title: A theoretical framework for early human studies: uncertainty, intervention ensembles, and boundaries.
abstract: Clinical development of novel therapeutics begins with a coordinated sequence of early phase clinical trials. Such early human studies confront a series of methodological and ethical challenges. In what follows, I propose a theoretical framework for early human studies aimed at informing the negotiation of these challenges. At the outset of clinical development, researchers confront a virtually undifferentiated landscape of uncertainty with respect to three variables: outcomes, their probability of occurrence, and operation dimensions needed to effectuate favorable outcomes. Early human trials transform this uncertain landscape into one where there are grounds for belief about risk and benefit for various combined operation dimensions. To accomplish this, studies set out with two aims. First, they identify a set of operation dimensions that, when combined as a package (intervention ensemble), elicits a reasonable probability of a target outcome. Second, they define the boundaries of dimension values within an intervention ensemble. This latter aim entails exposing at least some volunteers in early studies to treatments that are inactive or excessive. I provide examples that illustrate the way early human studies discover and delimit intervention ensembles, and close by offering some implications of this framework for ethics, methodology, and efficiency in clinical development of new interventions.
authors.affiliation: Biomedical Ethics Unit/Experimental Medicine, McGill University, 3647 Peel Street, Montreal, QB H3A 1X1, Canada. jonathan.kimmelman@mcgill.ca
authors.forename: Jonathan
authors.initials: J
authors.lastname: Kimmelman
mesh_terms: D002986:Clinical Trials as Topic / Q000145:classification / Q000379:methods*; D064420:Drug-Related Side Effects and Adverse Reactions; D023381:Endpoint Determination; D006801:Humans; D008962:Models, Theoretical; D061214:Patient Safety; D018579:Patient Selection; D012107:Research Design; D018570:Risk Assessment; D009626:Terminology as Topic; D016896:Treatment Outcome; D035501:Uncertainty