1. Informed Consent Ethics Forum 2012
Duquesne University
Thomas Goehring, Leah Gottlieb, Andrew Glaid, Sebastien Hebert, David George
Mentor: Dr. Mike Cascio

2. Issues Dealing with Implicit vs. Explicit Informed Consent Violations
Effectiveness of some tests demand providing a lack of information
Vaccines and placebos
If tests can have negative side effects should full and absolute information be given?
Is there a way to remove underlying fears/concerns which may influence autonomy in testing?

3. The Milgram Experiment
Stanley Milgram: Social Psychologist from Yale University
Experiment started in 1960s after Nazi war crime trials
Lenient on rules of experimentation
Experiment of obedience
Why good people do bad things
Do they obey out of fear or to appeal to higher powers?

4. The Test
Test subjects came from various classes and various occupations
Hired for about 4 dollars an hour
Subjects were told that they would be part of a study that would test punishment on learning ability

5. The Test
The subject and an actor decided which was to be the teacher and the learner
Fixed coin flip
Teacher receives test shock
Teacher asks learner a series of questions
A wrong answer leads to the learner being shocked, with each at a progressively higher voltage.
Learner would complain, yell, plead, etc. at higher shocks

6. The Test
At a certain point, teacher would hesitate to shock the learner
Experimenter would pressure teacher
If it happens four times, the experiment is halted
Only actual shock was given at test shock
Actor/Learner would give realistic screams and play tape recordings when “shocked”

7. General Considerations
One should have a true understanding of testing, treatments, and the liability of medical professionals
One should consider the validity of the results if participants are given too much information

8. Balancing Complexity, Length, and Information
Clear need to inform patients of risks/concerns and nature of procedures, regardless of type of procedure
Testing or vaccine trials
Many forms are lengthy and can be troublesome in countries with high illiteracy rates
Difficult to allow full autonomy of patients with complicated but necessary language
Shortening and simplification can lead to confusion or malpractice suits in the form of inadequate information

9. Effectiveness of Treatments
If a patient is given too much or too little information, results of testing may vary
Placebo effect (or nocebo effect) may occur
If patient is informed that they are not given the drug, they may leave study and greatly skew results
Should tests and consent forms clearly deny patients knowledge of a specific nature (placebo or treatment)?

10. HIV testing on women in a South African hospital (1998 study)
Many participants felt compelled to participate despite being reminded that the tests were voluntary
88% of participants wanted to know their HIV status, which contrasts to other countries where participants did not want to know their status
Patients, after entering, felt compelled to remain in the study

11. Results of Study Many participants worried about partners vs.
Relatively few participants worried about compromised job status
Many participants entered the study voluntarily vs.
Few participants felt they would be allowed to leave the study
These results raise the question of how effective informed consent was in this study

12. Circumstances of the Cases
Milgram: Nuremberg Trials, “only following orders”
Fully informing participants would have compromised experimental results
HIV: Differing backgrounds impact a person’s ability to understand short- and long-term implications.
Ex. What if the disease is not cured?

13. Breach of Ethical Issues and Values in the Milgram Case
Deception of participants resulted in duress “In a large number of cases the degree of tension [in the participants] reached extremes that are rarely seen in sociopsychological laboratory studies. Subjects were observed to sweat, tremble, stutter, bite their lips, groan, and dig their fingernails into their flesh. These were characteristic rather than exceptional responses to the experiment.”
Results of the study: A majority of participants continued with the experiment despite their own protests

14. Breach of Ethical Issues and Values in the HIV Research Case
Evaluation of the extent of informed consent
Perceived inability to abort participation
“…patients relinquished autonomy to professionals in the expectation of competence.”
Perceived loss of jobs upon positive diagnosis
Pre-Counseling: 93%
Post-Counseling: 39%
Results indicate that patients must be given clear counseling to understand their participation and treatment.
A lack of participation will not compromise the health care provided to them

15. Consequences and Outcomes
Milgram Experiment
HIV Testing

16. Milgram Experiment’s Consequences and Outcomes
People had to live with emotional scarring
Some even fainted or fell into fits of laughter
Believed to be do to anxiety from taking part in experiment
Milgram claimed that many enjoyed the experience
Milgram’s acceptance into the American Psychological Association was put on hold for a year

17. Consequences and Outcomes of Milgram Case
Later found to not be in violation of ethics
Study would need to be very useful to science and/or the general public and could only work if participants were not informed of what was going on
Participants who were emotionally damaged by the study suffered greatly
Tougher restrictions on ethical guidelines
tougher restrictions on experimental types
Prevention of similar experiments and science loses the ability to come to striking conclusions.
Studies are less objective

18. Consequences and Outcomes of the HIV Case
Permanency of HIV results on medical records
Give up autonomy for confidence in physicians’ abilities to provide treatment
Knowledge that medical practitioners know
Patients expect better care and feel protected by hospital staff
Concern with third parties finding out about medical records
Ex. insurance companies
Patients feel their jobs are at risk if they are HIV positive
By giving up autonomy and consent to HIV testing without actually wanting the treatment, patients can suffer a conflict of interest
Patients perceive that they have other options

19. Suggestions for Milgram Experiment
Peer-review of Milgram’s experimental design and form an opinion of the risks their colleagues’ research would cause on the subjects
Weighing of results’ importance against the potential damage to the subjects themselves
Only minimal harm should have been allowed
If risks were too great, then Milgram should have been denied permission to conduct his experiment

20. Milgram’s Legacy
Can be argued as for the greater good, or a unnecessary breach of ethical code
Helped prove the importance of ethics committees
Think about patient before thinking of the potential results
During Milgram’s time researchers often thought of ascertaining results before the welfare of the people participating in the studies
Attitude of the Nazi and Japanese scientists during WWII

21. Why know about Milgram’s legacy?
The general public would benefit from the information
Those greatest affected by ethics violations are typically those who are most uninformed
People may wonder what they are agreeing or how much their physician didn’t tell them before a procedure
With more information, patients can feel more at ease
Doctors can feel more comfortable knowing his patient is fully aware of his or her decision
Prevents possible lawsuits

22. HIV/AIDS Testing In Developed Nations
Negative stigma associated with AIDS
Testing should be done as discretely as possible
Results should go to the personal physician and patient only
Prevents information leaks
AIDS clinical trials: patients should be given all the information possible without complicated jargon or frightening them
Some AIDS treatments are known to have potentially serious consequences that should be addressed with each patient.
Without persuasion or coercion of any kind, patient must decide whether he or she will receive treatment
Patients can drop out of the study at any point in time without negative consequences

23. HIV/AIDS Testing In Undeveloped Nations
Doctors may not have the time or resources to spend going over long informed consent legal documents
Illiteracy, poor understanding, and language barriers often prove to be challenging obstacles for physicians
Despite a lack of options, patients should still have the right to refuse treatment
Prior to treatment, patients must have a firm grasp of the procedure
Including its possible consequences

24. HIV/AIDS currently HIV/AIDS is still a incurable disease
The negative association with AIDS makes informed consent and HIPPA laws even more necessary when it comes to testing and treatment
The possible side-effects of HIV/AIDS treatments teach society that one is allowed to either refuse the doctors recommended treatment or drop out a study without negative consequences

25. Sources
Banyard, Phillip. “The Case Against Milgram.” The Open University, 2012
Billikopf , Gregorio. “Milgram’s Experiment on Obedience to Authority.” Encina University of California Web.
Herrera, C. D. (2001), Ethics, Deception, and ‘Those Milgram Experiments’. Journal of Applied Philosophy, 18: 245–256. doi:  /
Karim QA, Karim SSA, Coovadia HM, Susser M. Informed consent for HIV testing in a South African hospital: is it truly informed and truly voluntary? Am J Pub Health 1998; 88: 637–40.
Veatch, Robert M. “The Basics of Bioethics.” Upper Saddle River, NJ: Pearson Education, Print.

26. Discussion Points What is the difference between morality and ethics?
How would you balance informed consent?
Are there cases where informed consent are absolutely necessary and results would not be influenced?