The moral and legal status of Health Care Workers in Cluster Randomized Trials: A response to Weijer and Taljaard.

In 2012 Charles Weijer and colleagues published "The Ottawa Statement on the ethical design and conduct of cluster randomized trials". In 2015, we reflected on this statement and argued that three recommendations in this statement need to be further refined. Weijer and Taljaard have responded to our comments in this issue of the journal. They agree with one of the proposed revisions but not with two others. In this commentary we argue that the main reason why there is disagreement about two of our refinements is that we have different views on the moral and legal status of the health care workers as "research participants" in cluster randomized trials. In this commentary we clarify misunderstandings about our view expressed in 2015 and elaborate on the positions of health care workers in CRTs. We argue that there is sufficient reason to doubt whether the rights and interests of HCWs should be protected by means of ethics guidance documents and laws on human subjects research. Their interests are protected in the first place by professional codes of conduct which ensure that they cannot provide substandard care. Furthermore, protection of HCWs by ethics guidance on human subjects research will create an enormous burden for principle investigators and research ethics committees. Further debate is essential to determine how the interests of HCWs in CRTs can be protected best.