Ethical issues surrounding controlled human infection challenge studies in endemic low-and middle-income countries

Controlled human infection challenge studies (CHIs) involve intentionally exposing research participants to, and/or thereby infecting them with, micro-organisms. There have been increased calls for more CHIs to be conducted in low- and middle-income countries (LMICs) where many relevant diseases are endemic. This article is based on a research project that identified and analyzed ethical and regulatory issues related to endemic LMIC CHIs via (a) a review of relevant literature and (b) qualitative interviews involving 45 scientists and ethicists with relevant expertise. In this article we argue that though there is an especially strong case for conducting CHIs in endemic (LMIC) settings, certain ethical issues related to the design and conduct of such studies (in such settings) nonetheless warrant particularly careful attention. We focus on ethical implications of endemic LMIC CHIs regarding (a) potential direct benefits for participants, (b) risks to participants, (c) third-party risks, (d) informed consent, (e) payment of participants, and (f) community engagement. We conclude that there is a strong ethical rationale to conduct (well-designed) CHIs in endemic LMICs, that certain ethical issues warrant particularly careful consideration, and that ethical analyses of endemic LMIC CHIs can inform current debates in research ethics more broadly.     

Community engagement in global health research that advances health equity

Community engagement is gaining prominence in global health research. So far, a philosophical rationale for why researchers should perform community engagement during such research has not been provided by ethics scholars. Its absence means that conducting community engagement is still often viewed as no more than a ‘good idea’ or ‘good practice’ rather than ethically required. In this article, we argue that shared health governance can establish grounds for requiring the engagement of low‐ and middle‐income country (LMIC) community members in global health research, where such research aims to help reduce health disparities. This philosophical basis has important implications for the ethical goals ascribed to engagement and the approach adopted to undertake it. We suggest the ethical goals of engagement in equity‐oriented global health research should include: (a) generating research topics and questions that reflect the key problems disadvantaged groups face in accessing healthcare, services and broader social determinants of health and (b) promoting the translation of research findings into policy and practice in ways that benefit the health of disadvantaged groups. We propose engagement practice should have the following features: deliberation with LMIC community members to make a range of project decisions, beginning with setting research topics and questions; inclusion of members of disadvantaged groups and those with the power to change policy and practice to benefit them; and purposeful structuring of deliberations to minimize the impact of power disparities between LMIC community members. Finally, we reflect on how these features differ from those typical of much current community engagement practice in LMICs.     

Study bystanders and ethical treatment of study participants—A proof of concept

The ethics of research on human subjects is often construed as a fine balance between the interests of patients in need of novel health interventions, and those of study participants who should remain safe in the process. But there is a third group in the mix. Some people belong to neither category, yet research can affect or jeopardize them. Call such people “bystanders.” This article shows that thinking about bystander protection can question whether there is an upper limit on the risks that studies may legitimately visit upon their participants. Thus, thinking about appropriate bystander protection can shed light on the appropriate protection of study participants. Core research ethics, which focuses on the latter, must consider the former as well.     

Why IRBs should protect bystanders in human research

Many types of human research activities present risks and burdens to third parties (e.g., bystanders). Few human protection policies directly address the protection of research bystanders, though some address it in passing. In what follows, I re-iterate reasons why bystanders are entitled to protections. I also argue that Institutional Review Boards (IRBs) are in the best position to signal to researchers and sponsors that bystanders should be protected in research. In some cases, IRB review would consist of evaluating bystander protection strategies directly; in other cases, this might entail merely certifying that another institutions, like a drug regulator, has taken adequate measures to protect the welfare of research bystanders.     

Bystanders and ethical review of research: Proceed with caution

Scientists seeking to conduct research with human subjects must first submit their proposals to research ethics committees (Institutional Review Boards [IRBs], in the United States). Some of these studies pose risks to “bystanders,” i.e., people who may be affected by the research but who are not enrolled as study subjects. Should IRBs expand their scope to include oversight over possible harms to bystanders as well as research subjects? This paper presents arguments against this step. Prior review of research with human subjects, despite its evident burden on the research enterprise, is a necessary caution, because the tension between the objectives of humane treatment of research subjects and sound scientific design and procedure has in the past led to serious abuses. This rationale is inapplicable in the case of bystanders. Moreover, in view of the many and varied effects of both research practices and scientific advances on the broader public over time, those who may be considered to be “bystanders” may potentially expand without limit; requiring IRBs to anticipate these distant and long-term effects as part of prior ethical review could greatly increase its burden and its deterrent effect on research. While conducting research without concern for serious potential harm to bystanders may be irresponsible and unethical, expanding the scope of prior review by IRBs to include risks to bystanders is not required by the principles governing human subjects research, and the costs and burdens of this expansion may outweigh any expected gains.     

Ethics of community engagement in field trials of genetically modified mosquitoes

Effective community engagement is an important legal, ethical, and practical prerequisite for conducting field trials of genetically modified mosquitoes, because these studies can substantially impact communities and it is usually not possible to obtain informed consent from each community member. Researchers who are planning to conduct field trials should develop a robust community engagement strategy that meets widely recognized standards for seeking approval from the affected population, such as timeliness, consent, information sharing, transparency, understanding, responsiveness, mutual understanding, inclusiveness, and respectfulness. Additional research is needed on the effectiveness of different methods of engaging communities in field trials of genetically modified mosquitoes and how to respond to public opposition to genetically modified organisms. For research programs involving the genetic modification of disease vectors to move forward, they must have public acceptance and support, which cannot be achieved without effective community engagement.     

The role of ethics in experimental marine biology and ecology

Although most countries have ethical guidelines for research involving human subjects and other sentient animals, the ethical issues associated with field research have received little attention. Most experimental marine biologists and ecologists operate without ethical guidelines or scrutiny, despite intermittent community concern about their activities. We offer suggestions on how marine biologists and ecologists can protect the future of research involving the field collection and experimental manipulation of organisms by developing mechanisms to address community concerns that such research is ethically responsible. We urge experimental marine biologists and ecologists to take pre-emptive initiatives by encouraging: (1) institutional animal ethics committees to broaden their terms of reference to include environmental ethics; (2) scientific societies to develop codes of ethics to guide the environmental research conducted by their members; (3) editorial boards of journals to require the research they publish to conform to an appropriate code of ethics, and (4) management agencies that issue permits for field research to establish an ethics committee to advise them on the ethical issues raised by specific research proposals. We conclude that the resultant administrative burden on scientists would be low but that the penalties of operating without such protection can be high.     

Risky research and bystander consent

There is no quick and easy answer to the question whether research activities that endanger bystanders without their consent ever thereby violate those bystanders’ rights. We cannot dismiss the idea that bystanders possess strong rights against researchers simply on the grounds that they are, after all, merely bystanders. Indeed, it is easy to imagine scenarios in which researchers would be morally required to gain the informed consent of bystanders whom they risk harming. Whether bystander consent is required in any particular real-world case will depend, in part, upon exactly how the research activity endangers them.     

Community Members' Engagement with and Involvement in Genomic Research: Lessons to Learn from the Field

In this paper, we describe the potential role laypersons on ethics committees can play in ensuring community concerns are addressed in the design and implementation of genomic research. We draw inferences from the outcome of an empirical study of the impact of training of laypersons to address community engagement issues in ethics review of research protocol. While this paper does not advocate a particular solution, it describes the importance of community engagement in genomic research, the current limitations there are in engaging communities in the design of these research projects and how communities can be indirectly engaged in the design and implementation of genomic research through the engagement of laypersons on ethics committees. However, to ensure that these laypersons can play this role, their capacity needs to be built to play this role appropriately. There is evidence to show that where resources are invested in building the capacity of laypersons to play their role as community ‘watchdogs’ in research, they play this role aptly. Community engagement is important in genomic research as genomic researchers will increasingly require community perspectives in critical ethics decision making.     

Ethical challenges at the science-policy interface: an ethical risk assessment and proposition of an ethical infrastructure

Developing an interface between knowledge holders, stakeholders and decision makers on biodiversity issues, just as any science-policy interface, will face many challenges. In the crucial endeavour to tackle all those challenges, determining an ethical course of actions will be essential to the prestige and credibility of such an interface. The paper identifies and assesses potential ethical risks that may arise in interactions between science, society and policy and uses the Network of Knowledge (NoK) process as an example to show how an ethical infrastructure could be developed for minimizing the ethical risks and their potential consequences. Indeed, when various actors from different spheres (politics, academia, lobbyism, media, etc.) are called upon to interact within one process as complex as the NoK, the integrity and credibility of the latter are at high risk of being compromised if the ethical risks are not adequately addressed. In order to limit those risks, which science-policy interfaces such as IPCC and IPBES have already encountered, we propose to set up an ethical governance infrastructure that will guide (and regulate) interactions among internal actors of the NoK (knowledge coordination body, secretariat, expert working groups, etc.) as well as with external actors (requesters, stakeholders, etc.). A thorough evaluation of the interaction between the actors for every step of the process is carried out and potential ethical risks are identified. Suggestions as to how the risks can be handled and prevented are presented and integrated as part of an ethical infrastructure. The main objective of the paper is to address how a science-policy interface and the scientific community as a whole would benefit from implementing ethical measures and instruments to help prevent sensitive issues and undesired consequences undermining credibility and legitimacy.     

The sequential analysis of aggressive acts during hierarchy formation: an application of the ‘jigsaw puzzle’ approach

The ‘jigsaw puzzle’ approach is a general method for investigating how interactions among individuals cumulate to form the overall patterns of dominance behaviour in groups. Here, the model is used to discover how aggressive interactions between pairs of individuals modify subsequent interactions with bystanders or third parties. The model indicates that four sequences of successive, aggressive acts are possible in component triads of larger groups: two ensure transitive attack relationships and two can lead to either transitive or intransitive relationships. An application of the model to 14 groups of four hens demonstrates that the two sequences guaranteeing transitivity make up 77% of all sequences. More specifically, hens attacking one group member usually go on to attack a second member, and hens receiving one attack frequently receive a second attack from a bystander. In contrast, an attacked hen rarely ‘redirects’ an attack to a bystander, and a bystander rarely attacks a group member who has just attacked another individual. The application of the jigsaw puzzle approach to aggressive sequences in other species is discussed. Data available for several primate species corroborate the findings in hens and provide support for the method as a general tool for investigating the proximate mechanisms of hierarchy formation.     

Functions of post‐conflict affiliation with a bystander differ between aggressors and victims in Japanese macaques

Post‐conflict affiliative interactions with a bystander, an uninvolved third party, have been reported in several species. The functions of these interactions could vary depending on whether the individual was an aggressor or a victim in a conflict. We examined the occurrence of and three potential functions for bystander affiliation—substitute for reconciliation, self‐protection and consolation (stress reduction)—in a free‐ranging group of Japanese macaques. We predicted that in this despotic species, the function of bystander affiliations for victims was self‐protection, whereas this was not so for aggressors. We found that compared to control situations, both aggressors and victims engaged in bystander affiliation soon after a conflict, confirming the occurrence of bystander affiliation. Victims were less likely to receive further aggression when bystander affiliation occurred than when no such interaction occurred, consistent with the explanation that post‐conflict bystander affiliation functions as self‐protection for victims. Aggressors were less likely to perform self‐scratching, an indicator of post‐conflict stress, when bystander affiliation occurred. This suggests that such affiliations benefited aggressors by reducing stress. Self‐scratching was not less frequent after affiliation with a bystander who was familiar with the former opponent, indicating that substitute reconciliation did not apply for either aggressors or victims. When bystander affiliation occurred, the bystander was a more familiar individual for aggressors and victims than the former opponent was. In conclusion, aggressors benefited in stress reduction, whereas victims benefited in self‐protection through affiliation with bystanders with whom they have a good relationship. Our study indicated that monkeys cope with post‐conflict problems according to their roles or situations not only by reconciliation but also by bystander affiliation.     

Ethical considerations in fish research

Fishes are used in a wide range of scientific studies, from conservation research with potential benefits to the species used to biomedical research with potential human benefits. Fish research can take place in both laboratories and field environments and methods used represent a continuum from non-invasive observations, handling, through to experimental manipulation. While some countries have legislation or guidance regarding the use of fish in research, many do not and there exists a diversity of scientific opinions on the sentience of fish and how we determine welfare. Nevertheless, there is a growing pressure on the scientific community to take more responsibility for the animals they work with through maximising the benefits of their research to humans or animals while minimising welfare or survival costs to their study animals. In this review, we focus primarily on the refinement of common methods used in fish research based on emerging knowledge with the aim of improving the welfare of fish used in scientific studies. We consider the use of anaesthetics and analgesics and how we mark individuals for identification purposes. We highlight the main ethical concerns facing researchers in both laboratory and field environments and identify areas that need urgent future research. We hope that this review will help inform those who wish to refine their ethical practices and stimulate thought among fish researchers for further avenues of refinement. Improved ethics and welfare of fishes will inevitably lead to increased scientific rigour and is in the best interests of both fishes and scientists.     

Developing the ethics of implementation research in health

Implementation research (IR) is growing in recognition as an important generator of practical knowledge that can be translated into health policy. With its aim to answer questions about how to improve access to interventions that have been shown to work but have not reached many of the people who could benefit from them, IR involves a range of particular ethical considerations that have not yet been comprehensively covered in international guidelines on health research ethics. The fundamental ethical principles governing clinical research apply equally in IR, but the application of these principles may differ depending on the IR question, context, and the nature of the proposed intervention. IR questions cover a broad range of topics that focus on improving health system functioning and improving equitable and just access to effective health care interventions. As such, IR designs are flexible and often innovative, and ethical principles cannot simply be extrapolated from their applications in clinical research. Meaningful engagement with all stakeholders including communities and research participants is a fundamental ethical requirement that cuts across all study phases of IR and links most ethical concerns. Careful modification of the informed consent process may be required in IR to permit study of a needed intervention. The risks associated with IR may be difficult to anticipate and may be very context-specific. The benefits of IR may not accrue to the same groups who participate in the research, therefore justifying the risks versus benefits of IR may be ethically challenging. The expectation that knowledge generated through IR should be rapidly translated into health policy and practice necessitates up-front commitments from decision-makers to sustainability and scalability of effective interventions. Greater awareness of the particular ethical implications of the features of IR is urgently needed to facilitate optimal ethical conduct of IR and uniform ethical review.     

Receiving post-conflict affiliation from the enemy's friend reconciles former opponents

The adaptive function of bystander initiated post-conflict affiliation (also: consolation & appeasement) has been debated for 30 years. Three influential hypotheses compete for the most likely explanation but have not previously been tested with a single data set. The consolation hypothesis argues that bystander affiliation calms the victim and reduces their stress levels. The self-protection hypothesis proposes that a bystander offers affiliation to either opponent to protect himself from redirected aggression by this individual. The relationship-repair hypothesis suggests a bystander can substitute for a friend to reconcile the friend with the friend''s former opponent. Here, we contrast all three hypotheses and tested their predictions with data on wild chimpanzees (Pan troglodytes verus) of the Taï National Park, Côte d''Ivoire. We examined the first and second post-conflict interactions with respect to both the dyadic and triadic relationships between the bystander and the two opponents. Results showed that female bystanders offered affiliation to their aggressor friends and the victims of their friends, while male bystanders offered affiliation to their victim friends and the aggressors of their friends. For both sexes, bystander affiliation resulted in a subsequent interaction pattern that is expected for direct reconciliation. Bystander affiliation offered to the opponent''s friend was more likely to lead to affiliation among opponents in their subsequent interaction. Also, tolerance levels among former opponents were reset to normal levels. In conclusion, this study provides strong evidence for the relationship-repair hypothesis, moderate evidence for the consolation hypothesis and no evidence for the self-protection hypothesis. Furthermore, that bystanders can repair a relationship on behalf of their friend indicates that recipient chimpanzees are aware of the relationships between others, even when they are not kin. This presents a mechanism through which chimpanzees may gain benefits from social knowledge.     

Bystanders,risks, and consent

This paper considers the moral status of bystanders affected by medical research trials. Recent proposals advocate a very low threshold of permissible risk imposition upon bystanders that is insensitive to the prospective benefits of the trial, in part because we typically lack bystanders' consent. I argue that the correct threshold of permissible risk will be sensitive to the prospective gains of the trial. I further argue that one does not always need a person's consent to expose her to significant risks of even serious harm for the sake of others. That we typically need the consent of participants is explained by the fact that trials risk harmfully using participants, which is very hard to justify without consent. Bystanders, in contrast, are harmed as a side-effect, which is easier to justify. I then consider whether the degree of risk that a trial may impose on a bystander is sensitive to whether she is a prospective beneficiary of that trial.     

Progress and opportunities in advancing near-term forecasting of freshwater quality

Near-term freshwater forecasts, defined as sub-daily to decadal future predictions of a freshwater variable with quantified uncertainty, are urgently needed to improve water quality management as freshwater ecosystems exhibit greater variability due to global change. Shifting baselines in freshwater ecosystems due to land use and climate change prevent managers from relying on historical averages for predicting future conditions, necessitating near-term forecasts to mitigate freshwater risks to human health and safety (e.g., flash floods, harmful algal blooms) and ecosystem services (e.g., water-related recreation and tourism). To assess the current state of freshwater forecasting and identify opportunities for future progress, we synthesized freshwater forecasting papers published in the past 5 years. We found that freshwater forecasting is currently dominated by near-term forecasts of water quantity and that near-term water quality forecasts are fewer in number and in the early stages of development (i.e., non-operational) despite their potential as important preemptive decision support tools. We contend that more freshwater quality forecasts are critically needed and that near-term water quality forecasting is poised to make substantial advances based on examples of recent progress in forecasting methodology, workflows, and end-user engagement. For example, current water quality forecasting systems can predict water temperature, dissolved oxygen, and algal bloom/toxin events 5 days ahead with reasonable accuracy. Continued progress in freshwater quality forecasting will be greatly accelerated by adapting tools and approaches from freshwater quantity forecasting (e.g., machine learning modeling methods). In addition, future development of effective operational freshwater quality forecasts will require substantive engagement of end users throughout the forecast process, funding, and training opportunities. Looking ahead, near-term forecasting provides a hopeful future for freshwater management in the face of increased variability and risk due to global change, and we encourage the freshwater scientific community to incorporate forecasting approaches in water quality research and management.     

Ectogestation ethics: The implications of artificially extending gestation for viability,newborn resuscitation and abortion

Recent animal research suggests that it may soon be possible to support the human fetus in an artificial uterine environment for part of a pregnancy. A technique of extending gestation in this way (“ectogestation”) could be offered to parents of extremely premature infants (EPIs) to improve outcomes for their child. The use of artificial uteruses for ectogestation could generate ethical questions because of the technology’s potential impact on the point of “viability”—loosely defined as the stage of pregnancy beyond which the fetus may survive external to the womb. Several medical decisions during the perinatal period are based on the gestation at which infants are considered viable, for example decisions about newborn resuscitation and abortion, and ectogestation has the potential to impact on these. Despite these possible implications, there is little existing evidence or analysis of how this technology would affect medical practice. In this paper, we combine empirical data with ethical analysis. We report a survey of 91 practicing Australian obstetricians and neonatologists; we aimed to assess their conceptual understanding of “viability,” and what ethical consequences they envisage arising from improved survival of EPIs. We also assess what the ethical implications of extending gestation should be for newborn and obstetric care. We analyze the concept of viability and argue that while ectogestation might have implications for the permissibility of neonatal life-prolonging treatment at extremely early gestation, it should not necessarily have implications for abortion policy. We compare our ethical findings with the results of the survey.