Electronic Thesis and Dissertation Repository

Thesis Format

Monograph

Degree

Doctor of Philosophy

Program

Philosophy

Supervisor

Weijer, Charles

2nd Supervisor

Brehaut, Jamie

Affiliation

University of Ottawa

3rd Supervisor

McLeod, Carolyn

Abstract

Many randomized controlled trials run into difficulties to recruit enough participants. This can lead to the termination of trials, thereby exposing participants to unnecessary risks and hindering the progress of medicine. Behavioral science could help to overcome this problem. Behavioral science has led to a better understanding of what influences behavior. These influences can be used to enhance the recruitment of trial participants.

Attempting to influence the decision to participate in a trial, which should be made in the absence of controlling influences, does, however, raise ethical questions. This thesis aims to address these questions for three types of behavioral influences: financial incentives, leveraging trust-relationships, and nudges. It asks: when is it ethically permissible to use financial incentives, leverage trust-relationships, and nudge to recruit participants in clinical trials?

In the second chapter, I argue that small financial incentives are ethically permissible, but that large financial incentives should be avoided. I distinguish financial incentives from two other forms of payment to participants, and argue that exploitation arguments do not apply to financial incentives. I then argue that large financial incentives can lead to a diminished voluntariness and an unjust distribution of the risks and burdens of trial participation, which are reasons to keep financial incentives low.

In chapter three, I discuss the ethical permissibility of leveraging patient-physician trust relationships to recruit patient-participants. I first analyze the patient-physician trust relationship and, then, analyze four forms of involving physicians in the recruitment of their patients. I argue that each of these forms can be ethically acceptable, but only under certain conditions.

In the fourth chapter, I discuss the use of nudges in the recruitment of participants. I argue, against a common criticism that nudges undermine autonomy, that it can be rational to respond to nudges and that a decision based on a nudge can be authentic. Based on this discussion, I specify five conditions for the ethically permissible use of nudges in recruitment.

In my final chapter, I summarize the insights of these different chapters and formulate future directions for behavioral and ethical research.

Summary for Lay Audience

Many trials find it difficult to recruit enough participants. This can lead to the termination of trials, thereby exposing participants to unnecessary risks and hindering the progress of medicine. Behavioral science could help to overcome this problem. Behavioral science has led to a better understanding of what influences behavior. These influences can be used to enhance the recruitment of trial participants.

Attempting to influence the decision to participate in a trial, which should be made in the absence of controlling influences, does, however, raise ethical questions. This thesis aims to address these questions for three types of behavioral influences: financial incentives, leveraging trust-relationships, and influences that target people’s unconscious biases and habits (“nudges”). It asks: when is it ethically permissible to use financial incentives, leverage trust-relationships, and nudge to recruit participants in clinical trials?

In the second chapter, I argue that small financial incentives are ethically permissible, but that large financial incentives should be avoided. I distinguish financial incentives from two other forms of payment to participants, and argue that arguments concerning exploitation do not apply to financial incentives. I then argue that large financial incentives can lead to a diminished voluntariness and an unjust distribution of the risks and burdens of trial participation, which are reasons to keep financial incentives low.

In chapter three, I discuss the ethical permissibility of leveraging patient-physician trust relationships to recruit patient-participants. I first analyze the patient-physician trust relationship and, then, analyze four forms of involving physicians in the recruitment of their patients. I argue that each of these forms can be ethically acceptable, but only under certain conditions.

In the fourth chapter, I discuss the use of nudges in the recruitment of participants. I argue that nudges do not necessarily undermine autonomy, because a decision based on a nudge can be rational and conform to a person’s own preferences. Based on this discussion, I specify five conditions for the ethically permissible use of nudges in recruitment.

In my final chapter, I summarize the insights of these different chapters and formulate future directions for behavioral and ethical research.

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