archy

Bad ideas in medical research
A new report by the Institute of Medicine of the National Academies of Science recommends relaxing the rules for medical research on prisoners. Looking at that story in the paper yesterday, my Clever Wife read me the headline, "Panel Suggests Using Inmates in Drug Trials." My immediate reaction was, "reword it to 'Panel Suggests Using Prisoners in Medical Experimentation' and see what reaction you get."

If my rewording brings to mind thoughts of Mengele or the Tuskeegee institute, that's good. It should. Medical research on captive and powerless groups was horribly abused in the last century. I would much rather we be over cautious on this particular ethical question that allow those kind of crimes to continue.

There is no philisophical reason why using prisoners should be different from using any other group, say grad students or soldiers. From the researchers' point of view there are some special advantages in using prisoners, all of which relate to control and observation. With prisoners it is easy to know what they ate, when they slept, and how much they exercised. A prisoner isn't going to complicate things by taing a vacation and suddenly changing his habits for ten days. However, the very things that make a prisoner an ideal practical subject make them an unacceptable ethical risk.

The ethical problem rests on the question of coercion. In any kind of human medical trials, the experimental subjects must be fully informed going in and free to back out at any time. I can see no way to guarentee that the choice made by someone in a totally coercive environment, like a prison, is ever completely free. Lindsay Bayerstein explains the issues in detail:

Even if there are no explicit incentives to participate, inmates may still interpret a request to participate as an implied order. It is unethical to create a situation in which prisoners may sign on to a risky research project out of fear of reprisal (well-founded, or not). Prisoners often lack access to basic medical care and may be pressured into accepting experimental treatments because they can't obtain standard medical care.

Then there's the thorny issue of payment. On the one hand, free research subjects are frequently paid for their participation. If free subjects are getting paid, prisoners deserve the going rate. However, paying prisoners raises its own ethical complications. Risky medical experiments might be disproportionately attractive to people who have no other opportunities to make money.

Unlike children, prisoners are social outcasts. The institutional review board is not a loving parent who weighs the costs and benefits for individuals. Even the most thorough and conscientious committee would be making calculations on behalf large numbers of strangers from a marginalized group. The decisions of the review boards may be colored by society's disdain for prisoners. I doubt these committees will be as solicitous of the well-being of inmates as individual parents are about the welfare of their sick children.

Currently, prisoners do participate in low risk drug trials. Until we can completely guarentee a system of ethical safeguards for the prisoners' basic human rights and individual interests, we should not move into riskier areas of research. And, to repeat myself, I don't see how we can make that guarentee.

Other blogs are also discussing this.