In order to ensure the generalizability of clinical research studies, researchers and study sponsors are tasked with making efforts to ensure that research participants are racially and ethnically representative of the population at large. However, minorities and women continue to be underrepresented in medical research studies. To encourage participation in medical research studies, researchers are often inclined to offer compensation for study participation. However, it is vital that researchers consider the ethical implications of monetizing participation in medical research studies. The first aim of this paper is to discuss the ethical ramifications of providing compensation for research participation. Additionally, this paper will critically analyze the various ways of handling financial compensation for participation in medical research studies involving experimental drugs, devices or surgical techniques. Information for this paper was gathered by conducting a literature review and by analyzing 121 semi-structured interviews. Using an ethical framework, and supported by qualitative data from the interviews, this paper will discuss the ethical concerns that researchers must consider when offering monetary compensation in exchange for participation in medical research. Overall, the paper aims to show that in order for clinical research to be conducted ethically, we must grant potential participants the autonomy to use their own decision making framework when deciding whether or not to participate in a medical research study. While a potential participant’s decision to join a research study in exchange for financial compensation may raise concerns to some people, autonomy requires that the research institution respect each individual’s own motivations and decisions. / Urban Bioethics

As an oncology clinical researcher at an urban hospital, I reflected on patient stories and see overlying themes: financial hurdles, treatment delays, difficulties completing treatment, ineligibility for clinical trials, and other barriers to care specific to urban patients. Delays in cancer treatment have been linked to a decrease in overall survival; consequently, reducing observed blockades could be a matter of life and death. Clinical trials provide more treatment options while researching possible standard of care therapies for future patients. As novel anticancer treatments become more biomolecule specific and low minority enrollment on clinical trials used to validate these drugs continues, I ask, “Why”? I believe urban patients are unethically excluded from participating in clinical trials by overly restrictive study eligibility criteria, high out-of-pocket costs, lengthy informed consents written either not at the patient’s reading level or not in their language, as well as other deterrents associated with low socioeconomic status. More minority representation in clinic trials is necessary to ensure drugs seeking FDA approval are more representative of the population. I argue more needs to be done to make studies more inclusive. Though challenges enrolling urban patients onto clinical trials remains, I believe there are still ways to enhance their cancer care: 1) identifying or writing treatment clinical trials that are more inclusive; and 2) developing studies with interventions that target socioeconomic barriers to care. / Urban Bioethics

Schizophrenia is a disease which presents many challenges. Medically, legally, and socially, afflicted individuals face obstacles that decrease their overall quality of life. Some of these are sequela of the disease and its decrease in social functioning, or symptoms of paranoia and disorganization. However, others are placed on these individuals by society. This has created a lifestyle which is marred by comorbid medical conditions and a resistance to receive treatment. It also creates frequent contact with the legal system, leading to a disorganized home life, and a significant amount of time spent behind bars, and being victimized by others. Finally, many schizophrenic patients are unable to find jobs, and report being without significant supportive relationships in their lives, creating stress both on themselves and their families and caregivers. These difficulties in life can be inseparable from their disease and place schizophrenic patients at a further disadvantage. / Urban Bioethics

The pediatric emergency department (PED) provides a unique environment to consider ethical issues faced in modern healthcare. Using a combination of personal reflections and a review of current literature, ethics within the PED is explored as it pertains to four categories: informed consent, health literacy, language barrier, and implicit bias. Parental consent is generally required for pediatric care, but there are exceptions encountered in the PED. Although children typically cannot provide consent, soliciting assent respects their autonomy and maturing cognitive development. Limited health literacy is a prominent issue in the U. S., yet healthcare information continues to be delivered in ways that do not adequately account for this. Change will necessitate creative solutions and reorientation to a focus on health equity and justice. Physician implicit bias may be related to a patient’s negative behaviors or inherent characteristics (e.g. race), and can result in adverse health outcomes for affected children. Physicians should confront their subconscious biases through introspection, open discussion, and implicit-bias training. Access to healthcare information in one’s native language is a basic human right protected by law. Use of qualified medical interpreters can alleviate disparities faced by patients with limited English proficiency, but may be underutilized in the PED. / Urban Bioethics

The current opioid epidemic has had grave financial and mortal costs for our nation, and the numbers continue to climb despite our best efforts. In spite of attempts to limit the prescription of opioids and implementation of harm reduction strategies, it is clear that we are not doing enough for people struggling with drug addiction. There are many voices present in the war on drugs, however one that is noticeably absent from the conversation is that of people who inject drugs. It is clearly time to try something new which requires a fresh approach and a new point of view. Confronting the current crisis using a public health approach addresses the associated moral challenges faced in the past and provides a new lens to view potential challenges and solutions. With this new approach arises the need for a public health ethical framework to make ethically informed, community engaging, evidence based decisions on a societal, public health, and everyday level. In addition to this new public health ethics framework, the engagement of the community of people who inject drugs is no longer negotiable in order to develop more effective harm reduction interventions and policies. / Urban Bioethics

A main challenge in medicine concerns questions of how to integrate the context and values of patient perspectives with general conceptions of illness and treatment. With medicine increasingly focused on patient-centered and individualized care, approaches to medicine must find ways to gain access to and understand the patient in such a way that recognizes her story as real while at the same time maintaining the value of medicine as an objective practice. Adding to this is the reality that under current models of medicine and decision-making in medicine, healthcare disparities persist for persons belonging to marginalized and vulnerable populations, including racial and ethnic minorities, women, and LGBTQ persons, amongst others. I argue that an approach integrative of shared decision-making built upon a phenomenological framework is a good alternative on which to try and understand questions like these and begin to address disparities in healthcare. / Urban Bioethics

Prisons and jails have become the de facto psychiatric hospitals of the twenty-first century. In the wake of deinstitutionalization, as mental healthcare transitioned to a community-based model, many patients with mental illness found themselves incarcerated rather than hospitalized. Strict drug laws combined with the current opioid epidemic are now forcing the government to consider treatment over punishment, lest the prison populations continue to swell. It is time to strongly consider using the involuntary commitment for severe cases of substance abuse if the patient is unwilling to undergo rehabilitation. Refusing to wait for the federal government to act, cities and states around the nation have begun to experiment with novel solutions to these issues, working within the framework of the prison system to achieve better outcomes. / Urban Bioethics

The emergency department (ED) has often been considered the safety net of the American healthcare system. It earned this distinction because every person in the United States has access to a medical screening exam and stabilization at an ED regardless of their ability to pay. Unfortunately, over the past several decades, decreasing numbers of EDs and inpatient beds, coupled with increasing rates of ED usage, has led to crowding of EDs across the country. Crowding leads to unsafe conditions that may increase morbidity and mortality for patients, or cause patients to leave the ED without being evaluated by a physician. Essentially, crowding causes a barrier for patients to access their right to emergency evaluation. The problem of crowding is most pronounced in large urban communities, and these already frequently underserved patients suffer the most from the crowding burden. The main cause of crowding seems to be the boarding of admitted patients in the ED, however many often cite high rates of non-urgent patients presenting to the ED as a cause of crowding. Some have even suggested diverting non-urgent patients to help solve the problem of crowding. I became interested in this topic due to crowding concerns and initiatives to decrease the number of patients who left without being seen at my own institution. As I reviewed relevant research, I became aware of my own misconceptions and noted a trend of literature suggesting non-urgent patients are not the cause of crowding. Drawing on research from many different sources, paired with evaluation based on principles in bioethics, I have come to several conclusions. I believe the systematic diversion of non-urgent patients is unsafe, and that the unequal burden of ED crowding on urban communities represents an unjust barrier in access to care. We must continue to carefully research the demographics of patients frequently presenting to EDs to avoid perpetuating stereotypes about which types of patients are responsible for crowding. We should also look for ways to ease the crowding burden in urban communities. Additionally, we should take a qualitative assessment of our individual communities to determine if there are any particular reasons in our community that people choose to use the ED rather than other healthcare options. I believe these suggestions can be an important addition to the efforts already in motion to help reduce ED crowding and provide equitable access to emergency medical evaluation. / Urban Bioethics

The modern concept of Emergency Medical Services (EMS) has grown from its humble volunteerism origins to a multidisciplinary enterprise, outstretched into the realms of both healthcare and public service. As the American EMS community continues to assume greater responsibilities and further develop its professional standards, the moral foundations of this field open themselves to more thorough scrutiny. Upon examination, the major deficit in the ethical structuring of EMS becomes glaringly obvious: it exists as a piecemeal collection of its medical and militaristic counterparts unified by theoretical generalizations that avoid its inherently unique structure. If EMS wishes to matriculate into complete professionalism, or even continue its assumption of critical responsibilities surrounding the health and safety of others, then it must also develop and maintain its own individual ethical framework from which it operates. In doing so, an urban bioethical approach rooted in context-driven analysis and pragmatic solutions may provide the best guidance and protections for all those who interact with the EMS system while respecting the values of this distinctively prideful service. / Urban Bioethics

Hostile architecture is a passive design phenomenon in cities used to discourage the public presence of the unhoused population. Examples include benches with middle armrests to prevent individuals from lying to sleep and trashcans with locks to prevent garbage picking. These designs exist within a larger web of anti-homeless laws and regulations popularized by neoliberal governments as broader social welfare programs that support this vulnerable population are abandoned. The homeless population is one that faces several health disparities and increased mortality compared to the general population. Hostile architecture likely influences the health of the homeless and worsens these disparities by forcing these individuals to relocate to more remote and harmful places in the city. Due to this relationship, hostile architecture can and should be brought into the purview of the field of urban bioethics using several ethical frameworks. It is only through a multidisciplinary approach that research deficits can be addressed, and the plight of the homeless community be improved. / Urban Bioethics