--- doh2008.sync.norm.md 2013-10-22 19:35:37.343888974 +0200 +++ doh2013.sync.norm.md 2013-10-22 19:35:37.283889862 +0200 @@ -1,321 +1,381 @@ # WORLD MEDICAL ASSOCIATION DECLARATION OF HELSINKI **Ethical Principles for Medical Research Involving Human Subjects** World Medical Association Adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964, and amended by the: 29th WMA General Assembly, Tokyo, Japan, October 1975 35th WMA General Assembly, Venice, Italy, October 1983 41st WMA General Assembly, Hong Kong, September 1989 48th WMA General Assembly, Somerset West, Republic of South Africa, October 1996 52nd WMA General Assembly, Edinburgh, Scotland, October 2000 -53rd WMA General Assembly, Washington 2002 (Note of Clarification on -paragraph 29 added) -55th WMA General Assembly, Tokyo 2004 (Note of Clarification on -Paragraph 30 added) -59th WMA General Assembly, Seoul, October 2008 +53rd WMA General Assembly, Washington, DC, USA, October 2002 (Note of +Clarification added) +55th WMA General Assembly, Tokyo, Japan, October 2004 (Note of +Clarification added) +59th WMA General Assembly, Seoul, Republic of Korea, October 2008 +64th WMA General Assembly, Fortaleza, Brazil, October 2013 -## INTRODUCTION +## PREAMBLE [SYNC1-1] 1) The World Medical Association (WMA) has developed the Declaration of Helsinki as a statement of ethical principles for medical research involving human subjects, including research on identifiable human material and data. The Declaration is intended to be read as a whole and each of its -constituent paragraphs should not be applied without consideration of -all other relevant paragraphs. +constituent paragraphs should be applied with consideration of all other +relevant paragraphs. -2) Although the Declaration is addressed primarily to physicians, the -WMA encourages other participants in medical research involving human -subjects to adopt these principles. +2) Consistent with the mandate of the WMA, the Declaration is addressed +primarily to physicians. The WMA encourages others who are involved in +medical research involving human subjects to adopt these principles. + +## GENERAL PRINCIPLES [SYNC4-3] -4) The Declaration of Geneva of the WMA binds the physician with the +3) The Declaration of Geneva of the WMA binds the physician with the words, “The health of my patient will be my first consideration,” and the International Code of Medical Ethics declares that, “A physician shall act in the patient's best interest when providing medical care.” -3) It is the duty of the physician to promote and safeguard the health -·················· of patients, including those who are involved in +4) It is the duty of the physician to promote and safeguard the health, +well-being and rights of patients, including those who are involved in medical research. The physician's knowledge and conscience are dedicated to the fulfilment of this duty. 5) Medical progress is based on research that ultimately must include -studies involving human subjects. {[TO5'] Populations that …} +studies involving human subjects. -7) The primary purpose of medical research involving human subjects is +6) The primary purpose of medical research involving human subjects is to understand the causes, development and effects of diseases and improve preventive, diagnostic and therapeutic interventions (methods, -procedures and treatments). Even the best current interventions must be +procedures and treatments). Even the best proven interventions must be evaluated continually through research for their safety, effectiveness, efficiency, accessibility and quality. -9) Medical research is subject to ethical standards that promote respect -for all human subjects and protect their health and rights. Some -research populations are particularly vulnerable and need special -protection. These include those who cannot give or refuse consent for -themselves and those who may be vulnerable to coercion or undue -influence. +7) Medical research is subject to ethical standards that promote and +ensure respect for all human subjects and protect their health and +rights. -6) In medical research involving human subjects, the well-being of the -individual research subject must take precedence over all other -interests. +8) While the primary purpose of medical research is to generate new +knowledge, this goal can never take precedence over the rights and +interests of individual research subjects. -11) It is the duty of physicians who participate in medical research to +9) It is the duty of physicians who are involved in medical research to protect the life, health, dignity, integrity, right to self-determination, privacy, and confidentiality of personal information -of research subjects. {The responsibility for the protection of research +of research subjects. The responsibility for the protection of research subjects must always rest with the physician or other health care -professional and never the research subjects, even though they have -given consent. [FROM16]} +professionals and never with the research subjects, even though they +have given consent. -10) Physicians should consider the ethical, legal and regulatory norms +10) Physicians must · consider the ethical, legal and regulatory norms and standards for research involving human subjects in their own countries as well as applicable international norms and standards. No national or international ethical, legal or regulatory requirement should reduce or eliminate any of the protections for research subjects set forth in this Declaration. -13) Appropriate caution must be exercised in the conduct of medical -research that may harm the environment. +11) Medical research should be conducted in a manner that minimises +possible harm to the environment. -16) Medical research involving human subjects must be conducted only by -individuals with the appropriate scientific ···················· +12) Medical research involving human subjects must be conducted only by +individuals with the appropriate ethics and scientific education, training and qualifications. Research on patients or healthy volunteers requires the supervision of a competent and appropriately qualified -physician or other health care professional. {[TO11] The responsibility -for …} +physician or other health care professional. -{5') Populations that are underrepresented in medical research should be -provided appropriate access to participation in research. [FROM5]} +13) Groups that are underrepresented in medical research should be +provided appropriate access to participation in research. [SYNC31-14] -31) The physician may combine medical research with medical care only -································ to the extent that the research is +14) Physicians who combine medical research with medical care should +involve their patients in research only to the extent that this is justified by its potential preventive, diagnostic or therapeutic value and if the physician has good reason to believe that participation in the research study will not adversely affect the health of the patients who serve as research subjects. +15) Appropriate compensation and treatment for subjects who are harmed +as a result of participating in research must be ensured. + +## RISKS, BURDENS AND BENEFITS + [SYNC8-16] -8) In medical practice and in medical research, most interventions +16) In medical practice and in medical research, most interventions involve risks and burdens. -21) Medical research involving human subjects may only be conducted if -the importance of the objective outweighs the inherent risks and burdens +Medical research involving human subjects may only be conducted if ·· +the importance of the objective outweighs the ······ risks and burdens to the research subjects. [SYNC18-17] -18) Every medical research study involving human subjects must be +17) All medical research involving human subjects must be ······ preceded by careful assessment of predictable risks and burdens to the -individuals and communities involved in the research in comparison with -foreseeable benefits to them and to other individuals or communities -affected by the condition under investigation. +individuals and groups involved in the research in comparison with +foreseeable benefits to them and to other individuals or groups affected +by the condition under investigation. + +Measures to minimise the risks must be implemented. The risks must be +continuously monitored, assessed and documented by the researcher. [SYNC20-18] -20) Physicians may not participate in a research study involving human -subjects unless they are confident that the risks involved have been -adequately assessed and can be satisfactorily managed. Physicians must -immediately stop a study when the risks are found to outweigh the -potential benefits or when there is conclusive proof of positive and -beneficial results. +18) Physicians may not be involved in a research study involving human +subjects unless they are confident that the risks have been adequately +assessed and can be satisfactorily managed. + +When the risks are found to outweigh the potential benefits or when +there is conclusive proof of definitive outcomes, physicians must assess +whether to continue, modify or immediately stop the study. + +## VULNERABLE GROUPS AND INDIVIDUALS + +19) Some groups and individuals are particularly vulnerable and may have +an increased likelihood of being wronged or of incurring additional +harm. + +All vulnerable groups and individuals should receive specifically +considered protection. [SYNC17-20] -17) Medical research involving a disadvantaged or vulnerable population -or community is only justified if the research is responsive to the -health needs and priorities of this population or community and if there -is a reasonable likelihood that this population or community stands to -benefit from the results of the research. +20) Medical research with a vulnerable group is only justified if the +research is responsive to the health needs or priorities of this group +and the research cannot be carried out in a non-vulnerable group. In +addition, this group should stand to benefit from the knowledge, +practices or interventions that result from the research. -## PRINCIPLES FOR ALL MEDICAL RESEARCH +## SCIENTIFIC REQUIREMENTS AND RESEARCH PROTOCOLS [SYNC12-21] -12) Medical research involving human subjects must conform to generally +21) Medical research involving human subjects must conform to generally accepted scientific principles, be based on a thorough knowledge of the scientific literature, other relevant sources of information, and adequate laboratory and, as appropriate, animal experimentation. The welfare of animals used for research must be respected. -14) The design and performance of each research study involving human -subjects must be clearly described in a research protocol. +22) The design and performance of each research study involving human +subjects must be clearly described and justified in a research protocol. The protocol should contain a statement of the ethical considerations involved and should indicate how the principles in this Declaration have been addressed. The protocol should include information regarding -funding, sponsors, institutional affiliations, other potential conflicts -of interest, incentives for subjects and provisions for treating and/or -compensating subjects who are harmed as a consequence of participation -in the research study. The protocol should describe arrangements for -post-study access by study subjects to interventions identified as -beneficial in the study or access to other appropriate care or benefits. +funding, sponsors, institutional affiliations, potential conflicts of +interest, incentives for subjects and information regarding provisions +for treating and/or compensating subjects who are harmed as a +consequence of participation in the research study. + +In clinical trials, the protocol must also describe appropriate +arrangements for post-trial provisions. + +## RESEARCH ETHICS COMMITTEES [SYNC15-23] -15) The research protocol must be submitted for consideration, comment, -guidance and approval to a research ethics committee before the study -begins. This committee must be independent of the researcher, the -sponsor and any other undue influence. It must take into consideration +23) The research protocol must be submitted for consideration, comment, +guidance and approval to the concerned research ethics committee before +the study begins. This committee must be transparent in its functioning, +must be independent of the researcher, the sponsor and any other undue +influence and must be duly qualified. It must take into consideration the laws and regulations of the country or countries in which the research is to be performed as well as applicable international norms and standards but these must not be allowed to reduce or eliminate any of the protections for research subjects set forth in this Declaration. + The committee must have the right to monitor ongoing studies. The researcher must provide monitoring information to the committee, -especially information about any serious adverse events. No change to +especially information about any serious adverse events. No amendment to the protocol may be made without consideration and approval by the -committee. +committee. After the end of the study, the researchers must submit a +final report to the committee containing a summary of the study’s +findings and conclusions. + +## PRIVACY AND CONFIDENTIALITY [SYNC23-24] -23) Every precaution must be taken to protect the privacy of research -subjects and the confidentiality of their personal information and to -minimize the impact of the study on their physical, mental and social -integrity. +24) Every precaution must be taken to protect the privacy of research +subjects and the confidentiality of their personal information. -22) Participation by competent individuals as subjects in medical -research must be voluntary. Although it may be appropriate to consult -family members or community leaders, no competent individual may be -enrolled in a research study unless he or she freely agrees. +## INFORMED CONSENT + +25) Participation by individuals capable of giving informed consent as +subjects in medical research must be voluntary. Although it may be +appropriate to consult family members or community leaders, no +individual capable of giving informed consent may be enrolled in a +research study unless he or she freely agrees. [SYNC24-26] -24) In medical research involving competent human subjects ··· -················, each potential subject must be adequately informed of +26) In medical research involving human subjects capable of giving +informed consent, each potential subject must be adequately informed of the aims, methods, sources of funding, any possible conflicts of interest, institutional affiliations of the researcher, the anticipated benefits and potential risks of the study and the discomfort it may -entail, ···················· and any other relevant aspects of the +entail, post-study provisions and any other relevant aspects of the study. The potential subject must be informed of the right to refuse to participate in the study or to withdraw consent to participate at any time without reprisal. Special attention should be given to the specific information needs of individual potential subjects as well as to the methods used to deliver the information. After ensuring that the potential subject has understood the information, the physician or another appropriately qualified individual must then seek the potential subject’s freely-given informed consent, preferably in writing. If the consent cannot be expressed in writing, the non-written consent must be formally documented and witnessed. -33) At the conclusion of the study, patients entered into the study are -entitled to be informed about the outcome of the study and to share any -benefits that result from it, for example, access to interventions -identified as beneficial in the study or to other appropriate care or -benefits. +All medical research subjects should be given the option of being +informed about the general outcome and results of the study. [SYNC26-27] -26) When seeking informed consent for participation in a research study -the physician should be particularly cautious if the potential subject -is in a dependent relationship with the physician or may consent under -duress. In such situations the informed consent should be sought by an +27) When seeking informed consent for participation in a research study +the physician must be particularly cautious if the potential subject is +in a dependent relationship with the physician or may consent under +duress. In such situations the informed consent must be sought by an appropriately qualified individual who is completely independent of this relationship. -27) For a potential research subject who is incompetent, ······· -········ the physician must seek informed consent from the legally -authorized representative. These individuals must not be included in a +28) For a potential research subject who is incapable of giving informed +consent, the physician must seek informed consent from the legally +authorised representative. These individuals must not be included in a research study that has no likelihood of benefit for them unless it is -intended to promote the health of the population represented by the -potential subject, the research cannot instead be performed with -············ competent persons, and the research entails only minimal +intended to promote the health of the group represented by the potential +subject, the research cannot instead be performed with persons capable +of providing informed consent, and the research entails only minimal risk and minimal burden. -28) When a potential research subject who is deemed incompetent -················ is able to give assent to decisions about participation +29) When a potential research subject who is deemed incapable of giving +informed consent is able to give assent to decisions about participation in research, the physician must seek that assent in addition to the -consent of the legally authorized representative. The potential +consent of the legally authorised representative. The potential subject’s dissent should be respected. -29) Research involving subjects who are physically or mentally incapable +30) Research involving subjects who are physically or mentally incapable of giving consent, for example, unconscious patients, may be done only if the physical or mental condition that prevents giving informed -consent is a necessary characteristic of the research population. In -such circumstances the physician should seek informed consent from the -legally authorized representative. If no such representative is +consent is a necessary characteristic of the research group. ····· In +such circumstances the physician must seek informed consent from the +legally authorised representative. If no such representative is available and if the research cannot be delayed, the study may proceed without informed consent provided that the specific reasons for involving subjects with a condition that renders them unable to give informed consent have been stated in the research protocol and the study has been approved by a research ethics committee. Consent to remain in -the research should be obtained as soon as possible from the subject or -a legally authorized representative. - -## ADDITIONAL PRINCIPLES FOR MEDICAL RESEARCH COMBINED WITH MEDICAL CARE +the research must be obtained as soon as possible from the subject or a +legally authorised representative. [SYNC34-31] -34) The physician must fully inform the patient which aspects of the +31) The physician must fully inform the patient which aspects of their care are related to the research. The refusal of a patient to participate in a study or the patient’s decision to withdraw from the -study must never interfere with the patient-physician relationship. +study must never adversely affect the patient-physician relationship. -25) For medical research using identifiable human material or data, ···· -······································································ -··········· physicians must normally seek consent for the collection, -analysis, storage and/or reuse. There may be situations where consent -would be impossible or impractical to obtain for such research or would -pose a threat to the validity of the research. ······················ In +32) For medical research using identifiable human material or data, such +as research on material or data contained in biobanks or similar +repositories, physicians must seek informed consent for its collection, +storage and/or reuse. There may be exceptional situations where consent +would be impossible or impracticable to obtain for such research. In such situations the research may be done only after consideration and approval of a research ethics committee. +## USE OF PLACEBO + [SYNC32-33] -32) The benefits, risks, burdens and effectiveness of a new intervention -must be tested against those of the best current proven intervention, -except in the following circumstances: +33) The benefits, risks, burdens and effectiveness of a new intervention +must be tested against those of the best proven intervention(s), except +in the following circumstances: -- The use of placebo, or no treatment, is acceptable in studies where - no current proven intervention exists; or -- Where for compelling and scientifically sound methodological reasons - the use of placebo is necessary to determine the efficacy or safety - of an intervention and the patients who receive placebo or no - treatment will not be subject to any risk of serious or irreversible - harm. Extreme care must be taken to avoid abuse of this option. +Where no proven intervention exists, the use of placebo, or no +intervention, is acceptable; or + +Where for compelling and scientifically sound methodological reasons the +use of any intervention less effective than the best proven one, the use +of placebo, or no intervention is necessary to determine the efficacy or +safety of an intervention + +and the patients who receive any intervention less effective than the +best proven one, placebo, or no intervention will not be subject to +additional risks of serious or irreversible harm as a result of not +receiving the best proven intervention. + +Extreme care must be taken to avoid abuse of this option. + +## POST-TRIAL PROVISIONS + +34) In advance of a clinical trial, sponsors, researchers and host +country governments should make provisions for post-trial access for all +participants who still need an intervention identified as beneficial in +the trial. This information must also be disclosed to participants +during the informed consent process. + +## RESEARCH REGISTRATION AND PUBLICATION AND DISSEMINATION OF RESULTS [SYNC19-35] -19) Every clinical trial must be registered in a publicly accessible -database before recruitment of the first subject. +35) Every research study involving human subjects must be registered in +a publicly accessible database before recruitment of the first subject. -30) Authors, editors ····················· and publishers all have -ethical obligations with regard to the publication ················· of -the results of research. Authors · have a duty to make publicly +36) Researchers, authors, sponsors, editors and publishers all have +ethical obligations with regard to the publication and dissemination of +the results of research. Researchers have a duty to make publicly available the results of their research on human subjects and are -accountable for the completeness and accuracy of their reports. They -should adhere to accepted guidelines for ethical reporting. Negative and -inconclusive as well as positive results should be published or -otherwise made publicly available. Sources of funding, institutional -affiliations and conflicts of interest should be declared in the +accountable for the completeness and accuracy of their reports. All +parties should adhere to accepted guidelines for ethical reporting. +Negative and inconclusive as well as positive results must be published +or otherwise made publicly available. Sources of funding, institutional +affiliations and conflicts of interest must be declared in the publication. Reports of research not in accordance with the principles of this Declaration should not be accepted for publication. +## UNPROVEN INTERVENTIONS IN CLINICAL PRACTICE + [SYNC35-37] -35) In the treatment of a ·············· patient, where proven -interventions do not exist or ························ have been +37) In the treatment of an individual patient, where proven +interventions do not exist or other known interventions have been ineffective, the physician, after seeking expert advice, with informed -consent from the patient or a legally authorized representative, may use +consent from the patient or a legally authorised representative, may use an unproven intervention if in the physician's judgement it offers hope -of saving life, re-establishing health or alleviating suffering. Where -possible, this intervention should be made the object of research, +of saving life, re-establishing health or alleviating suffering. This +intervention should subsequently be made the object of research, designed to evaluate its safety and efficacy. In all cases, new -information should be recorded and, where appropriate, made publicly +information must be recorded and, where appropriate, made publicly available. +## ARTICLE INFORMATION + +Corresponding Author: World Medical Association, 13, ch. du Levant, CIB +- Bâtiment A, 01210 Ferney-Voltaire, France; wma@wma.net. + +Published Online: October 19, 2013. doi:10.1001/jama.2013.281053. + +Disclaimer: ©2013 World Medical Association, Inc. All Rights Reserved. +All intellectual property rights in the Declaration of Helsinki are +vested in the World Medical Association. The WMA has granted JAMA +exclusive rights to publish the English-language version of the +Declaration through December 31, 2013. + +Online-Only Content: Audio podcast is available at www.jama.com. +Copyright ©2013 American Medical Association + ## SOURCE -http://www.wma.net/en/30publications/10policies/b3/17c.pdf +http://www.wma.net/en/30publications/10policies/b3/ + +http://jama.jamanetwork.com/article.aspx?articleid=1760318