The Belmont Report: What is it and how does it relate to today’s clinical trials?
The quest to discover effective treatments and cures for diseases and conditions is a worthwhile and compelling goal. Scientific research is responsible for innovative breakthroughs that improve quality of life, extend survival, and even prove life-saving. But alongside the potential benefits of scientific research are the potential risks to the people who participate in the journey that makes breakthroughs possible. The Belmont Report identifies basic ethical principles for conducting research that involve human subjects and sets forth guidelines to assure these principles are followed throughout the research process. The Belmont Report is the result of over four years of meetings that began in 1976 and were conducted by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (Commission). With the Food and Drug Reauthorization Act of 2017’s recent amendment of the term patient experience data to now include both “physical and psychosocial impacts of a disease or condition, or related therapy or clinical investigation,” it is a particularly relevant and important time to revisit the ethical principles established in the Belmont Report.
History of the Belmont Report
The need for ethical principles first arose as a result of the reported atrocities inflicted on human subjects during World War II. During the Nuremberg War Crime Trials, the Nuremberg Code was drafted that set forth standards used to judge physicians and scientists who conducted biomedical experiments on concentration camp prisoners. The Nuremberg Code set the example for subsequent codes that established rules to help protect human subjects involved in research. But these rules were found to be inadequate to cover complex situations, at times in conflict, and frequently difficult to interpret or apply. The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Research (Bethesda, Md.) The Commission, 1978. To avoid the limitations of these past codes, the Belmont Report was deliberately broader and established three basic ethical principles: 1) respect for persons, 2) beneficence, and 3) justice.
The Three Basic Ethical Principles and Their Applicability to Clinical Trials
The first ethical principle in the Belmont Report, respect for persons, is made up of two important, but distinct, requirements. The first is the recognition that people are autonomous and entitled to their own opinions and choices, unless detrimental to others. The second is the recognition that due to various reasons, not all people are capable of self-determination and instead require protection. The amount of protection provided to an individual should depend on the risk of harm and the likelihood of benefit offered by the research. The Report promotes the idea that in most cases, respect for persons demands that people enter into research voluntarily and with adequate information.
The Report’s second ethical principle, beneficence, is the recognition that people are treated in an ethical manner not only by respecting their decisions and protecting them from harm, but also by making efforts, or, more specifically, making it an obligation, to secure their well-being. The Belmont Report identifies two general and complementary rules regarding beneficence: 1) do not harm, and 2) maximize possible benefits and minimize possible harms. While the obligation to “do no harm” is often the focus of discussions, the obligation to maximize possible benefits, while minimizing possible harms, is an obligation that warrants equal consideration. The Report notes that it is the obligation of scientific investigators and members of their institutions to think about both maximizing benefits and reducing risks in their research. Also discussed is the obligation of society at large to recognize longer term benefits and risks that may result from the improvement of knowledge and development of novel medical, psychotherapeutic, and social procedures. These obligations closely align with the Cancer Support Community’s belief that in order to maximize the benefits and minimize the risks of clinical trials, both physical data and patient experience data should be required to be collected as part of the research.
The last of the Belmont Report’s three basic ethical principles, justice, raises questions about who ought to receive the benefits of research and who ought to bear its burdens. Following a provocative discussion of equality and differential treatment, the Belmont Report considers the need to scrutinize whether some classes of people - economically disadvantaged, racial and ethnic minorities, or persons confined to institutions - are systematically selected as research subjects due to their position or vulnerability rather than their connection to the problem being researched. Today, the principle of justice may demand scrutiny of whether classes of people considered compromised or vulnerable are excluded from participation in clinical trials due to financial and other barriers even though they have a connection to the problem being considered. The Report states that justice demands therapeutic devices and procedures developed from public funds must not provide advantages only to those who can afford them.
Though approximately forty years have passed since the 1979 publication of the Belmont Report, the three basic ethical principles identified and set forth as guidelines for the conduct of biomedical and behavioral research involving human subjects - respect for persons, beneficence, and justice - remain particularly relevant and necessary for today’s clinical trials.
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