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Uninformed refusals: objections to enrolment in clinical trials conducted under an Exception from Informed Consent for emergency research
  1. Victoria Vorholt1,
  2. Neal W Dickert2,3,4
  1. 1 Emory University, Atlanta, Georgia, USA
  2. 2 Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
  3. 3 Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
  4. 4 Emory Center for Ethics, Atlanta, Georgia, USA
  1. Correspondence to Dr Neal W Dickert, Division of Cardiology, ECCRI, Emory University School of Medicine, Atlanta, GA 30329, USA; njr{at}


Clinical trials in emergency situations present unique challenges, because they involve enrolling individuals who lack capacity to consent in the context of acute illness or injury. The US Department of Health and Human Services and Food and Drug Administration regulations allowing an Exception from Informed Consent (EFIC) in these circumstances contain requirements for community consultation, public disclosure and restrictions on study risks and benefits. In this paper, we analyse an issue raised in the regulations that has received little attention or analysis but is ethically complex. This challenge is when to solicit and honour objections to EFIC trial enrolment, including from non-legally appointed representatives. We address novel questions involving whose objections should be honoured, what level of understanding is necessary for objections to be considered valid and how hard investigators should work to offer an opportunity to object. We present a set of criteria that provide conceptual and practical guidance. We argue that objections should be honoured if they undermine one of the key assumptions that allows for the permissibility of EFIC trials: that individuals would likely not object to enrolment based on their values or preferences. We then clarify the practical implications of this approach through examination of three cases of refusal in an EFIC study.

  • research ethics
  • informed consent
  • emergency medicine
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  • Contributors NWD and VV both conceived the manuscript. Both authors contributed substantially to drafting, critically reviewing and editing the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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