PI or Private Investigator
This case highlights potential dilemmas encountered by postdoctoral fellows in a research setting. Does informed consent entitle a researcher to use a credit bureau to locate study participants after three years? It also explores the ways that confidentiality might be jeopardized.
Bob, a study manager for a health study conducted two or three years ago, needs to locate participants to follow up on some incomplete data. At the outset of the study, the researchers obtained the subjects' informed consent. In the consent process, subjects were informed of the reason for the study, told that they would be asked to complete two questionnaires, and informed of the benefits and risks of participating and their rights as study subjects. The initial consent form included a statement that mentioned the possibility of re-contact in the future. However, it provided no information about how the contact, if necessary, would be made. At the end of a questionnaire, subjects were asked to provide the name, address and phone number of a friend or relative who would know how to contact them two or three years later. Some of the participants did not give this information.
1. Should the participants have been told how future contact would be made?
2. Should an attempt be made to contact study subjects who did not give a relative or a friend's contact information?
In trying to locate participants, Bob found that some of the subjects' contact information was invalid. He contacted directory assistance in an attempt to get new telephone numbers. For those with unlisted numbers or no information in directory assistance, Bob used the Internet to search. If these two methods did not produce valid information, he contacted the clinic where the study took place. However, some of the study subjects were no longer patients at the clinic. Bob then referred to the question that asked for subjects' contact information. However, not all of these sources had good contact information. During the approval process, the institutional review board (IRB) never discussed the issue or agreed that providing contact information on a relative or friend would imply consent for follow-up contact at any time.
In an effort to locate subjects to complete the data and please the principal investigator, who wants to conduct a follow-up study, Bob decided to use a credit bureau to trace the subjects for a small charge. The subjects' names, addresses and phone numbers with invalid contact information, including those who did not give a relative's or friend's contact information, were sent to a credit bureau. Bob was happy to learn that the credit search produced new information (including a Social Security number) for about a fifth of the missing subjects. But there were still a number of subjects to locate.
3. Should the IRB have been asked to approve use of a credit bureau to locate missing subjects?
4. Should Bob have sent subjects' contact information to a credit bureau?
5. Should the study subjects have been told during the initial informed consent phase that a credit bureau would be used to contact them if necessary?
6. Should the participants' Social Security numbers have been obtained and used to locate them?
Bob learned that another credit bureau provides software to use for searches, and he ordered it. In using this software, Bob learned that every time a credit search is run on someone, it has the potential to lower the person's credit rating. He also found out that his company's name was listed on the report, and he purchased an option from the software company that would exclude the company's name from the report.
7. Should Bob's company have ordered the software for in-house tracing of study subjects?
8. Should Bob's company have prevented its name from appearing on the credit reports?
9. Did use of a credit bureau and credit search software jeopardize the confidentiality of the subjects' contact information?
Brian Schrag, ed., Research Ethics: Cases and Commentaries, Volume 5, Bloomington, Indiana: Association for Practical and Professional Ethics, 2001.
Nature of the study
It is not clear from the case description whether this project was initially designed as a longitudinal study with expected follow-up research (or at least data collection) or whether it simply intended to allow for the possibility of follow-up, perhaps to clarify information or to do further research. What does seem clear, given the fact that the initial consent form mentioned the possibility of re-contact, is that the follow-up contact was not simply someone's afterthought several years after the study was completed. It appears that a clear decision to do this particular follow-up seems to have been made years after the end of the study.
It is also not clear if this study was therapeutic or nontherapeutic. If it was a therapeutic study, there might be reasons to follow up with subjects for their benefit. I shall assume for the purposes of the discussion that it was a nontherapeutic study and hence the re-contact of subjects was not for their welfare.
The case raises a number of issues. Is the mere contacting of subjects years after a study is completed an ethical issue, does such an action require obtaining informed consent? Is the means of relocating subjects of a study years after the study is complete an ethical issue, and does that activity require informed consent? Should such issues have been addressed in the original study protocol? Having failed to address such issues adequately in the initial protocol, what ought to be done at later stages?
What we do know in this case is that the attempt to re-contact former subjects did have consequences for them. Some of the participants were contacted without their knowledge of the process or consent. Some participants may have been re-contacted against their wishes and without their consent. Some experienced an invasion of their privacy. Information on subjects' credit ratings was apparently obtained by the study manager and perhaps shared with others. A smaller group may have had their credit ratings harmed without their knowledge or consent. Merely participating in the original study made them vulnerable to harms inflicted by the researcher that had nothing to do with the content of the study.
Is the mere contacting of study participants years after the study has been completed an ethical issue? Some subjects may know from the outset that they do not wish to be contacted after the end of a study. Mere participation in a study does not mean one has surrendered any rights to be left alone or to have one's privacy respected in subsequent years. Much can happen to subjects in the interval after a study is completed. Depending on the study, there may be a variety of reasons subjects may wish not to be contacted. For example, they may not want their current intimate contacts to know they had participated in the study. They may simply prefer to not be disturbed, and that itself is a moral reason for them not to be contacted. For these considerations, researchers are morally required to obtain informed consent from such subjects for future contact.
Is the means of locating persons, even those who have given consent to be recontacted, an ethical issue? Clearly it is. Would anyone consent to allow a researcher to use a credit bureau to track one down, particularly if that negatively affects one's credit rating? Surely not. It would not occur to most of us that was a possibility. But the possibility does underline the fact that there are limits to what we would agree to in terms of procedures used to track us down, even if we give consent to be re-contacted.
Without knowledge of the nature of the study, the need for follow up or any therapeutic value to the participants, it is difficult to fully assess the moral seriousness of the actions in this case or to suggest what actions ought to be taken at later stages of the case. However, it is sometimes better to exercise preventive ethics, to take steps to avoid the ethical issues from arising rather that trying to solve the ethical problems after the fact. Adequate informed consent procedures established during the study could have gone a long way toward avoiding the ethical issues raised in this case.
Since the possibility of re-contacting subjects was anticipated from the beginning of the study, the investigators should have proposed a much more carefully thought out informed consent procedure to ensure that participants clearly gave their informed consent to be re-contacted.
Although the form mentioned the possibility of re-contact, it is not clear how explicit the request for permission to re-contact was, nor whether there was a blurring of the distinction between 1) consent to participate in this study and 2) consent to be contacted in the indefinite future for some unspecified purpose. It may well be that consent to participate in the study ought to be separated from consent to be re-contacted sometime in the indefinite future for some unspecified purpose. Participants may have been willing to participate but not willing to consent to re-contact. Some did not provide contact information, and it is not clear whether that should be interpreted as agreeing to participate in the current study but refusing to be re-contacted.
If re-contact is (less likely) actually the initiation of a new study, then it is not clear that it is appropriate to combine the informed consent to participate in the original study with consent to participate sometime in the future in a study of unspecified nature. The informed consent information presumably supplied details only for this study and, even if adequate to obtain informed consent for this study, could not be adequate for consent to an unspecified later study. Given these uncertainties, it is not at all clear that the informed consent for future contact was actually adequate for any of the subjects. It is even less clear that it was adequate for those who gave no future contact information.
If we assume the protocol should have included obtaining a clear and independent informed consent to re-contact, what would be reasonable for the researchers to say, regarding the method of contact, in order for the consent to be informed?
If one is contemplating the task of contacting subjects three years after completion of the original study, it should be obvious to the researchers from the start that some systematic procedure to locate subjects will need to be followed. (If the size of the pool is such that data would be useful only if virtually everyone in the study can be contacted, then it may not be wise to plan on re-contact unless an ethical means of successfully contacting all subjects is possible.) Obviously, the method outlined in the protocol was inadequate: Asking participants to list next of kin or other contacts did not produce a complete initial list of contacts.
One possibility would be to institute a tracking system to update contact information on a regular basis - every six months, for example. Each update would include and constitute a renewed permission to maintain contact.
However it is to be done, if the researchers expected to get informed consent for re-contacting subjects, they had an obligation to anticipate the difficulty of locating subjects and design a protocol accordingly. It does not take a rocket scientist to recognize there are acceptable and ethical ways of locating people and unethical and unacceptable ways of locating people. Obviously, technology is changing rapidly, and there may be possibilities of violating privacy in order to find contact information that were not thought of at the original point of consent. Nevertheless, the informed consent should include some assurances that the means used to find participants will stop short of violating their privacy or other interests.
Given all this, the researchers had an obligation to devise an informed consent form that would inform subjects of the purposes of re-contacting them in the future and the procedures that would be used to locate them. If the researchers failed to provide that in the protocol, the IRB had an obligation to raise the issue. Neither of them did so in this case.
Later stages of the case
Having failed to obtain an adequate informed consent for re-contact at the time of the study, what, if anything, should be done three years later when the researcher decides to do a follow-up study?
The researchers might use the contact information provided by subjects in the first place. There is, in the original consent form, at least a fig leaf of informed consent to be recontacted. If that strategy does not yield enough subjects for the study, the researchers should return to the IRB with a proposal for locating subjects for whom contact has been lost. It is the researchers' responsibility to obtain that approval from the IRB. It is the obligation of the IRB to see that the methods proposed to locate subject do not violate their interests. The researchers are also responsible for overseeing the actions of the study manager. It is clearly not the responsibility of the study manager to devise procedures on his own.
If no ethical means can be developed for locating subjects, then the study using these subjects should be abandoned. It may be that failure to find and contact the subjects means this study cannot go forward, and some useful or important information may be lost. It is not the case that the importance of the work automatically outweighs the means used to find the subjects merely because the technological means of locating the subjects are at hand. Poor initial planning and design by the PI are the reasons for the lost knowledge. That cannot be an excuse for the later unethical treatment of subjects.
Author: Brian Schrag, Indiana University.
With the increased use of computers and innovative technology, access to information is more readily available. This case highlights the ethical issues surrounding the use of this new technology in research to gain access to information and possible infringements on the rights of study subjects. In research involving human subjects, complete data are important. Hence, researchers' ability to reach study participants to verify or gain complete information is crucial. Over the course of time, the potential for losing contact with the participants increases, and the completeness of data becomes jeopardized. Along with greater access to computers, the development of the super highway of information (world wide web) has enabled people who were once lost to research, friends, family, etc., to be located. To help evaluate this case, it is important to consider the Belmont Report, which provides the ethical principles and guidelines that govern research with human subjects research; the Fair Credit Reporting Act of 1970; and the Code of Fair Information Practices (Johnson, 1994).
The first part of the case deals with Bob, a manager for a health study, who is trying to locate some study participants to follow up on incomplete data. Even though the consent form stated that future contact was possible, it did not mention the method(s) that the researchers would use to locate the participants. Further, the protocol for locating subjects after the study's end was never discussed with the IRB. It is quite likely that some study participants would have declined participation if they had known that a credit bureau would be used to contact them. However, this strategy was the last resort, and the number of queries sent to the credit bureau was minimal. The researchers did try to plan for attrition by asking the participants to provide the names, addresses, and phone numbers of friends or relatives who would know how to contact them two or three years later, but some of the participants did not provide this information. Another question is whether the participants who chose not to give a friend's or relative's contact information did not want to be contacted in the future. In that case, use of the credit bureau to locate these subjects may not have been justified.
It is important to know that the information collected and maintained by the credit bureau is legal, and rights to the information is available to others with a fee. Many banks, department stores, car dealerships, etc. use credit bureaus to verify the financial status of their prospective customers. However, it is important to note that customers give the stores and dealerships permission to check their credit. The research study did not inform the subjects or get their permission to search their credit reports for updated phone numbers or addresses.
The first principle listed in the Belmont Report is respect for persons. This principle refers to deception in research. The subjects were deceived in assuming that future contact would be established using the information they had already provided. It is clear that the researchers did not intend to deceive the subjects, given that the researchers did try to get additional information to help with contacting the subjects in the future.
Bob struggles to locate study subjects using various indirect methods such as directory assistance and the contact information provided by some of the subjects. Despite his efforts, these methods produced little new information. Bob lost sight of the principles listed in the Belmont Report by failing to consider the principles of respect for persons, beneficence and justice. He was so eager to use this new technology that he failed to consider the risks involved. Bob could have jeopardized the trust of the participants if they had found out about the tracing. He should have consulted the IRB, since the use of a credit agency was a change in the study's approved protocol.
In conducting human subjects research, all information collected from the subjects must be kept confidential. The consent form informs the subjects that only the immediate study staff will have access to information about them; that information will be released only be for the purpose of research; and that it will not have any identifying information attached or obtainable. By sending information to the credit bureau, Bob violated the confidentiality rules.
A second risk was to the subjects' credit ratings. The subjects should have been told that a credit bureau would be used to locate them in the event that other methods were not productive. The use of Social Security numbers was not fair, since that information was not requested from or given by the participants.
This final part of the case highlights the use and misuse of access to information when Bob learned of another credit-reporting company that provides software for independent credit searches. If the use of a credit bureau is ethical for research purposes, Bob should have ordered the software and restricted the use of the computer and software to authorized study personnel. This step would have preserved the confidentiality of the data and protected the subjects from harm. Searching someone's credit, even if only to find a telephone number, could adversely affect an individual's credit rating. Bob should have consulted with the IRB and weighed the pros and cons of using this resource.
Bob should not have tried to remove his company's name from the report because that was dishonest. The Credit Reporting Act of 1970 requires credit agencies to make their records available to subjects and to allow for corrections to credit reports. This Act would have allowed the study participants to remove the research company's name and reduce the risk of an adverse effect on their credit ratings.