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Earl J, Dawson L, Rid A. The Social Value Misconception in Clinical Research. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024:1-17. [PMID: 39007856 DOI: 10.1080/15265161.2024.2371119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
Clinical researchers should help respect the autonomy and promote the well-being of prospective study participants by helping them make voluntary, informed decisions about enrollment. However, participants often exhibit poor understanding of important information about clinical research. Bioethicists have given special attention to "misconceptions" about clinical research that can compromise participants' decision-making, most notably the "therapeutic misconception." These misconceptions typically involve false beliefs about a study's purpose, or risks or potential benefits for participants. In this article, we describe a misconception involving false beliefs about a study's potential benefits for non-participants, or its expected social value. This social value misconception can compromise altruistically motivated participants' decision-making, potentially threatening their autonomy and well-being. We show how the social value misconception raises ethical concerns for inherently low-value research, hyped research, and even ordinary research, and advocate for empirical and normative work to help understand and counteract this misconception's potential negative impacts on participants.
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Affiliation(s)
- Jake Earl
- Walter Reed Army Institute of Research
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Smith JN, Smolenski J, Lang BH, Blumenthal-Barby J. From Opioid Overdose to LVAD Refusals: Navigating the Spectrum of Decisional Autonomy. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:8-10. [PMID: 38635427 DOI: 10.1080/15265161.2024.2329496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Affiliation(s)
| | | | - Ben H Lang
- Baylor College of Medicine
- Oxford University
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Piscitello GM, Parker WF. Do-Not-Resuscitate Orders by COVID-19 Status Throughout the First Year of the COVID-19 Pandemic. Chest 2024; 165:601-609. [PMID: 37778695 PMCID: PMC10925541 DOI: 10.1016/j.chest.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 09/13/2023] [Accepted: 09/25/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND At the beginning of the COVID-19 pandemic, whether performing CPR on patients with COVID-19 would be effective or increase COVID-19 transmission to health care workers was unclear. RESEARCH QUESTION Did the prevalence of do-not-resuscitate (DNR) orders by COVID-19 status change over the first year of the pandemic as risks such as COVID-19 transmission to health care workers improved? STUDY DESIGN AND METHODS This cross-sectional study assessed DNR orders for all adult patients admitted to ICUs at two academic medical centers in Chicago, IL, between April 2020 and April 2021. DNR orders by COVID-19 status were assessed using risk-adjusted mixed-effects logistic regression and propensity score matching by patient severity of illness. RESULTS The study population of 3,070 critically ill patients were 46% Black, 53% male, with median age (interquartile range [IQR]) 63 (50-73) years. Eighteen percent were COVID-19 positive and 27% had a DNR order. Black and Latinx patients had higher absolute rates of DNR orders than White patients (30% vs 29% vs 23%; P = .006). After adjustment for patient characteristics, illness severity, and hospital location, DNR orders were more likely in patients with COVID-19 in the nonpropensity score-matched (n = 3,070; aOR, 2.01; 95% CI, 1.64-2.38) and propensity score-matched (n = 1,118; aOR, 1.91; 95% CI, 1.45-2.52) cohorts. The prevalence of DNR orders remained higher for patients with COVID-19 than patients without COVID-19 during all months of the study period (difference in prevalence over time, P = .751). INTERPRETATION In this multihospital study, DNR orders remained persistently higher for patients with COVID-19 vs patients without COVID-19 with similar severity of illness during the first year of the pandemic. The specific reasons why DNR orders remained persistently elevated for patients with COVID-19 should be assessed in future studies, because these changes may continue to affect COVID-19 patient care and outcomes.
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Affiliation(s)
- Gina M Piscitello
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA; Palliative Research Center, University of Pittsburgh, Pittsburgh, PA.
| | - William F Parker
- Department of Pulmonary and Critical Care, University of Chicago, Chicago, IL; MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL
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Hofmann B. Undermining autonomy and consent: the transformative experience of disease. JOURNAL OF MEDICAL ETHICS 2024; 50:195-200. [PMID: 37137696 DOI: 10.1136/jme-2023-108906] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/20/2023] [Indexed: 05/05/2023]
Abstract
Disease radically changes the life of many people and satisfies formal criteria for being a transformative experience. According to the influential philosophy of Paul, transformative experiences undermine traditional criteria for rational decision-making. Thus, the transformative experience of disease can challenge basic principles and rules in medical ethics, such as patient autonomy and informed consent. This article applies Paul's theory of transformative experience and its expansion by Carel and Kidd to investigate the implications for medical ethics. It leads to the very uncomfortable conclusion that disease involves transformative experiences in ways that can reduce people's rational decision-making ability and undermine the basic principle of respect for autonomy and the moral rule of informed consent. While such cases are limited, they are crucial for medical ethics and health policy and deserve more attention and further scrutiny.
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Affiliation(s)
- Bjørn Hofmann
- Centre for Medical Ethics, University of Oslo Faculty of Medicine, Oslo, Norway
- Institute for the Health Sciences, Norwegian University of Science and Technology Faculty of Medicine and Health Sciences, Gjøvik, Norway
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Church PT, Dahan M, Rule A, Janvier A, Stewart JE, Maypole JS, Fehlings D, Litt JS, Banihani R. NICU Language, Everyday Ethics, and Giving Better News: Optimizing Discussions about Disability with Families. CHILDREN (BASEL, SWITZERLAND) 2024; 11:242. [PMID: 38397354 PMCID: PMC10887718 DOI: 10.3390/children11020242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/01/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024]
Abstract
The Neonatal Intensive Care Unit (NICU) has a language and culture that is its own. For professionals, it is a place of intense and constant attention to microdetails and cautious optimism. For parents, it is a foreign place with a new and unique language and culture. It is also the setting in which they are introduced to their child and parenthood for this child. This combination has been referred to as an emotional cauldron. The neonatal ethics literature mainly examines complex ethical dilemmas about withholding/drawing life sustaining interventions for fragile children. Rarely are everyday ethics or mundane ethics discussed. Microethics describe the mundane, discrete moments that occur between patients/families and clinicians. A key piece of these microethics is the language used to discuss patient care. Perception of prognoses, particularly around long-term neurodevelopmental outcome, is shaped with the language used. Despite this, clinicians in the NICU often have no specific training in the long-term neurodevelopment outcomes that they discuss. This paper focuses on the microethics of language used to discuss long-term neurodevelopmental outcomes, the developmental neuroscience behind language processing, and offers recommendations for more accurate and improved communication around long-term outcomes with families with critically ill neonates.
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Affiliation(s)
| | - Maya Dahan
- Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada (R.B.)
| | - Amy Rule
- Children’s Healthcare of Atlanta, Atlanta, GA 30342, USA
| | | | - Jane E. Stewart
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (J.E.S.)
| | | | - Darcy Fehlings
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON M4G 1R8, Canada;
| | - Jonathan S. Litt
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (J.E.S.)
| | - Rudaina Banihani
- Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada (R.B.)
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Holm A, Rodkjær LØ, Bekker HL. Integrating Patient Involvement Interventions within Clinical Practice: A Mixed-Methods Study of Health Care Professional Reasoning. MDM Policy Pract 2024; 9:23814683241229987. [PMID: 38362059 PMCID: PMC10868494 DOI: 10.1177/23814683241229987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 01/13/2024] [Indexed: 02/17/2024] Open
Abstract
Background. Patient involvement interventions are complex interventions that improve patient involvement in treatment and care in health care systems. Studies report several benefits of patient involvement interventions and that health care professionals are positive about using them. However, they have not been explored as a collected group of interventions throughout the continuum of care and treatment. In addition, the relationship between patient involvement interventions and the clinical reasoning process of health care professionals has not been thoroughly studied. Design. This mixed-methods study was conducted at Aarhus University Hospital in Denmark between April and November 2022 using interview data from 12 health care professionals and survey data from 420 health care professionals. Informants were medical doctors, nurses, midwives, dietitians, physiotherapists, and occupational therapists who had direct contact with patients during their daily care and treatment. Quantitative data were analyzed using descriptive statistics; qualitative data were analyzed via inductive and deductive content analysis. Results. Communication and interaction were seen as overarching aspects of patient involvement, with patient involvement interventions being defined as concrete tools and methods to enhance health care professionals' explicit clinical reasoning process. Limitations. It is unclear if results are representative of all health care professionals at the hospital or only those with a positive view of patient involvement interventions. Conclusions. Patient involvement interventions are viewed as beneficial for patients and fit with the clinical reasoning of health care professionals. Clinical reasoning may be an active ingredient in the development and implementation of patient involvement interventions. Implications. In practice, health care professionals need training in person-centered communication and the ability to articulate their clinical reasoning explicitly. In research, a more in-depth understanding of the interrelations between patient involvement interventions and clinical reasoning is needed. Highlights Communication and interaction are the fundamental goals of patient involvement in practice, regardless of which patient involvement intervention is being used.Clinical reasoning is often an unconscious process using tacit knowledge, but the use of patient involvement interventions may be a way for health care professionals (at both individual and group levels) to become more explicit about and aware of their reflections.Clinical reasoning can be viewed as a mechanism of change in the development and implementation of patient involvement interventions.
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Affiliation(s)
- Anna Holm
- Research Centre for Patient Involvement, Department of Public Health, Aarhus University and Aarhus University Hospital, Denmark
- Department of Intensive Care, Aarhus University Hospital, Denmark
| | - Lotte Ørneborg Rodkjær
- Research Centre for Patient Involvement, Department of Public Health, Aarhus University and Aarhus University Hospital, Denmark
- Department of Infectious Disease, Aarhus University Hospital, Denmark
| | - Hilary Louise Bekker
- Research Centre for Patient Involvement, Department of Public Health, Aarhus University and Aarhus University Hospital, Denmark
- Leeds Unit of Complex Intervention Development (LUCID), Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, UK
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7
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Buturovic Z. Risk aversion and rational choice theory do not adequately capture complexities of medical decision-making. JOURNAL OF MEDICAL ETHICS 2023; 49:761-762. [PMID: 37596056 DOI: 10.1136/jme-2023-109337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/28/2023] [Indexed: 08/20/2023]
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da Silva MDAP, Corradi-Perini C. The Mapping of Influencing Factors in the Decision-Making of End-of-Life Care Patients: A Systematic Scoping Review. Indian J Palliat Care 2023; 29:234-242. [PMID: 37700891 PMCID: PMC10493695 DOI: 10.25259/ijpc_292_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 01/27/2023] [Indexed: 09/14/2023] Open
Abstract
Decisions in end-of-life care are influenced by several factors, many of which are not identified by the decision maker. These influencing factors modify important decisions in this scenario, such as in decisions to adapt to therapeutic support. This presented scoping review aims to map the factors that influence end-of-life care decisions for adult and older adult patients, by a scoping review. The review was carried out in 19 databases, with the keyword 'clinical decision-making' AND 'terminal care' OR 'end-of-life care' and its analogues, including publications from 2017 to 2022. The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. The search resulted in 3474 publications, where the presence of influencing factors in end-of-life decision-making for adults and the elderly was applied as a selection criterion. Fifty-four (54) of them were selected, which means 1.5% of all the results. Among the selected publications, 89 influencing factors were found, distributed in 54 (60.6%) factors related to the health team, 18 (20.2%) to patients, 10 (11.2%) related to family or surrogates and 7 (7.8%) factors related to the decision environment. In conclusion, we note that the decision-making in end-of-life care is complex, mainly because there is an interaction of different characters (health team, patient, family, or surrogates) with a plurality of influencing factors, associated with an environment of uncertainty and that result in a critical outcome, with a great repercussion for the end of life, making it imperative the recognition of these factors for more competent and safe decision-making.
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Affiliation(s)
| | - Carla Corradi-Perini
- Bioethics Graduate Program, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
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Hofmann B. To Consent or Not to Consent to Screening, That Is the Question. Healthcare (Basel) 2023; 11:healthcare11070982. [PMID: 37046909 PMCID: PMC10094591 DOI: 10.3390/healthcare11070982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 03/31/2023] Open
Abstract
The objective of this article is to address the controversial question of whether consent is relevant for persons invited to participate in screening programs. To do so, it starts by presenting a case where the provided information historically has not been sufficient for obtaining valid informed consent for screening. Then, the article investigates some of the most relevant biases that cast doubt on the potential for satisfying standard criteria for informed consent. This may indicate that both in theory and in practice, it can be difficult to obtain valid consent for screening programs. Such an inference is profoundly worrisome, as invitees to screening programs are healthy individuals most suited to make autonomous decisions. Thus, if consent is not relevant for screening, it may not be relevant for a wide range of other health services. As such, the lack of valid consent in screening raises the question of the relevance of one of the basic ethical principles in healthcare (respect for autonomy), one of the most prominent legal norms in health legislation (informed consent), and one of the most basic tenets of liberal democracies (individual autonomy). Thus, there are good reasons to provide open, transparent, and balanced information and minimize biases in order to ascertain informed consent in screening.
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Hofmann B. Biases in bioethics: a narrative review. BMC Med Ethics 2023; 24:17. [PMID: 36879251 PMCID: PMC9990212 DOI: 10.1186/s12910-023-00894-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 02/16/2023] [Indexed: 03/08/2023] Open
Abstract
Given that biases can distort bioethics work, it has received surprisingly little and fragmented attention compared to in other fields of research. This article provides an overview of potentially relevant biases in bioethics, such as cognitive biases, affective biases, imperatives, and moral biases. Special attention is given to moral biases, which are discussed in terms of (1) Framings, (2) Moral theory bias, (3) Analysis bias, (4) Argumentation bias, and (5) Decision bias. While the overview is not exhaustive and the taxonomy by no means is absolute, it provides initial guidance with respect to assessing the relevance of various biases for specific kinds of bioethics work. One reason why we should identify and address biases in bioethics is that it can help us assess and improve the quality of bioethics work.
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Affiliation(s)
- Bjørn Hofmann
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU), PO Box 191, 2801, Gjøvik, Norway. .,The Centre of Medical Ethics at the University of Oslo, Oslo, Norway.
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11
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Job C, Adenipekun B, Cleves A, Samuriwo R. Health professional's implicit bias of adult patients with low socioeconomic status (SES) and its effects on clinical decision-making: a scoping review protocol. BMJ Open 2022; 12:e059837. [PMID: 36523234 PMCID: PMC9748961 DOI: 10.1136/bmjopen-2021-059837] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Despite efforts to improve population health and reduce health inequalities, higher morbidity and mortality rates for people with lower socioeconomic status (SES) persist. People with lower SES are said to receive worse care and have worse outcomes compared with those with higher SES, in part due to bias and prejudice. Implicit biases adversely affect professional patient relationships and influence healthcare-related decision-making. A better understanding of the relationship between SES and healthcare-related decision-making is therefore essential to address socioeconomic inequalities in health. AIM To scope the reported impact of health professionals bias about SES on clinical decision-making and its effect on the care of adults with lower SES in wider literature. METHODS This scoping review will use Joanna Briggs Institute methods and will report its findings in line with Preferred Items for Systematic Reviews and Meta-Analyses for Protocols and Scoping Reviews guidelines. Data analysis, interpretation and reporting will be underpinned by the PAGER (Patterns, Advances, Gaps, Evidence for Practice and Research recommendations) framework and input from a patient and public interest representative. A systematic search for literature will be conducted on various, pertinent databases to identify relevant literature such as peer-reviewed articles, editorials, discussion papers and empirical research papers. Additionally, other sources of relevant literature such as policies, guidelines, reports and conference abstracts, identified through key website searches will be considered for inclusion. ETHICS AND DISSEMINATION Ethical approval is not required for this scoping review. The results will be disseminated through an open access peer-reviewed international journal, conference presentations and a plain language summary that will be shared with the public and other relevant stakeholders.
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Affiliation(s)
- Claire Job
- Cardiff University College of Biomedical and Life Sciences, Cardiff, UK
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Bami Adenipekun
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Anne Cleves
- Velindre University NHS Trust Library, Cardiff University Information Services, Cardiff, UK
| | - Ray Samuriwo
- School of Nursing and Healthcare Leadership, University of Bradford, Bradford, UK
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Polyakov A, Amor DJ, Savulescu J, Gyngell C, Georgiou EX, Ross V, Mizrachi Y, Rozen G. Polygenic risk score for embryo selection—not ready for prime time. Hum Reprod 2022; 37:2229-2236. [PMID: 35852518 PMCID: PMC9527452 DOI: 10.1093/humrep/deac159] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/23/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Numerous chronic diseases have a substantial hereditary component. Recent advances in human genetics have allowed the extent of this to be quantified via genome-wide association studies, producing polygenic risk scores (PRS), which can then be applied to individuals to estimate their risk of developing a disease in question. This technology has recently been applied to embryo selection in the setting of IVF and preimplantation genetic testing, with limited data to support its utility. Furthermore, there are concerns that the inherent limitations of PRS makes it ill-suited for use as a screening test in this setting. There are also serious ethical and moral questions associated with this technology that are yet to be addressed. We conclude that further research and ethical reflection are required before embryo selection based on PRS is offered to patients outside of the research setting.
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Affiliation(s)
- Alex Polyakov
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne , Melbourne, VIC, Australia
- Reproductive Biology Unit, The Royal Women’s Hospital , Parkville, VIC, Australia
- Melbourne IVF , East Melbourne, VIC, Australia
| | - David J Amor
- Murdoch Children’s Research Institute , Parkville, VIC, Australia
- Department of Paediatrics, Royal Children’s Hospital, University of Melbourne , Parkville, VIC, Australia
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford , Oxford, UK
- Biomedical Ethics Research Group, Murdoch Children's Research Institute , Melbourne, VIC, Australia
- Melbourne Law School, University of Melbourne , Melbourne, VIC, Australia
| | - Christopher Gyngell
- Melbourne Law School, University of Melbourne , Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne , Melbourne, VIC, Australia
| | - Ektoras X Georgiou
- Reproductive Biology Unit, The Royal Women’s Hospital , Parkville, VIC, Australia
| | - Vanessa Ross
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne , Melbourne, VIC, Australia
- Reproductive Biology Unit, The Royal Women’s Hospital , Parkville, VIC, Australia
- Melbourne IVF , East Melbourne, VIC, Australia
| | - Yossi Mizrachi
- Reproductive Biology Unit, The Royal Women’s Hospital , Parkville, VIC, Australia
| | - Genia Rozen
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne , Melbourne, VIC, Australia
- Reproductive Biology Unit, The Royal Women’s Hospital , Parkville, VIC, Australia
- Melbourne IVF , East Melbourne, VIC, Australia
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Saposnik G, Camacho A, Díaz-Abós P, Brañas-Pampillón M, Sánchez-Menéndez V, Cabello-Moruno R, Terzaghi M, Maurino J, Málaga I. Therapeutic Decision-Making Under Uncertainty in the Management of Spinal Muscular Atrophy: Results From DECISIONS-SMA Study. Neurol Ther 2022; 11:1209-1219. [PMID: 35657490 PMCID: PMC9338192 DOI: 10.1007/s40120-022-00366-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/13/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction There are many uncertainties about treatment selection and expectations regarding therapeutic goals and benefits in the new landscape of spinal muscular atrophy (SMA). Our aim was to assess treatment preferences and expectations of pediatric neurologists caring for patients with SMA. Methods DECISIONS-SMA is a non-interventional, cross-sectional pilot study that assessed pediatric neurologists with expertise in SMA from across Spain. Participants were presented with 11 simulated case scenarios of common encounters of patients with SMA type 1 and 2 to assess treatment initiation, escalation, or switches. We also asked for the expected benefit with new therapies for four simulated case scenarios. Participants completed a behavioral battery to address their tolerance to uncertainty and aversion to ambiguity. The primary outcome was therapeutic inertia (TI), defined as the number of simulated scenarios with lack of treatment initiation or escalation when warranted over the total (11) presented cases. Results A total of 35 participants completed the study. Participants’ mean (SD) expectation for achieving an improvement by starting a new therapy for SMA type 1 (case 1, a 5-month-old) and SMA type 2 (case 6, a 1-year-old) were both 59.6% (± 21.8), but declined to 20.2% (± 12.2) for a case scenario of a 16-year-old treatment-naïve patient with long-standing SMA type 2 with severe disability. The mean (SD) TI score was 4.2 (1.7), and 3.29 (1.5) for treatment initiation. Of a total 385 individual responses, TI was observed in 147 (38.2%) of treatment choices. The multivariable analysis showed that lower aversion to ambiguity (p = 0.019) and lower expectation of treatment response (p = 0.007) were associated with higher TI after adjustment for participants’ age and years of experience. Older age (p = 0.019), lower years of experience (p = 0.035), lower aversion to ambiguity (p = 0.015), and lower expectation of treatment benefits (p = 0.006) were associated with inertia for treatment initiation. Conclusions Pediatric neurologists managing patients with SMA were optimistic regarding treatment improvement in cases with early diagnosis, but had lower expectations when treatment delays and advanced patient age were present. Low aversion to ambiguity, low expectation of treatment benefits, and lower clinical experience were more likely to make suboptimal decisions, resulting in lack of treatment initiation, escalation, and TI. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-022-00366-4.
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Affiliation(s)
- Gustavo Saposnik
- Clinical Outcomes and Decision Neuroscience Unit, Li Ka Shing Institute, University of Toronto, Toronto, Canada. .,Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada.
| | - Ana Camacho
- Division of Child Neurology, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | | | | | | | | | - María Terzaghi
- Clinical Outcomes and Decision Neuroscience Unit, Li Ka Shing Institute, University of Toronto, Toronto, Canada
| | | | - Ignacio Málaga
- Child Neurology Unit, Hospital Universitario Central de Asturias, Oviedo, Spain
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Mamode N, Van Assche K, Burnapp L, Courtney A, van Dellen D, Houthoff M, Maple H, Moorlock G, Dor FJMF, Lennerling A. Donor Autonomy and Self-Sacrifice in Living Organ Donation: An Ethical Legal and Psychological Aspects of Transplantation (ELPAT) View. Transpl Int 2022; 35:10131. [PMID: 35387400 PMCID: PMC8979023 DOI: 10.3389/ti.2022.10131] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/02/2022] [Indexed: 11/26/2022]
Abstract
Clinical teams understandably wish to minimise risks to living kidney donors undergoing surgery, but are often faced with uncertainty about the extent of risk, or donors who wish to proceed despite those risks. Here we explore how these difficult decisions may be approached and consider the conflicts between autonomy and paternalism, the place of self-sacrifice and consideration of risks and benefits. Donor autonomy should be considered as in the context of the depth and strength of feeling, understanding risk and competing influences. Discussion of risks could be improved by using absolute risk, supra-regional MDMs and including the risks to the clinical team as well as the donor. The psychological effects on the donor of poor outcomes for the untransplanted recipient should also be taken into account. There is a lack of detailed data on the risks to the donor who has significant co-morbidities.
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Affiliation(s)
- Nizam Mamode
- Department of Transplantation, Guys and St Thomas NHS Foundation Trust, London, United Kingdom
- *Correspondence: Nizam Mamode,
| | - Kristof Van Assche
- Research Group Personal Rights and Property Rights, University of Antwerp, Antwerp, Belgium
| | - Lisa Burnapp
- Department of Transplantation, Guys and St Thomas NHS Foundation Trust, London, United Kingdom
| | - Aisling Courtney
- Regional Nephrology and Transplant Unit, Belfast City Hospital, Belfast, United Kingdom
| | - David van Dellen
- Department of Renal and Pancreas Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Mireille Houthoff
- Erasmus MC Transplant Institute, Department of Internal Medicine, University Medical Centre, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Hannah Maple
- Department of Transplantation, Guys and St Thomas NHS Foundation Trust, London, United Kingdom
| | - Greg Moorlock
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Frank J. M. F. Dor
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Annette Lennerling
- The Transplant Centre, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Erel M, Marcus EL, Dekeyser-Ganz F. Practitioner Bias as an Explanation for Low Rates of Palliative Care Among Patients with Advanced Dementia. HEALTH CARE ANALYSIS 2022; 30:57-72. [PMID: 33782805 DOI: 10.1007/s10728-021-00429-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2021] [Indexed: 02/05/2023]
Abstract
Patients with advanced dementia are less likely than those with other terminal illnesses to receive palliative care. Due to the nature and course of dementia, there may be a failure to recognize the terminal stage of the disease. A possible and under-investigated explanation for this healthcare disparity is the healthcare practitioner who plays a primary role in end-of-life decision-making. Two potential areas that might impact provider decision-making are cognitive biases and moral considerations. In this analysis, we demonstrate how the cognitive biases and moral considerations of practitioners related to clinical decision-making are inherent in clinical practice and may impact on providers' accuracy related to diagnostic and treatment related decision-making associated with patients with advanced dementia. Anchoring, default, availability, representativeness and framing biases are cognitive biases based on the "Two System Model" that relate to decision-making in end-of-life care. In patients with advanced dementia, those biases may result in a tendency to adhere to traditional mandatory care, involving an aggressive approach to care, which values saving lives at all costs, without taking into account the possible suffering and long-term consequences. Aspects such as moral sensitivity and moral courage play an important role in ethical decision-making related to advanced dementia. Investigations of clinical decision-making that include the cognitive biases and ethical considerations of practitioners might advance the comprehensive understanding of the clinical decision-making process related to care of patients with advanced dementia and promote the quality of care given to this population.
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Affiliation(s)
- Meira Erel
- Henrietta Szold Hadassah-Hebrew University School of Nursing, Kiryat Hadassah, POB 1200, 9112001, Jerusalem, Israel.
- Faculty of Medicine, Hadassah-Hebrew University, Jerusalem, Israel.
| | - Esther-Lee Marcus
- Henrietta Szold Hadassah-Hebrew University School of Nursing, Kiryat Hadassah, POB 1200, 9112001, Jerusalem, Israel
- Faculty of Medicine, Hadassah-Hebrew University, Jerusalem, Israel
- Geriatric Division, Herzog Medical Center, Givat Shaul Street, POB 3900, 9103702, Jerusalem, Israel
| | - Freda Dekeyser-Ganz
- Henrietta Szold Hadassah-Hebrew University School of Nursing, Kiryat Hadassah, POB 1200, 9112001, Jerusalem, Israel
- Jerusalem College of Technology, 11 Beit-Hadfus, Jerusalem, 9548311, Israel
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Gordon G, Williamson G, Gkofa V, Schmidt U, Brockmeyer T, Campbell I. Participants' experience of approach bias modification training with transcranial Direct Current Stimulation as a combination treatment for binge eating disorder. EUROPEAN EATING DISORDERS REVIEW 2021; 29:969-984. [PMID: 34460140 DOI: 10.1002/erv.2859] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/25/2021] [Accepted: 08/09/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE This study explored participants' experience of approach bias modification training (ABM) with transcranial Direct Current Stimulation (tDCS) for binge eating disorder (BED) within a randomised controlled trial (RCT). A subset of participants who completed the RCT were interviewed to attain feedback on treatment experience and outcomes. METHOD 15 participants with BED who completed the RCT were recruited, using purposive sampling. Participants received six sessions of concurrent ABM training with either real or sham tDCS. Semi-structured interviews relating to study experience and treatment outcomes were conducted and data were analysed thematically. RESULTS The combined ABM and tDCS intervention was deemed acceptable and worthwhile by participants interviewed across both intervention groups. Negative preconceptions of tDCS were an initial deterrent to study participation for some, yet the brain stimulation experience was found to be tolerable. Minor and transient sensations and side effects attributed to tDCS were reported by most participants during and after stimulation, in addition to less pleasant aspects of ABM training, with no significant adverse effects reported by interviewees. Positive outcomes were described by participants across both intervention groups, relating to changes in BED symptoms and to broader beneficial effects on associated cognitive and emotional factors. Two participants experienced a shift in autonomy, attributed to tDCS and the combined intervention respectively. CONCLUSIONS Adults with symptoms of BED found concurrent ABM and tDCS sessions to be acceptable, despite initial apprehension about the safety of tDCS. Findings are relevant to the neuroethics literature and may inform science communication strategies on neuromodulation treatments.
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Affiliation(s)
- Gemma Gordon
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Grace Williamson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Vasiliki Gkofa
- Division of Psychiatry, University College London, London, UK
| | - Ulrike Schmidt
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Timo Brockmeyer
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, University of Gottingen, Goettingen, Germany
| | - Iain Campbell
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Elternzentrierte ethische Entscheidungsfindung für Frühgeborene im Grenzbereich der Lebensfähigkeit – Reflexion über die Bedeutung probabilistischer Prognosen als Entscheidungsgrundlage. Ethik Med 2021. [DOI: 10.1007/s00481-021-00653-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
ZusammenfassungFrühgeborene im Grenzbereich der Lebensfähigkeit befinden sich in einer prognostischen Grauzone. Das bedeutet, dass deren Prognose zwar schlecht, aber nicht hoffnungslos ist, woraus folgt, dass nach Geburt lebenserhaltende Behandlungen nicht obligatorisch sind. Die Entscheidung für oder gegen lebenserhaltende Maßnahmen ist wertbeladen und für alle Beteiligten enorm herausfordernd. Sie sollte eine zwischen Eltern und Ärzt*innen geteilte Entscheidung sein, wobei sie unbedingt mit den Präferenzen der Eltern abgestimmt sein sollte. Bei der pränatalen Beratung der Eltern legen die behandelnden Ärzt*innen üblicherweise numerische Schätzungen der Prognose vor und nehmen in der Regel an, dass die Eltern ihre Behandlungspräferenzen davon ableiten. Inwieweit probabilistische Daten die Entscheidungen der Eltern in prognostischen Grauzonen tatsächlich beeinflussen, ist noch unzureichend untersucht. In der hier vorliegenden Arbeit wird eine Studie reflektiert, in welcher die Hypothese geprüft wurde, dass numerisch bessere oder schlechtere kindliche Prognosen die Präferenzen werdender Mütter für lebenserhaltende Maßnahmen nicht beeinflussen. In dieser Studie zeigte sich, dass die elterlichen Behandlungspräferenzen eher von individuellen Einstellungen und Werten als von Überlegungen zu numerischen Ergebnisschätzungen herzurühren scheinen. Unser Verständnis, welche Informationen werdende Eltern, die mit einer extremen Frühgeburt konfrontiert sind, wünschen und brauchen, ist noch immer unvollständig. Bedeutende medizinische Entscheidungen werden keineswegs nur rational und prognoseorientiert gefällt. In der vorliegenden Arbeit wird diskutiert, welchen Einfluss der Prozess der Entscheidungsfindung auf das Beratungsergebnis haben kann und welche Implikationen sich aus den bisher vorliegenden Studienergebnissen ergeben – klinisch-praktisch, ethisch und wissenschaftlich.
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Monzani D, Pancani L, Rusconi P, Pravettoni G. Perceived Onset Time of Medical Conditions: The Interplay Between Subjective Fear and Risk in Four Lifestyle Domains. Psychol Rep 2021; 125:2981-3005. [PMID: 34324370 DOI: 10.1177/00332941211036028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Engaging in unhealthy behaviors (e.g., smoking, drinking) and not engaging in healthy ones (e.g., exercising, consuming fruit and vegetables) are both relatively prevalent among individuals despite the available information about their risks for health. People's perception of an event's time course can be used to gauge their risk perception for that event thus casting light on any possible misperception and suggesting directions for health-promoting interventions. This study investigates people's perception of the time of onset of 5 noncommunicable diseases (e.g., "having high blood pressure") associated with 4 health-related behaviors: Smoking, drinking, exercising, and eating fruit and vegetable. Participants from Italy (N = 214) and the UK (N = 151) gave onset time estimates of how long they thought it would take for 5 noncommunicable diseases to occur in the life of an 18-year-old person who starts or stops adopting those health-related behaviors. Results showed that participants who rated the noncommunicable diseases as more likely to themselves perceived the onset time of these diseases as more temporally proximal. Participants who were more afraid of developing the noncommunicable diseases estimated their onset time as delayed.
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Affiliation(s)
- Dario Monzani
- Department of Oncology and Hemato-Oncology, University of Milan, Italy; Applied Research Division for Cognitive and Psychological Science, European Institute of Oncology IRCCS, Milan, Italy
| | - Luca Pancani
- Department of Psychology, University of Milano - Bicocca, Italy
| | - Patrice Rusconi
- School of Psychology, University of Surrey, UK; Department of Cognitive Sciences, Psychology, Education and Cultural Studies, 18980University of Messina, Italy
| | - Gabriella Pravettoni
- Department of Oncology and Hemato-Oncology, University of Milan, Italy; Applied Research Division for Cognitive and Psychological Science, European Institute of Oncology IRCCS, Milan, Italy
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Lazaridis C, Mansour A. To Decompress or Not? An Expected Utility Inspired Approach To Shared decision-making For Supratentorial Ischemic Stroke. Neurocrit Care 2021; 34:709-713. [PMID: 33604879 DOI: 10.1007/s12028-021-01198-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
Patients with large territorial supratentorial infarctions are at high risk of cerebral edema, increased intracranial pressure, tissue herniation and death. There is strong evidence supporting prompt decompressive craniectomy after large hemispheric ischemic stroke as a means to reduce mortality. Nevertheless, functional outcomes can vary significantly. Clinical trials have traditionally judged these outcomes by a priori dichotomization without taking into account individual patient and caregiver preferences. If these are not incorporated into shared decision-making, there are significant risks in both directions, i.e. producing outcomes that may be judged as unacceptable to survivors, or not offering life-saving treatments to patients that according to their own values could be beneficial. In the absence of decision aids, we explore insights from decision theory and propose an expected utility-inspired approach as a supplementary navigating tool in the decision-making process. Four patient case scenarios are discussed as a demonstration of using individualized rankings of outcome preferences, and deriving expected utilities for interventions such as decompressive craniectomy versus medical therapy. The ultimate aim of the suggested approach is to assure that patient values are elicited and incorporated, and possible range and nature of outcomes are discussed, and by attempting to connect best available means to patient individualized ends.
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Affiliation(s)
- Christos Lazaridis
- Neurocritical Care Unit, Departments of Neurology, and Surgery (Section of Neurosurgery), University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, USA.
| | - Ali Mansour
- Neurocritical Care Unit, Departments of Neurology, and Surgery (Section of Neurosurgery), University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, USA
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Lazaridis C. Deciding Under Uncertainty: The Case of Refractory Intracranial Hypertension. Front Neurol 2020; 11:908. [PMID: 32973664 PMCID: PMC7468512 DOI: 10.3389/fneur.2020.00908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/14/2020] [Indexed: 02/05/2023] Open
Abstract
A challenging clinical conundrum arises in severe traumatic brain injury patients who develop intractable intracranial hypertension. For these patients, high morbidity interventions such as surgical decompression and barbiturate coma have to be considered against a backdrop of uncertain outcomes including prolonged states of disordered consciousness and severe disability. The clinical evidence available to guide shared decision-making is mainly limited to one randomized controlled trial, the RESCUEicp. However, since the publication of this trial significant controversy has been ongoing over the interpretation of the results. Is the mortality benefit from surgery merely a trade off for unacceptable long-term disability? How should treatment options, possible outcomes, and results from the trial be communicated to surrogates? How do we incorporate patient values into forming plans of care? The aim of this article is to sketch an approach based on insights from Decision Theory, and specifically deciding under uncertainty. The mainstream normative decision theory, Expected Utility (EU) theory, essentially says that, in situations of uncertainty, one should prefer the option with greatest expected desirability or value. The steps required to compute expected utilities include listing the possible outcomes of available interventions, assigning each outcome a utility ranking representing an individual patient's preferences, and a conditional probability given each intervention. This is a conceptual framework meant to supplement, and enhance shared decision making by assuring that patient values are elicited and incorporated, the possible range and nature of outcomes is discussed, and finally by attempting to connect best available means to patient-individualized ends.
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Affiliation(s)
- Christos Lazaridis
- Neurocritical Care Unit, Department of Neurology, University of Chicago Medical Center, Chicago, IL, United States.,Section of Neurosurgery, Department of Surgery, University of Chicago Medical Center, Chicago, IL, United States
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Houk T. On Nudging's Supposed Threat to Rational Decision-Making. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2020; 44:403-422. [PMID: 31356661 DOI: 10.1093/jmp/jhz014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Nudging is a tool of libertarian paternalism. It involves making use of certain psychological tendencies in order to help people make better decisions without restricting their freedom. However, some have argued that nudging is objectionable because it interferes with, or undermines, the rational decision-making of the nudged agents. Opinions differ on why this is objectionable, but the underlying concerns appear to begin with nudging's threat to rational decision-making. Those who discuss this issue do not make it clear to what this threat to rationality amounts. In this paper I evaluate what effect nudging has on our decision-making and I argue that it does not typically interfere with our rationality in a problematic way. Perhaps nudging is objectionable for other reasons, but we should not argue that nudging is objectionable based on concerns about rational decision-making.
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Affiliation(s)
- Timothy Houk
- McGovern Medical School, The University of Texas Health Science Center, Houston, Texas, USA
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22
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Horne BD, Nevo D, Adali S, Manikonda L, Arrington C. Tailoring heuristics and timing AI interventions for supporting news veracity assessments. COMPUTERS IN HUMAN BEHAVIOR REPORTS 2020. [DOI: 10.1016/j.chbr.2020.100043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
The ethical dilemmas and predominant frameworks surrounding decision making for critically ill newborns have evolved substantially over the last 40 years. A shared decision-making approach is now favored, involving an exchange of information between parents and clinicians that emphasizes parental values and preferences, resulting in a personalized approach to decision making. In this review, we summarize the history of clinical decision making with a focus on the NICU, highlight different models of decision making, describe the advantages and current limitations of shared decision making, and discuss the ongoing and future challenges of decision making in the NICU amidst medical innovations and emerging technologies.
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Affiliation(s)
- Anne Sullivan
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA
| | - Christy Cummings
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA
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24
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Hofmann B. Biases distorting priority setting. Health Policy 2019; 124:52-60. [PMID: 31822370 DOI: 10.1016/j.healthpol.2019.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 09/24/2019] [Accepted: 11/24/2019] [Indexed: 02/08/2023]
Abstract
Modern health care faces an ever widening gap between technological possibilities and available resources. To handle this challenge we have constructed elaborate systems for health policy making and priority setting. Despite such systems many health care systems provide a wide range of documented low-value care while being unable to afford emerging high-value care. Accordingly, this article sets out asking why priority setting in health care has so poor outcomes while relevant systems are well developed and readily available. It starts to identify some rational and structural explanations for the discrepancy between theoretical efforts and practical outcomes in priority setting. However, even if these issues are addressed, practical priority setting may still not obtain its goals. This is because a wide range of irrational effects is hampering priority setting: biases. By using examples from the literature the article identifies and analyses a wide range of biases indicating how they can distort priority setting processes. Overuse, underuse, and overinvestment, as well as hampered disinvestment and undermined priority setting principles are but some of the identified implications. Moreover, while some biases are operating mainly on one level, many are active on the micro, meso and on the macro level. Identifying and analyzing biases affecting priority setting is the first, but crucial, step towards improving health policy making and priority setting in health care.
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Affiliation(s)
- Bjørn Hofmann
- Institute for the Health Sciences at the Norwegian University of Science and Technology, Gjøvik, Norway; The Centre of Medical Ethics at the University of Oslo, Norway.
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25
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Ghanouni A, Waller J, Stoffel ST, Vlaev I, von Wagner C. Acceptability of risk-stratified breast screening: Effect of the order of presenting risk and benefit information. J Med Screen 2019; 27:52-56. [PMID: 31575328 DOI: 10.1177/0969141319877669] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objective To test whether reduced-frequency risk-stratified breast screening would be perceived more favourably by transposing the order of information on benefits and risks. Methods After reading vignettes describing non-stratified three-yearly screening and a risk-stratified alternative with five-yearly invitations for women at low risk, 698 women completed an online survey. Participants were allocated at random to information on screening benefits followed by risks, or vice versa, and asked to state preferences for either screening system. Participants also rated perceived magnitude of screening benefits and risks, and breast cancer susceptibility. Results Binomial logistic regression did not find order effects on preferences (p = 0.533) or perceived benefits of screening (p = 0.780). Perceived screening risks were greater when risks were presented first (p < 0.0005). Greater perceived susceptibility was associated with lower proportions preferring risk-stratified screening (15% vs. 39% in highest and lowest groups; p = 0.002), as were greater perceived screening benefits (e.g. 13% vs. 45% in highest and lowest groups; p < 0.0005). Conclusions No information order effect on preferences was observed. Information order did affect screening risk perceptions. Efforts to improve perceptions may need to be more intensive than those tested. Women perceiving themselves as high risk or perceiving greater benefits of screening may be particularly averse to less frequent screening.
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Affiliation(s)
- Alex Ghanouni
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Jo Waller
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Sandro T Stoffel
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Ivo Vlaev
- Warwick Business School, University of Warwick, Coventry, UK
| | - Christian von Wagner
- Research Department of Behavioural Science and Health, University College London, London, UK
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Lazaridis C. End-of-life Considerations and Shared Decision Making in Neurocritical Care. Continuum (Minneap Minn) 2019; 24:1794-1799. [PMID: 30516607 DOI: 10.1212/con.0000000000000673] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The goal of shared decision making in the neurocritical care setting is to form plans of care that are consistent with best medical practice and are respectful of the patient's values. Close cooperation and meaningful interaction must be achieved with family members so that the patient's "person can emerge" through discussions. This article highlights several caveats that can subvert this complex process, including the cognitive biases that affect both clinicians and surrogates. Impact, optimism, and gain-framing biases may be particularly relevant when considering patients who are receiving neurocritical care. Practitioners need to be cognizant of the distorting influences of these biases and make attempts to neutralize them. Quality of survival and the nature and degree of deficits are often the dominant concerns after patients experience acute severe brain injuries. Care should be taken to avoid conflating medical facts and value judgments when discussing prognoses.
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Miyata-Sturm A. Blameworthy bumping? Investigating nudge's neglected cousin. JOURNAL OF MEDICAL ETHICS 2019; 45:257-264. [PMID: 30630970 DOI: 10.1136/medethics-2018-105179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 12/04/2018] [Accepted: 12/12/2018] [Indexed: 06/09/2023]
Abstract
The realm of non-rational influence, which includes nudging, is home to many other morally interesting phenomena. In this paper, I introduce the term bumping, to discuss the category of unintentional non-rational influence. Bumping happens constantly, wherever people make choices in environments where they are affected by other people. For instance, doctors will often bump their patients as patients make choices about what treatments to pursue. In some cases, these bumps will systematically tend to make patients' decisions worse. Put another way: doctors will sometimes harm their patients by bumping them in systematic (although still unintentional) ways. I use the case of medical overuse, the provision of medical services where the likely harm outweighs the likely benefit to the patient, as a touchstone for arguing that doctors who systematically bump their patients towards harm can be blameworthy for their unwitting influence.
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Withdrawal of Life-Sustaining Treatments in Perceived Devastating Brain Injury: The Key Role of Uncertainty. Neurocrit Care 2019; 30:33-41. [PMID: 30143963 DOI: 10.1007/s12028-018-0595-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Withdrawal of life-sustaining treatment (WOLST) is the leading proximate cause of death in patients with perceived devastating brain injury (PDBI). There are reasons to believe that a potentially significant proportion of WOLST decisions, in this setting, are premature and guided by a number of assumptions that falsely confer a sense of certainty. METHOD This manuscript proposes that these assumptions face serious challenges, and that we should replace unwarranted certainty with an appreciation for the great degree of multi-dimensional uncertainty involved. The article proceeds by offering a taxonomy of uncertainty in PDBI and explores the key role that uncertainty as a cognitive state, may play into how WOLST decisions are reached. CONCLUSION In order to properly share decision-making with families and surrogates of patients with PDBI, we will have to acknowledge, understand, and be able to communicate the great degree of uncertainty involved.
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Abstract
BACKGROUND Surgeons present patients with complex information at the perioperative appointment. Emotions likely play a role in surgical decision-making, and disgust is an emotion of revulsion at a stimulus that can lead to avoidance. OBJECTIVE The purpose of this study was to determine the impact of disgust on intention to undergo surgical resection for colorectal cancer and recall of perioperative instructions. DESIGN This was a cross-sectional observational study conducted online using hypothetical scenarios with nonpatient subjects. SETTINGS The study was conducted using Amazon's Mechanical Turk. PATIENTS Survey respondents were living in the United States. MAIN OUTCOME MEASURES Surgery intention and recall of perioperative instructions were measured. RESULTS A total of 319 participants met the inclusion criteria. Participants in the experimental condition, who were provided with detailed information and pictures about stoma care, had significantly lower surgery intentions (mean ± SD, 4.60 ± 1.15) compared with the control condition with no stoma prompt (mean ± SD, 5.14 ± 0.91; p = 0.05) and significantly lower recall for preoperative instructions (mean ± SD, 13.75 ± 2.38) compared with the control condition (mean ± SD, 14.36 ± 2.19; p = 0.03). Those within the experimental conditions also reported significantly higher state levels of disgust (mean ± SD, 4.08 ± 1.74) compared with a control condition (mean ± SD, 2.35 ± 1.38; p < 0.001). State-level disgust was found to fully mediate the relationship between condition and recall (b = -0.31) and to partially mediate the effect of condition on surgery intentions (b = 0.17). LIMITATIONS It is unknown whether these results will replicate with patients and the impact of competing emotions in clinical settings. CONCLUSIONS Intentions to undergo colorectal surgery and recall of preoperative instructions are diminished in patients who experience disgust when presented with stoma information. Surgeons and care teams must account for this as they perform perioperative counseling to minimize interference with recall of important perioperative information. See Video Abstract at http://links.lww.com/DCR/A776.
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Abstract
The shift away from paternalistic decision-making and toward patient-centered, shared decision-making has stemmed from the recognition that in order to practice medicine ethically, health care professionals must take seriously the values and preferences of their patients. At the same time, there is growing recognition that minor and seemingly irrelevant features of how choices are presented can substantially influence the decisions people make. Behavioral economists have identified striking ways in which trivial differences in the presentation of options can powerfully and predictably affect people's choices. Choice-affecting features of the decision environment that do not restrict the range of choices or significantly alter the incentives have come to be known as "nudges." Although some have criticized conscious efforts to influence choice, we believe that clinical nudges may often be morally justified. The most straightforward justification for nudge interventions is that they help people bypass their cognitive limitations-for example, the tendency to choose the first option presented even when that option is not the best for them-thereby allowing people to make choices that best align with their rational preferences or deeply held values. However, we argue that this justification is problematic. We argue that, if physicians wish to use nudges to shape their patients' choices, the justification for doing so must appeal to an ethical and professional standard, not to patients' preferences. We demonstrate how a standard with which clinicians and bioethicists already are quite familiar-the best-interest standard-offers a robust justification for the use of nudges.
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Fridman I, Hart JL, Yadav KN, Higgins ET. Perspectives on using decision-making nudges in physician-patient communications. PLoS One 2018; 13:e0202874. [PMID: 30231040 PMCID: PMC6145510 DOI: 10.1371/journal.pone.0202874] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 08/11/2018] [Indexed: 11/18/2022] Open
Abstract
Patients engaging in shared decision making must weigh the likelihood of positive and negative outcomes and deal with uncertainty and negative emotions in the situations where desirable options might not be available. The use of "nudges," or communication techniques that influence patients' choices in a predictable direction, may assist patients in making complex decisions. However, nudging patients may be perceived as inappropriate influence on patients' choices. We sought to determine whether key stakeholders, physicians, and laypersons without clinical training consider the use of nudges to be ethical and appropriate in medical decision making. Eighty-nine resident-physicians and 336 Mechanical-Turk workers (i.e., non-clinicians) evaluated two hypothetical preference-sensitive situations, in which a patient with advanced cancer chooses between chemotherapy and hospice care. We varied the following: (1) whether or not the patient's decision was influenced by a mistaken judgment (i.e., decision-making bias) and (2) whether or not the physician used a nudge. Each participant reported the extent to which the communication was ethical, appropriate, and desirable. Both physicians and non-clinicians considered using nudges more positively than not using them, regardless of an initial decision-making bias in patients' considerations. Decomposing this effect, we found that physicians viewed the nudge that endorsed hospice care more favorably than the nudge that endorsed chemotherapy, while non-clinicians viewed the nudge that endorsed chemotherapy more favorably than the nudge that endorsed hospice care. We discuss implications and propose exploring further physicians' and patients' differences in the perception of nudges; the differences may suggest limitations for using nudges in medical decisions.
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Affiliation(s)
- Ilona Fridman
- Columbia Business School, Columbia University, New York, NY, United States of America
- * E-mail:
| | - Joanna L. Hart
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, United States of America
- Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, PA, United States of America
- Center of Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, PA, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Kuldeep N. Yadav
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, United States of America
- Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, PA, United States of America
- Center of Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, PA, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America
| | - E. Tory Higgins
- Columbia Business School, Columbia University, New York, NY, United States of America
- Department of Psychology, Columbia University, New York, NY, United States of America
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Berger JT, Miller DR. Denial and Dyads: Patients Whose Surrogates and Physicians Are Unrealistically Optimistic. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:29-31. [PMID: 30235103 DOI: 10.1080/15265161.2018.1498939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Offodile AC, Clemens MW. Decisions and Incisions: The Role of Choice Architecture in Surgical Decision Making. Aesthet Surg J 2018; 38:575-577. [PMID: 29370334 DOI: 10.1093/asj/sjy009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Anaeze C Offodile
- Department of Plastic and Reconstructive Surgery, MD Anderson Cancer Center, Houston, TX
| | - Mark W Clemens
- Department of Plastic and Reconstructive Surgery, MD Anderson Cancer Center, Houston, TX
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Affiliation(s)
- Scott D. Halpern
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia PA, 19146
- Center for Health Incentives and Behavioral Economics (CHIBE), Leonard Davis Institute of Health Economics, University of Pennsylvania
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
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Berger J. Informed Consent Is Inadequate and Shared Decision Making Is Ineffective: Arguing for the Primacy of Authenticity in Decision-Making Paradigms. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:45-47. [PMID: 29111926 DOI: 10.1080/15265161.2017.1378759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Allen MB, Reese PP. The Ethics of Promoting Living Kidney Donation Using Nonargumentative Influence: Applications, Concerns, and Future Directions. Am J Transplant 2016; 16:3378-3384. [PMID: 27438695 DOI: 10.1111/ajt.13972] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 07/05/2016] [Accepted: 07/10/2016] [Indexed: 01/25/2023]
Abstract
Recommendations from the 2014 Consensus Conference on Best Practices in Living Kidney Donation reflect increasing attention to overcoming barriers to donation as a means of expanding access to living donor kidney transplantation. "High priority" initiatives include empowering transplant candidates and their loved ones in their search for a living kidney donor. Transplant programs are assuming an unprecedented role as facilitators of patients' solicitation for donors, and nonprofits are promoting living kidney donation (LKD) in the community. New strategies to promote LKD incorporate "nonargumentative" forms of influence (i.e. approaches to shaping behavior that do not attempt to persuade through reason) such as appeals to emotion, messenger effects and social norms. These approaches have raised ethical concerns in other settings but have received little attention in the transplantation literature despite their increasing relevance. Previous work on using nonargumentative influence to shape patient behavior has highlighted implications for (1) the relationship between influencer and influenced and (2) patient autonomy. We argue that using nonargumentative influence to promote LKD is a promising strategy that can be compatible with ethical standards. We also outline potential concerns and solutions to be implemented in practice.
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Affiliation(s)
- M B Allen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - P P Reese
- Renal Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA.,Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA
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Rhodes R. How to Respond to Knowledge About Biases. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:29-31. [PMID: 27111364 DOI: 10.1080/15265161.2016.1159759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Morar N, Skorburg JA. Toward an Ecological Bioethics. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:35-37. [PMID: 27111367 DOI: 10.1080/15265161.2016.1159756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Weiss EM, Munson DA. Action and Uncertainty in Neonatal Intensive Care. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:31-33. [PMID: 27111365 DOI: 10.1080/15265161.2016.1159755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Niker F, Reiner PB, Felsen G. Pre-Authorization: A Novel Decision-Making Heuristic That May Promote Autonomy. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:27-29. [PMID: 27111363 DOI: 10.1080/15265161.2016.1159761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Schwartz PH. Comparative Risk: Good or Bad Heuristic? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:20-22. [PMID: 27111360 PMCID: PMC4991541 DOI: 10.1080/15265161.2016.1159765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Schwab AP. Applying Heuristics and Biases More Broadly and Cautiously. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:25-27. [PMID: 27111362 DOI: 10.1080/15265161.2016.1159764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Scanlan C, Stewart C, Kerridge I. Decision Making in the Shadow of Death. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:23-24. [PMID: 27111361 DOI: 10.1080/15265161.2016.1161404] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
| | | | - Ian Kerridge
- c University of Sydney and Royal North Shore Hospital
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