A Tale of Two Capacities: Including Children and Decisionally Vulnerable Adults in Biomedical Research

The participation of individuals who lack decision-making capacity is essential for advancing genomics research and neuroscience, but raises ethical and legal challenges relating to vulnerability, consent, and exclusion. Capacity differences between populations and individuals, the dynamics of capacity over time, and evolving legal consent and capacity regimes all raise uncertainty for researchers, institutional review boards, and policy makers. We review international ethical and legal best practices for including children and decisionally vulnerable adults in health research. Research ethics norms and literature tend to split such groups into narrow silos, which results in inconsistency and conceptual confusion, or to lump them together, which fails to take into account morally relevant differences. Through a narrative review of international norms, we identify challenges common to both groups, while drawing out distinctions reflecting their opposite capacity trajectories. Our comparison between these two populations clarifies underlying ethical concepts and offers opportunities for critique. Children need protection to foster their long-term autonomy, while decisionally vulnerable adults need to be provided with support in order to exercise their autonomy. This leads to differences in how researchers determine who lacks capacity, who has authority to consent, and what criteria guide such decision-making. We also consider how capacity issues color contemporary research governance debates over broad consent, data protection compliance, data sharing, and the return of individual research results and incidental findings.