Of Drowning Children and Doubtful Analogies

In this issue of the Hastings Center Report, James Sabin and his colleagues ask what responsibility investigators in a learning health organization have to patients when research-particularly research of which patients might be unaware-illuminates problematic aspects of the patients' care. Sabin and his colleagues were confronted by this question in the midst of designing a randomized controlled trial that sought to determine if an educational intervention targeted at patients with atrial fibrillation and their clinicians reduces underuse of oral anticoagulants. Worried about harm that might befall patients in the control group and fearing that they would be negligent bystanders if they knew these patients were at risk and did nothing, the investigators adopted a "workaround." But the "workaround," I suggest, was not a solution to the negligent bystander problem. Nor was it a solution to the problem as I would alternatively frame it-how to address instances of suboptimal patient care identified through research within learning health organizations.