[This is one of the finalists in the 2025 review contest, written by an ACX reader who will remain anonymous until after voting is done. I'll be posting about one of these a week for several months. When you've read them all, I'll ask you to vote for a favorite, so remember which ones you liked]

If you've been following this blog for long, you probably know at least a bit about pharmaceutical research. You might know a bit about the sort of subtle measures pharmaceutical companies take to influence doctors' prescribing habits, or how it takes billions of dollars on average to bring a new medication to market, or something about the perverse incentives which determine the FDA's standards for accepting or rejecting a new drug. You might have some idea what kinds of hoops a company has to jump through to conduct actual research which meets legal guidelines for patient safety and autonomy.

You may be less familiar though, with how the sausage is actually made. How do pharmaceutical companies actually go through the process of testing a drug on human participants?

I'm going to be focusing here on a research subject's view of what are known as Phase I clinical trials, the stage in which prospective drugs are tested for safety and tolerability. This is where researchers aim to answer questions like "Does this drug have any dangerous side effects?" "Through what pathways is it removed from a patient's body?" and "Can we actually give people enough of this drug that it's useful for anything?" This comes before the stage where researchers test how good a drug is at actually treating any sort of disease, when patients who're suffering from the target ailments are given the option receive it as an experimental treatment. In Phase I clinical trials, the participants are healthy volunteers who're participating in research for money. There are almost no cases in which volunteer participation is driven by motivations other than money, because the attitudes between research participants and clinicians overwhelmingly tend to be characterized by mutual guarded distrust. This distrust is baked into the process, both on a cultural level among the participants, and by the clinics' own incentives.

All of what follows is drawn from my own experiences, and experiences that other participants in clinical pharmaceutical research have shared with me, because for reasons which should become clear over the course of this review, research which systematically explores the behaviors and motives of clinical research participants is generally not feasible to conduct.

https://www.astralcodexten.com/p/your-review-participation-in-phase