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ABSTRACT. This paper introduces the term "structural coercion" to underscore the ways in which broader social, economic, and political contexts act upon individuals to compel them to enroll as subjects in clinical research. The paper challenges the adequacy of the concepts of "coercion" and "undue influence" in determining when research participation is voluntary. Acknowledging structural coercion shifts the frame of ethical deliberation away from specific individuals and specific studies to see important patterns in research participation by salient demographic characteristics. The effects of structural coercion manifest themselves in particular research settings, but unlike the conventional form of coercion, it is not rooted in the researcher-participant relationship or linked to particular study protocols. By extracting voluntariness from entrenched conceptions of the researcher-participant dyad, this paper proposes approaches to minimize the effects of structural coercion while creating new ethical imaginaries for review boards and researchers alike.
Whether intended or not, conceptions of informed consent are often rooted in archetypal notions of the researcher and pro- spective study participant. The former is assumed problemati- cally to be a disinterested yet humanitarian individual who is well trained to conduct robust science. The latter is often characterized as being mo- tivated by some altruistic notions about the contribution to science and society they are making even as they seek some personal benefit from the research. Cast in a dyad, the researcher has the responsibility to inform the participant thoroughly about the purpose of the research, the risks and benefits of participation, and any alternatives to research available, as well as the participant's right to withdraw from the study at any time. The prospective study participant, in turn, has the responsibility to take an interest in the information being communicated about the study, read the informed consent form carefully, and ask questions when in need of further clarification. The influences of larger social, cultural, economic, and/or political realities are almost extraneous within this rubric.1 Indeed, the idealized process of informed consent seeks to minimize or eradicate the effects that social context can have on the researcher and especially the prospective study participant. In practice, however, there is now a large body of evidence that emphasizes the profound effects that social and economic contexts have both on researchers' and participants' decision-...