Clarifying Confusions about Coercion

Clarifying Confusions about Coercion Jennifer S. Hawkins (bio) and Ezekiel J. Emanuel (bio) One of the most common criticisms of informed consent to research is that the subjects have been "coerced" into participating in clinical studies. Discussion of "coercion" is common in scholarly articles, in discussions within IRBs, in ethics consultations, at presentations given at bioethics and medical conferences, and in ethics committee meetings. But many of these uses are incorrect, and it's time we cleaned up our language. Such claims have appeared especially frequently in recent years in discussions of research conducted in developing countries. Noting that potential subjects may be poor, uneducated, naive about research, and lacking alternative, nonresearch-related forms of health care, commentators claim subjects have "no choice" but to participate and therefore equate lack of good choices with coercion. For example, in an article on trials of the efficacy of HIV preventions, Isabelle de Zoysa and colleagues cautioned investigators to "remind themselves that offering the trial participants access to extensive services that are not otherwise available to them may be coercive in itself."1 But discussion of "coercion" is not new. In an influential article in the late 1980s about developing world research, Nicholas Christakis wrote: It is difficult to avoid coercing subjects in most settings where clinical investigation in the developing world is conducted. African subjects with relatively little understanding of medical aspects of research participation, indisposed toward resisting the suggestions of Western doctors, perhaps operating under the mistaken notion that they are being treated, and possibly receiving some ancillary benefits from participation in research, are very susceptible to coercion.2 And in the early 1970s, in a now famous passage, Franz Ingelfinger claimed to find an element of coercion in every "investigator-subject transaction," although particularly when the subject is not a healthy volunteer: Incapacitated and hospitalized because of illness, frightened by strange and impersonal routines, and fearful for his health and perhaps life, he is far from exercising a free power of choice when the person to whom he anchors all his hopes asks: "Say, you wouldn't mind, would you, if you joined some of the other patients on this floor and helped us carry out some very important research we are doing?" When "informed consent" is obtained it is not the student, the destitute bum, or the prisoner to whom by virtue of his condition the thumb screws of coercion are most relentlessly applied; it is the most used and useful of all experimental subjects, the patient with disease.3 Ingelfinger's liberal construal of coercion is repeated in a recent edition of an influential book on informed consent, in which a group of authors led by J.W. Berg treat "coercive" as roughly equivalent to any kind of pressure or narrowing of options: "Physicians should be aware of how vulnerable patients may be to the coercive influence of unrealistic hope, especially those suffering from chronic, life-threatening disorders."4 In these and similar cases, commentators are worried either about the decision-making conditions subjects face or about the decision-making process they undergo. In many of these cases, however, coercion is confused either with an assortment of nonmoral problems or with different kinds of moral transgressions. This confusion obstructs clear and critical thinking: we run the risk that the moral language we and others use may do our moral End Page 16 thinking for us. Everyone knows that coercion is bad, after all; if a practice is coercive then plainly it should be stopped, and the "coerced" decisions should be set aside. Thus we may be led to faulty conclusions and faulty recommendations for change—and even when we discover a genuine moral wrong, if we misidentify it we are unlikely to respond to it appropriately. In this case, the use of a word has extremely important practical implications: how one understands a problem shapes what one does about it. What Is Coercion? In its simplest definition, coercion involves a threat that makes a certain choice irresistible. 5 "Irresistible" here does not refer to how the victim feels about her choices. Rather, it identifies cases where the choices are so weighted that only one reasonable course of action...