTS: Eighty-six consecutive interhospital-transferred patients. Nearly all were white men, with a median age of 62.5 years. Fifty percent had three or more active medical problems and 17% had been transferred from intensive care units. MEASUREMENTS AND MAIN RESULTS: The authors defined informed consent as a discussion of benefits, risks, and alternatives to transfer. Following transfer, patients and physicians were interviewed using standardized parallel questionnaires. Physician-patient communication regarding the benefits and risks of transfer was infrequent. Informed consent was reported for none of the transfers by patient interview, compared with 11% of the transfers assessed by physician interview. Risks of transfer were discussed infrequently according to both physicians (17%) and patients (13%). Physicians perceived a risk to the patient in 21% of patient transfers, and in 36% of transfers defined by objective criteria as high-risk. Physicians recalled discussing benefits of transfer more frequently than did patients (80% vs. 42%,t test, p less than 0.001). Physicians also recalled discussing alternatives to transfer more frequently than did patients (61% vs. 18%, t test p less than 0.001). CONCLUSIONS: Verbal informed consent is obtained infrequently prior to interhospital transfer of patients. Risks of transfer are seldom perceived and discussed with patients.

Aged↗

Informed consent for medical procedures: local and national practices.

BACKGROUND: No studies have assessed whether clinicians obtain informed consent for invasive medical procedures, and there are no explicit national standards to guide the process. HYPOTHESIS: Informed consent practices are inconsistent for commonly performed invasive medical procedures. METHODS: A simple questionnaire was electronically mailed and/or faxed to training program directors of critical care medicine and internal medicine departments, and to ICU directors in the state of Connecticut. The questionnaire listed common invasive medical procedures and asked the respondents to check those for which practitioners routinely obtain informed consent in their hospital. RESULTS: The three samples, national intensivists (88 respondents), Connecticut intensivists (29 respondents), and national internists (56 respondents) demonstrated heterogeneity of consenting practices. The rate of obtaining consent for common vascular access procedures ranged from 20 to 90%. The rates of obtaining consent for Foley catheterization and nasogastric intubation were uniformly < 10%, and those for endoscopic procedures were > 90%. Separate consent (beyond the general consent to treat) was not uniformly obtained for the transfusion of blood products (range, 74 to 93%) and common diagnostic medical procedures (eg, thoracentesis, paracentesis, or lumbar puncture; range, 77 to 96%). Surgical intensivists reported that the obtaining of consent for invasive procedures was less routine compared to medical intensivists. Lower rates of consent were noted by those respondents who used a "blanket" consent form, which was signed at the time of hospital admission, to cover subsequent procedures. CONCLUSIONS: In this relatively small sample, there was no uniform practice of informed consent for commonly performed invasive medical procedures. Consent was routinely obtained for GI endoscopy, bronchoscopy, and medical research, and was not obtained for Foley catheterization and nasogastric intubation. The obtaining of consent for vascular cannulation and diagnostic procedures was not routine in the ICUs of a substantial number of respondents. Explicit standards that delineate specifically which procedures require consent may be required to assure more uniform practices.

Connecticut↗

Informed consent for invasive procedures in a community hospital medical intensive care unit.

OBJECTIVE: To describe the informed consent practices in the medical intensive care unit (MICU) of a university-affiliated, community teaching hospital. DESIGN: Prospective, observational study. SUBJECTS: 177 critically ill patients. MEASUREMENTS: Study personnel identified all critically ill patients who had an invasive medical procedure during the study period (120 days). It was first determined whether written informed consent was obtained for the procedure. If it was, standardized questionnaires were used to determine whether consent-givers recalled the indications, complications, and alternatives of invasive medical procedures. Documentation of consent and of the performance of invasive procedures in the medical records was also examined. An educational in-service was created to help improve the informed consent process. After a 45-day lead-in (control) period, the in-service was administered and IC was again studied for 75 days. RESULTS: A total of 181 procedures were performed on 112 patients over 120 days in the MICU. The rates of written consent for invasive procedures averaged 89%; rates of consent were not affected by the educational in-service. Following administration of the in-service, consent-givers recalled a greater number of complications (2.5 to 4.1, P=0.01) and documentation of consent improved. CONCLUSIONS: These results suggest that informed consent can be obtained procedure-by-procedure, as needed, at a high frequency, and with reasonable consenter comprehension.

Adult↗

Informed consent: law, clinical reality, and the role of the family physician.

Informed consent is typically seen as most relevant to surgical and other invasive specialties. Although family physicians perform fewer high-risk procedures, they are nonetheless extensively involved in the informed consent process because of the comprehensive and continuing nature of the family physician-patient relationship. Family physicians have a particularly important role in helping their patients to understand what diagnostic or therapeutic alternatives are available. Family physicians have an independent role in the informed consent process, as well as a collaborative role in the context of consultation and referral. Legal rules that require disclosure of alternatives to the patient by the treating physician are examined in the context of the family physician's role as a coordinator of patient care. Practical suggestions regarding discussion of alternatives, extent of disclosure, coordination with consulting physicians, and encouragement of patients' participation in discussions are offered.

Disclosure↗

Coping with the complexities of informed consent in dermatologic surgery.

Few medico-legal issues have generated as much controversy as informed consent--the right of patients to be fully informed about the risks, complications, and alternatives to a medical treatment or surgical procedure before deciding whether or not to submit to it. This paper discusses the complexities inherent in the legal doctrine of informed consent and their implications for dermatologic surgery. Particular emphasis is placed on the legal requirements for informed consent, as well as the problems associated with informing patients and their potential solutions.

Comprehension↗

[Informed consent. Historical background and current problems].

At present, informed consent is essential before patients can participate in clinical trials. The fact that a doctor asks the patient for informed consent is an expression of respect for the patient's right to make decisions about his own body. The request is made in recognition of the fact that optimal treatment can only be ensured by means of clinically controlled trials. The need for regulation of research arose at the beginning of the present century when pharmacological development accelerated. The Nürenberg Declaration was elaborated after the second world war and, subsequently, the Helsinki Declarations I and II. In these, directives are established for clinical research and for the rights of participants. A number of conditions make it difficult to fulfill these intentions. It may be difficult to ensure that the patient has adequate basic knowledge. The patient may feel that he is in a state of dependence on the doctor which influences his possibility to choose freely. Confidence between doctor and patient may be undermined if the patient is requested to participate in randomization for choice of treatment. Doctors know too little about how valid information can be ensured.

Ethics, Medical↗

What should patients be told prior to a medical procedure? Ethical and legal perspectives on medical informed consent.

Ethicists and the medicolegal system agree that patients have rights to information prior to an elective medical procedure. Yet, it is far from clear whether there is at the present time an adequate framework for informing patients. Medicolegally, court cases as early as the 1900s strongly emphasized the preservation of individual rights to information in the patient-physician relationship. Most recently, an increasing number of states use the criterion of what a "reasonable man" would want as the basis for medical informed consent. Medical ethicists also have offered general principles for consideration by physicians: the importance of patient autonomy and preferences in decisions related to their own health care. This report examines the historical development of informed consent in the United States, legal and ethical perspectives in medical informed consent, and the pragmatic issues yet to be considered by physicians in keeping their duty to inform patients prior to a medical procedure.

Decision Making↗

Priorities for disclosure of the elements of informed consent for research: a comparison between parents and investigators.

BACKGROUND: Disclosure is a key element of the informed consent process. This study examines and compares the priorities for disclosure of the elements of informed consent between parents of paediatric research subjects and investigators. METHODS: The study sample comprised 184 parents who had been approached for permission to allow their child to participate in a clinical anaesthesia or surgery study. Parents were asked to rank 11 elements of informed consent that they believed were most important for them to know before allowing their child to participate in a research study. In addition, 38 investigators were asked to rank, in order of importance, the same elements that they felt were most important for parents to know. RESULTS: The results showed that risk was the most important element considered by both parents and investigators. However, parents placed significantly greater importance on knowledge of the potential benefits to their child (direct) and to other children (indirect) compared with investigators, and less importance on the details of the protocol and the element of voluntariness. CONCLUSIONS: These results demonstrated differences in the priorities for disclosure of the elements of consent between parents and investigators. As such, they may be important in directing the investigator to focus on the elements that are most important to parents and thus maximize their ability to provide truly informed consent.

Adult↗

Informed consent: a medical decision (II).

The obtaining of informed consent prior to urography is a practice of some radiologists based largely on legal considerations. Because of the possibility of inducing anxiety, a relevant factor in idiosyncratic reactions, radiologists should not obtain informed consent prior to the urographic examination.

Contrast Media↗

Informed consent for labor epidurals: a survey of Society for Obstetric Anesthesia and Perinatology anesthesiologists from the United States.

BACKGROUND: Ethicists agree that informed consent is a process rather than just simply the signing of a form. It should provide the patient with needed information and understanding to authorize a procedure. Essential elements of informed consent for women requesting labor epidurals include a description of the procedure, the risks and benefits, and alternative treatments for analgesia including the associated risks and benefits. The purpose of this pilot study was to determine practices and opinions of obstetric anesthesiologists regarding informed consent for parturients. METHODS: Questionnaires were sent to 885 anesthesiologists who were members of the Society of Obstetric Anesthesia and Perinatology based in United States institutions in 2002. RESULTS: Of the 885 questionnaires sent, 448 (51%) were returned with 47% from academic and 47% from private practice institutions. Forty-six percent worked as part of an obstetric anesthesia team; 51% worked in centers where there were >3000 deliveries/year. Sixty-eight percent suggested that "parturients in active labor are able to give informed consent for labor epidural analgesia." Thirteen percent recommend antenatal anesthesia consults for parturients inquiring about labor epidurals and 41% participated in childbirth classes. Responses did not differ significantly between physicians in academic vs. private practice. More obstetric team practices than non-team practices participated in childbirth education (54% vs. 30%, P < 0.0001). CONCLUSION: Despite the painful, stressful circumstances confronted by parturients, many respondents (76% in academic, 64% in private practice) thought that women in active labor are able to give informed consent.

Academic Medical Centers↗

Thomas G. Orr Memorial Lecture. Surgical informed consent: what it is and is not.

A more systematic approach to addressing the crucial issue of informed consent is needed in medical education. Surgeons cannot afford gaps in their medical education regarding the communication process with patients. We found that many surgical residents and faculty understand the mechanics of the informed consent process quite well and could perform well under the artificial circumstances of our video interview. Whether they would do as well if a real patient was considering nonoperative therapy, or was a ne'er-do-well, or an alcoholic is not known. Two main causes of interference with the process have been identified: conflicting messages which surgeons get from within the profession, from the courts, and from within themselves and lack of time for dialogue with patients, and poor timing of the consent process. Areas that were uncovered that need further investigation include the barrier created by some surgeons' internal, often unrecognized, biases about surgery being the only satisfactory mode of treatment for some illnesses and some surgeons' belief that longevity should be the goal of all therapy, without considering that for some patients, maintenance of certain quality lifestyles is more important than a longer life. We hope that surgeons can learn to look at the informed consent process as a wonderful opportunity to communicate their personal concern for the patient as a person, not just a sick gallbladder to remove, and that this process can become the channel through which the wounded relationship of the patient and the physician can be healed.

Communication↗

[An investigation into the obtainment of informed consent for HIV-tests in psychiatric patients].

AIDS confronts the psychiatrist with the dilemma of stress resulting from a positive test result on the one hand and the responsibility of preventing the spread of the disease on the other hand. Psychiatric disturbances sometimes limit a patient's ability to give informed consent, which is an ethical precondition to testing. The legal standards of informed consent are discussed. During the 6-month period after the first HIV-positive test at Weskoppies Hospital, a further 48 patients were tested; 42 were examined to test the obtaining of informed consent. Diagnoses, reasons for testing and results were noted. Comprehension of the nature of the illness and the implications of the test were examined in a structured clinical interview. The nature of consent and the feedback of the result to the patient were examined. Results indicate that the psychiatric disturbance is a poor indication of the ability to give informed consent. The latter should be evaluated separately. If informed consent cannot be obtained, the patient should be treated as positive until accountability has been restored. Written consent offers the patient the opportunity to assimilate written information and contributes to informed consent. AIDS remains a problem of education and the feedback of seronegativity will help to curb future high-risk behaviour.

AIDS Serodiagnosis↗