Moral Entanglements

The Ancillary-Care Obligations of Medical Researchers

Henry S. Richardson

Explores a neglected topic in medical research ethics

Moral Entanglements

The Ancillary-Care Obligations of Medical Researchers

Henry S. Richardson

Description

The philosopher Henry Richardson's short book is a defense of a position on a neglected topic in medical research ethics. Clinical research ethics has been a longstanding area of study, dating back to the aftermath of the Nazi death-camp doctors and the Tuskegee syphilis study. Most ethical regulations and institutions (such as Institutiional Review Boards) have developed in response to those past abuses, including the stress on obtaining informed consent from the subject. Richardson points out that that these ethical regulations do not address one of the key dilemmas faced by medical researchers -- whether or not they have obligations towards subjects who need care not directly related to the purpose of the study, termed "ancillary care obligations." Does a researcher testing an HIV vaccine in Africa have an obligation to provide anti-retrovirals to those who become HIV positive during the trial? Should a researcher studying a volunteer's brain scan, who sees a possible tumor, do more than simply refer him or her to a specialist? While most would agree that some special obligation does exist in these cases, what is the basis of this obligation, and what are its limits? Richardson's analysis of those key questions and the development of his own position are at the heart of this book, which will appeal to bioethicists studying research ethics, to policy makers, and to political and moral philosophers interested in the obligations of beneficence, one of the key issues in moral theory.

" 'Philosophy recovers itself,' wrote John Dewey, 'when it ceases to be a device for dealing with the problems of philosophers and becomes a method, cultivated by philosophers, for dealing with the problems of men.' Henry Richardson confronts a problem in the ethics of medical research that is often (as his many real-life examples show) a matter of life and death. The problem is unexplored and quite difficult: Richardson finds he must craft new theory to deal with it. The theory he creates shows how we become morally entangled with others without intending to, as we enter into intimacies with them. This theory of moral entanglement is a genuine discovery in philosophy, with application across a wide range of human relationships. Since the theory was designed for medical researchers it also provides a bespoke ethical framework, as well as specific guidance, for researchers in the field. This book shows practical philosophy at its best: inspired by real problems, responding with powerful solutions." -- Leif Wenar, Chair of Ethics, King's College London

"A medical researcher investigating transmission of malaria may find that a subject has another disease. Does the researcher have an obligation to devote some of the team's resources to treating this disease? The traditional principles of research ethics do not ask much less answer this important question. In this theoretically and practically rich book, Henry Richardson seeks to provide an answer and to identify issues that need further exploration. He argues that "ancillary care obligations" are explained by "moral entanglement" and cannot be justified by traditional principles of justice or the duty to rescue. He is admirably soft-hearted and tough-minded in combining his long demonstrated philosophical acuity with a deep knowledge of the problems on the ground. Richardson's book is characterized by great generosity towards those who need help, towards the problems faced by researchers, and towards the scholarly community - even those with whom he disagrees." - Alan Wertheimer, Senior Research Scholar, Department of Bioethics, National Institutes of Health

"In this important book, Henry Richardson sculpts a new path for research ethics, one that focuses on ethical obligations of ancillary-care in clinical trials and medical research, particularly in developing countries, but with relevance throughout the world. In Moral Entanglements, Richardson extends the reach of his analysis both deep within and outside the research itself, recognizing the broader moral backdrop relevant for society-wide judgments of justice, and the special relationships that exist within the medical research context, about what is or is not owed research participants in situations of medical need. Rather than leave such important decisions up to the vagaries of politics or ad hoc assessments, this book sets out a comprehensive theoretical framework with principles to guide such decisions in the everyday lives of both medical researchers and research participants. This book significantly contributes to the ethics of ancillary-care in medical and public health research and judiciously enlightens questions and potential resolutions to these vital global and domestic problems." - Jennifer Prah Ruger, Associate Professor, Yale Schools of Public Health and Medicine

Moral Entanglements

The Ancillary-Care Obligations of Medical Researchers

Henry S. Richardson

Preface
Chapter 1: Medical Researchers' Ancillary-Care Obligations:
A Perplexing Issue
Ancillary-Care Obligations and the Distinctive Ancillary-Care Obligation
Chapter 2: Special Ancillary-Care Obligations: The Partial-Entrustment Model
The Existing Lack of Guidance
Scope: Partial Entrustment of Aspects of Health
The Variable Strength of Ancillary-Care Claims
Combining the Tests of Scope and Strength
Controversy Surrounding the Scope Requirement
Chapter 3: The Moral Basis of the Partial Entrustment
A Range of Intimacies
The Duty to Warn
Autonomy-Centered Reasons for Privacy Rights
Ancillary Duties of Care
Why Those Accepting Privacy Waivers Take on Special Responsibilities
How the Duty to Warn Blocks Maintaining a Tactful Silence
How the Duty to Warn Indirectly Supports Tactful Engagement
How the Duty of Tactful Engagement Provides a Focus for Beneficence
Returning to the Context of Medical Research
Potential Rival Accounts: Vulnerability and Threat Avoidance
Chapter 4: Justice, Exploitation, and Ancillary Care
Why Special Ancillary-Care Obligations Cannot Rest on Justice
Will Providing Ancillary Care Conflict with Justice?
Justice Reinforcing Ancillary-Care Claims
Chapter 5: Limits on the Waiver of Ancillary-Care Obligations
The Difficulty of Annulling Ancillary-Care Claims
Moral Constraints on Soliciting Waivers of Ancillary-Care Claims
Chapter 6: Gradations of Ancillary-Care Responsibility
Within the Scope: Minimally, Clearly, or Centrally?
Variations in the Expectable Depth of the Researcher-Participant Relationship
Variation in Relative Cost
Putting These Factors Together
Conclusion
Chapter 7: Issues for Further Exploration
Needed Conceptual Work
What Does It Mean To Provide Ancillary Care?
Who Are the Researchers?
Who Are What are some of the important boundaries of What if ancillary non-medical problems are encountered?
Needed Empirical Work
Chapter 8: Philosophical Implications and Practical Steps
Philosophical Implications
Practical Steps
References

Tables
Table 1: General and Special Grounds of Ancillary-Care Obligations
Table 2: Functions of Obtaining Informed Consent

Figures
Figure 1: The Partial-Entrustment Model's Two Tests
Figure 2: The Elements Generating Privacy-Based Moral Entanglements
Figure 3: Privacy-Based Moral Entanglements: Putting the Pieces Together
Figure 4: Four Grades of Ancillary-Care Obligation for ART Provision

Cases
Advanced Cervical Cancer in a HIV-transmission Study
Brain Scans
Grimes v. the Kennedy Krieger Institute
Juba
Malaria Researchers and Schistosomiasis
N's Seatmate's Pills
Quinodyne
The Massage Therapist and the Mole
the Nepal Newborn Washing Study
The Old Man and the Groceries
The Participant's Feverish Child
The Reporter and the Peasant
The Tax Accountant and the Gambling Addict
Transfusion for a Jehovah's Witness
Welts

Moral Entanglements

The Ancillary-Care Obligations of Medical Researchers

Henry S. Richardson

Author Information

Professor of Philosophy, Georgetown University. Author of DEMOCRATIC AUTONOMY (OUP 2003)

Moral Entanglements

The Ancillary-Care Obligations of Medical Researchers

Henry S. Richardson

Reviews and Awards

"Henry Richardson has the rare talent of digging deep theoretically, while being attentive to contextual complexities and constraints of practice. For a decade he has been exploring the moral landscape of medical researchers' ancillary care responsibilities. This inquiry has yielded a carefully crafted and rigorously argued book. Through comprehensively examining ancillary care obligations, Richardson illuminates the neglected phenomenon of moral entanglements that arise in professional encounters, and in ordinary life, when privacy rights are waived. Reading his book will reward all those interested in the ethics of clinical research, professional ethics, and moral philosophy." -Franklin G. Miller, Ph.D., Department of Bioethics, National Institutes of Health

"In this wonderful book-distinguished by very careful philosophical analysis and real-world examples-Henry Richardson elaborates the "partial-entrustment" model he and Leah Belsky first advanced a decade ago regarding researchers' obligations to provide care that is ancillary to the purposes of their research projects. He situates this model in a broader set of "entanglements" that will feel very familiar to any person who has engaged not only in medical research but in any complex inter-personal interaction that isn't cabined by the four corners of an explicit contract. Everyone with an interest in biomedical research and research ethics should read this book: they will profit both from recognizing the pervasive issues on which it shines a bright light and from its thoughtful and nuanced responses." - Alexander M. Capron, University Professor, University of Southern California & Former Director, Ethics, Trade, Human Rights and Health Law, WHO

"This book sets out the most comprehensive framework to date for delineating the special responsibilities of researchers to address healthcare needs encountered in research in low-resource settings. By asserting that when particular moral conditions can be met, researchers have obligations to take demanding steps to address entrusted conditions, the account in this book provides decision-makers at the coalface with a clear focus. The author also clearly sets out how this framework relates to previous conceptual contributions to the contested area of 'ancillary care' obligations in research." - Catherine Slack, HIV AIDS Vaccines Ethics Group, South African AIDS Vaccines Initiative, South Africa

"As the author notes in his conclusion, the 'practical neglect of the issue of ancillary care seems to have been accompanied by a widely shared theoretical blind spot.' But Richardson has remedied that error of omission and left us with a fine volume that will be a touchstone for future scholarship and regulation. It is an inspired and highly readable analysis." -- Notre Dame Philosophical Reviews

"Moral Entanglements repays close study and sets a fine example of the kind of work to which normative ethics should aspire: engaged, relevant, philosophically rich, and insightful." -- Ethics