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- •Tribute to Sumner J. Yaffe, MD
- •Foreword
- •Contributors
- •Contents
- •1. Clinical Trials Involving Children: History, Rationale, Regulatory Framework, and Technical Considerations
- •2. Clinical Pharmacokinetics in Infants and Children
- •3. Developmental Pharmacodynamics, Receptor Function, and Drug Action in Newborns and Children
- •4. Drug Absorption, Distribution, Metabolism, Excretion, and Transporters in Newborns and Children
- •5. Pharmacogenetics, Pharmacogenomics, and Pharmacoproteomics in Newborns and Children
- •6. Ethics of Drug Research in Newborns and Children
- •7. Precision Medicine and Therapeutic Drug Monitoring
- •8. Drug Formulations for Children
- •9. Role of Placenta in Drug Metabolism and Drug Transfer
- •10. Maternal Medications During Pregnancy and Lactation
- •11. Principles of Neonatal Pharmacology

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John D. Lantos
C H A P T E R
6
Ethics of Drug Research in Newborns and Children
In the prior edition of this textbook, Russell and colleagues noted the ongoing
concern and debate about the moral, ethical, and legal issues that surround
drug research and evaluation in infants and children. They noted tension that
can exist between our ongoing quest for new knowledge, on the one hand,
and, our obligation to adhere to the highest ethical standards in protecting
research participants, on the other. Those tensions have gotten more complex.
Children are a uniquely vulnerable population for medical research
because they can be easily exploited. This became apparent when ethicists
scrutinized research done by Saul Krugman and colleagues in the 1950s and
the Willowbrook State School in New York. Willowbrook was a residential
facility for children with a variety of neurocognitive problems. In order to
better understand the natural history and etiology of hepatitis, Krugman
studied hepatitis transmission in these children. Some of his study designs
involved deliberate infection of children with bodily fluids from other
children who had active hepatitis. Although these studies were done with
parental permission, Beecher argued that they were unacceptable because the
risks to the children were too high and the informed consent process lacked
details about those risks.
1
The controversies over Willowbrook continued for decades and would
eventually lead to regulations that mandated special protections for children.
In 1970, theologian Paul Ramsey wrote of the Willowbrook studies, “Such
use of captive populations of children for purely experimental purposes
ought to be made legally impossible... stopped by legal acknowledgement of

the moral invalidity of parental or legal proxy consent for the child to
procedures having no relation to a child’s own diagnosis or treatment.”
1
Ramsey’s important qualification—that special attention should be paid to
studies “having no relation to the child’s diagnosis or treatment”—would
later become one pillar of federal regulation of pediatric research. Goldby
supported Ramsey’s concerns and also argued that “it was indefensible to
give potentially dangerous infected material to children.” Goldby highlighted
that extra protection was especially important for children with cognitive
defects and in studies that were not designed to provide direct benefit to the
child.
2
Krugman defended the studies on the grounds that the children involved
did, in fact, benefit, because, instead of being admitted to the overcrowded
wards at the underfunded facility, children in the studies were admitted to a
clinical research unit where they would be isolated from exposure to
pathogens. He wrote, “Their exposure in the hepatitis unit would be
associated with less risk than the type of institutional exposure where
multiple infections could occur.”
3
In 1982, medical historian David Rothman wrote of Willowbrook that the
parental consent was meaningless because “[t]he consent form that parents
signed to allow their children to be infected with the virus read as though
their children were to receive a vaccine against the virus.”4 Furthermore, he
argued, parents often consented to the studies in order to get their children
out of the overcrowded wards at Willowbrook and into the far superior
accommodations of the research wing. This, he argued, was coercive and
possibly discriminatory because it would more likely attract poor children
than rich children whose parents could afford places other than
Willowbrook.
The debate over Willowbrook illustrates the central tension in pediatric
research. The tension is between two noble goals. Everyone fervently hopes
to discover new effective treatments childhood illnesses, and they also want
to protect children from the harms of research. The tension between these
two goals—protection and progress—is inevitable. Reasonable people can
disagree about the proper balance in any particular intervention.
Current federal guidelines are a nuanced attempt to find the right balance.
Because they are nuanced, however, they can also be difficult to interpret.
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