Deferential Vulnerability comes into play when individuals (Vulnerable subjects) submit or subordinate themselves to an authority figure before making any decision
concerning their existence or day-to-day living within a specific environment and relationships.
Before having an examination on individuals susceptible to deferential Vulnerability, it is essential that we understand who ‘Vulnerable subjects’ really are. The knowledge provided by this article will provide students and researchers with essential knowledge in mastering biology and other medical research subjects.
Who are the Vulnerable Subjects?
Vulnerable subjects are the people who are not able to provide voluntary informed consent due to either of the following:
- The limitations in their decision-making abilities
- Risk of exploitation, or
- Their situational circumstances.
There are four common types of abuses in human research:
Common Types of Abuses in Human Research
Coercion is the use of credible threat of force to harm with the intention of controlling another person.
Manipulation is the deliberate management and design of information or conditions meant to make subjects to make a decision they wouldn’t make on their own. Examples of manipulation of information include: exaggerating, withholding information, or lying.
3. Physical Control
Physical control represents subjects who are forced to participate in research. When an individual has no choice on whether or not to participate in a study, then they are under the complete physical control of the researchers.
4. Undue Influence
Undue influence is the misuse of power in leading or influencing your subordinates; hence making your subordinates make decisions that they wouldn’t make on their own.
Understanding Deferential Vulnerability
Usually, deferential Vulnerability occurs when an individual feels subordinate to another individual due to but not limited to class, gender, or knowledge.
Individuals may also have deferential Vulnerability due to cultural reasons. Unlike in the western cultures where the sick are allowed to make their own decisions regarding medical treatment, most of the non-western societies do not.
Deferential Vulnerability is very evident in medical research and in the traditional non-western cultures, especially African cultures.
Forms of Deferential Vulnerability
Deferential Vulnerability may occur when a patient chooses to defer to the authority of another family member when making decisions related to their health.
To defer means to agree to follow the options of someone else, that is to allow someone else to make decisions for you.
Such decisions are not necessarily under coercion or duress. The patient makes decisions based on directives or advice from authority figures. The authority figures are usually recognized by his or her cultural, religious or community customs.
Such Vulnerability may result to voluntariness and acquiescence in the consent process.
Patients susceptible to such Vulnerability usually leave their medical practitioners in a very complicated situation as the law requires consent from the patient themselves. This makes the process of decision making ineffective.
Another form of deferential Vulnerability occurs in more conserved traditional families whereby female patients have to be accompanied by a male member of their families, such as dad, brother, or husband.
In this case, decisions are made by the family as opposed to the western world where the patient is left to make decisions on their own. This sort of circumstances makes women vulnerable.
Others, especially of the African culture, consult their forefathers or ancestors.
Relatives of a patient may ask medical practitioners to allow them to take their child home for sacrifices. A cow or goat is usually sacrificed to the ancestors. The relatives may also defer to a traditional healer to get guidance on the way forward.
The concept of Informed consent
Informed consent is the process of having an understanding of the benefits and risks involved with a specific medical procedure.
Medical practitioners are expected by law to give a patient all the information about a specific test or treatment so that the patient can decide if they wish to continue with the procedure.
The legal term of failing to provide informed consent before performing a test or procedure is known as ‘battery’. It is a form of assault.
Informed consent is equally essential when medical researchers recruit patients for medical research and other clinical trials. This is because there could be significant risks involved in the entire research process.
However, there are circumstances where there are exceptions to informed consent. The most common exemptions include:
i. Incompetence in which an individual is not able to give or refuse permission for treatment or testing.
ii. During emergencies whereby there is an immediate need for medical treatment to prevent serious and irreversible harm.
iii. In paediatrics, legal guardians or patients are allowed to give consent because their children are under the age of 18. Children under the age of 18 are considered minors, and hence they cannot make decisions insofar as medical treatment is concerned.
Components of Informed Consent
There are four components of informed consent:
You have to have the capacity or ability to make decisions.
You must be able to comprehend the information given.
The doctor must provide all relevant information regarding tests, procedures, benefits, and expected risks.
You must be able to grant consent without duress or coercion voluntarily.
Deferential Vulnerability Versus Informed Consent
Deferential Vulnerability interferes with informed consent because the process is not entirely voluntary.
It increases the risk of harm that informed consent would have compromised. This is because subjects are not able to protect their interests.
The individuals affected by deferential Vulnerability are subject to exploitation because of their subordinate status.
Other Forms of Vulnerability in the Process of Research
- Cognitive Vulnerability
- Institutional Vulnerability
- Situational Vulnerability
- Medical Vulnerability
- Social Vulnerability and
- Economic Vulnerability
Cognitive or Communicative Vulnerability
Cognitive Vulnerability means that the person is not in a position to make an informed decision on whether to give consent or not. Such subjects are not able to understand information and make decisions. It is also known as communicative Vulnerability. Such individuals include minors or those who have dementia. Such subjects can be vulnerable in this manner because of either of the three reasons:
Situational cognitive Vulnerability
These subjects can make informed decisions; however, they are in situations that cannot allow them to make decisions effectively. Such circumstances include stressful emergencies such as the loss of loved ones, and so forth.
Capacity-related Cognitive Vulnerability
These are the young children and adults having cognitive impairments that have affected their decision-making ability, hence lacking the capacity to make informed decisions.
These are the subjects who read or study a different language in comparison to the researchers. It, therefore, becomes difficult to communicate with the researchers.
Institutional Vulnerability means that the subject may be of maximum cognitive capacity to consent; however, these individuals are subject to the authority of bodies or persons who could be having conflicting interests. They are also said to be dependent.
Examples of individuals subjected to this kind of Vulnerability are the people working for the military and other disciplinary forces and medical students. Incarcerated individuals are also institutionally vulnerable.
Medical Vulnerability usually affects individuals suffering from diseases that do not have a satisfactory standard way of treatment. Such individuals are vulnerable to anyone promising them a ‘miracle cure.’ Such conditions include rare disorders or metastatic cancer. Individuals with rare diseases are subjected to research because their physicians believe that research is the only best alternative to standard treatment.
Medical Vulnerability creates the risk that informed consent could be motivated by the desire to get treatment or a misunderstanding of the potential benefits of the research.
Medical Vulnerability increases the chances of exploitation since the victims have unreasonable expectations regarding the benefits; the researchers may also have misled them about the benefits and risks of the investigation.
Social Vulnerability arises from the position of certain groups in society. These groups are either stereotyped, could have been discriminated against in the past, may have recently immigrated into a new area, maybe economically disadvantaged or may not speak the language. The perceptions devalue members of such groups, their welfare, their contributions to the society as well as their interests.
Prospective subjects have the cognitive ability to make decisions but may be easily lured to participate in research due to the expected financial benefits. These subjects are disadvantaged insofar as the distribution of social goods and services is concerned. Hence making it easier to exploit them economically. Such individuals could participate in research because they do not want to lose access to some of the privileges or benefits.
The subjects may also be offered free healthcare services for conditions not related to the research; hence enrolling in an investigation they could otherwise not participate.