title: Strengths and weaknesses of guideline approaches to safeguard voluntary informed consent of patients within a dependent relationship.
abstract: BACKGROUND
  It is thought that a dependent relationship between patients and physicians who enroll their own patients in research compromises voluntary informed consent. Therefore, several ethical guidelines for human subject research provide approaches to mitigate these compromises. Currently, these approaches have not been critically evaluated. In this article, we analyze the approaches of ethical guidelines to manage the influence of a dependent relationship between patients and physicians on voluntary informed consent and discuss the strengths and weaknesses of these approaches.
  
  
  METHODS
  We performed a review of international ethical guidance documents on human subject research, listed in the Oxford Textbook of Clinical Research Ethics and found through cross referencing. We also searched Global Ethics Observatory (GEObs) and the World Health Organization (WHO) website. Guidelines from all years were eligible for inclusion. The date last searched was December 2013.
  
  
  CONCLUSIONS
  We identified two basic guideline approaches: 1. A process approach, which focuses on the person who obtains informed consent, that is, an independent individual, such as a research nurse or counselor; and 2. A content approach, emphasizing the voluntary nature of participation. Both approaches are valuable, either because the influence of the physician may diminish or because it empowers patients to make voluntary decisions. However, the approaches also face challenges. First, research nurses are not always independent. Second, physician-investigators will be informed about decisions of their patients. Third, involvement of a counselor is sometimes unfeasible. Fourth, the right to withdraw may be difficult to act upon in a dependent relationship.
  
  
  CONCLUSIONS
  Current guideline approaches to protect voluntary informed consent within a dependent relationship are suboptimal. To prevent compromises to voluntary informed consent, consent should not only be obtained by an independent individual, but this person should also emphasize the voluntary nature of participation. At the same time, dependency as such does not imply undue influence. Sometimes the physician may be best qualified to provide information, for example, for a very specialized study. Still, the research nurse should obtain informed consent. In addition, patients should be able to consult a counselor, who attends the informed consent discussions and is concerned with their interests. Finally, both physicians and research nurses should disclose research interests.
authors.affiliation: Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands. S.A.S.Dekking@umcutrecht.nl.
authors.forename: Sara A S
authors.initials: SA
authors.lastname: Dekking
authors.forename: Rieke
authors.initials: R
authors.lastname: van der Graaf
authors.forename: Johannes J M
authors.initials: JJ
authors.lastname: van Delden
mesh_terms: D003858:Dependency, Psychological; D006801:Humans; D007258:Informed Consent / Q000941:ethics* / Q000592:standards*; D010817:Physician-Patient Relations / Q000941:ethics*; D017410:Practice Guidelines as Topic / Q000592:standards*