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Maksimova MV, van Thiel GJMW, Tromp Y, Lechner R, van Delden JJM, Bloem LT. Balancing ethical norms and duties for the introduction of new medicines through conditional marketing authorization: a research agenda. Front Med (Lausanne) 2024; 11:1408553. [PMID: 39005652 PMCID: PMC11242744 DOI: 10.3389/fmed.2024.1408553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/13/2024] [Indexed: 07/16/2024] Open
Abstract
The European Medicines Agency's conditional marketing authorization (CMA) aims to expedite patient access to medicines for unmet medical needs by shifting a part of the drug development process post-authorization. We highlight ethical issues surrounding CMA, comprising (i) the complexity of defining unmet medical need; (ii) poor understanding of CMA and its impact on informed consent; (iii) hope versus unrealistic optimism; (iv) implications of prolonged post-authorization studies and potential patient harm; (v) rights and duties of patients surrounding participation in post-authorization studies; (vi) access to previously authorized CMA medicines; and (vii) the "benefit slippage" phenomenon, defined as the gradual shift of strict criteria to less strict criteria. We propose a comprehensive research agenda to address these ethical issues, and stress the need for multi-stakeholder engagement to ensure patient-centered use of CMA.
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Affiliation(s)
- Mariia V. Maksimova
- Department of Bioethics and Health Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Ghislaine J. M. W. van Thiel
- Department of Bioethics and Health Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Yke Tromp
- Department of Bioethics and Health Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Rosan Lechner
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, Netherlands
| | - Johannes J. M. van Delden
- Department of Bioethics and Health Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Lourens T. Bloem
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
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Dorfman N, Snellman L, Kerley Y, Kostick-Quenet K, Lazaro-Munoz G, Storch EA, Blumenthal-Barby J. Hope and Optimism in Pediatric Deep Brain Stimulation: Key Stakeholder Perspectives. NEUROETHICS-NETH 2023; 16:17. [PMID: 37905206 PMCID: PMC10615366 DOI: 10.1007/s12152-023-09524-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 06/29/2023] [Indexed: 11/02/2023]
Abstract
Introduction Deep brain stimulation (DBS) is utilized to treat pediatric refractory dystonia and its use in pediatric patients is expected to grow. One important question concerns the impact of hope and unrealistic optimism on decision-making, especially in "last resort" intervention scenarios such as DBS for refractory conditions. Objective This study examined stakeholder experiences and perspectives on hope and unrealistic optimism in the context of decision-making about DBS for childhood dystonia and provides insights for clinicians seeking to implement effective communication strategies. Materials and Methods Semi-structured interviews with clinicians (n = 29) and caregivers (n = 44) were conducted, transcribed, and coded. Results Using thematic content analysis, four major themes from clinician interviews and five major themes from caregiver interviews related to hopes and expectations were identified. Clinicians expressed concerns about caregiver false hopes (86%, 25/29) and desperation (68.9%, 20/29) in light of DBS being a last resort. As a result, 68.9% of clinicians (20/29) expressed that they intentionally tried to lower caregiver expectations about DBS outcomes. Clinicians also expressed concern that, on the flip side, unrealistic pessimism drives away some patients who might otherwise benefit from DBS (34.5%, 10/29). Caregivers viewed DBS as the last option that they had to try (61.3%, 27/44), and 73% of caregivers (32/44) viewed themselves as having high hopes but reasonable expectations. Fewer than half (43%, 19/44) expressed that they struggled setting outcome expectations due to the uncertainty of DBS, and 50% of post-DBS caregivers (14/28) expressed some negative feelings post treatment due to unmet expectations. 43% of caregivers (19/44) had experiences with clinicians who tried to set low expectations about the potential benefits of DBS. Conclusion Thoughtful clinician-stakeholder discussion is needed to ensure realistic outcome expectations.
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Affiliation(s)
- Natalie Dorfman
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | | | | | - Kristin Kostick-Quenet
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | | | - Eric A Storch
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
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Kostick-Quenet K, Kalwani L, Torgerson L, Muñoz K, Sanchez C, Storch EA, Blumenthal-Barby J, Lázaro-Muñoz G. Deep Brain Stimulation for Pediatric Dystonia: Clinicians' Perspectives on the Most Pressing Ethical Challenges. Stereotact Funct Neurosurg 2023; 101:301-313. [PMID: 37844562 PMCID: PMC10586720 DOI: 10.1159/000530694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 03/30/2023] [Indexed: 10/18/2023]
Abstract
INTRODUCTION Pediatric deep brain stimulation (pDBS) is commonly used to manage treatment-resistant primary dystonias with favorable results and more frequently used for secondary dystonia to improve quality of life. There has been little systematic empirical neuroethics research to identify ethical challenges and potential solutions to ensure responsible use of DBS in pediatric populations. METHODS Clinicians (n = 29) who care for minors with treatment-resistant dystonia were interviewed for their perspectives on the most pressing ethical issues in pDBS. RESULTS Using thematic content analysis to explore salient themes, clinicians identified four pressing concerns: (1) uncertainty about risks and benefits of pDBS (22/29; 72%) that poses a challenge to informed decision-making; (2) ethically navigating decision-making roles (15/29; 52%), including how best to integrate perspectives from diverse stakeholders (patient, caregiver, clinician) and how to manage surrogate decisions on behalf of pediatric patients with limited capacity to make autonomous decisions; (3) information scarcity effects on informed consent and decision quality (15/29; 52%) in the context of patient and caregivers' expectations for treatment; and (4) narrow regulatory status and access (7/29; 24%) such as the lack of FDA-approved indications that contribute to decision-making uncertainty and liability and potentially limit access to DBS among patients who may benefit from it. CONCLUSION These results suggest that clinicians are primarily concerned about ethical limitations of making difficult decisions in the absence of informational, regulatory, and financial supports. We discuss two solutions already underway, including supported decision-making to address uncertainty and further data sharing to enhance clinical knowledge and discovery.
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Affiliation(s)
- Kristin Kostick-Quenet
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Lavina Kalwani
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Laura Torgerson
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Katrina Muñoz
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Clarissa Sanchez
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Eric A. Storch
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | | | - Gabriel Lázaro-Muñoz
- Center for Bioethics, Harvard Medical School, Cambridge, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
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Olcaysoy Okten I, Gollwitzer A, Oettingen G. When knowledge is blinding: The dangers of being certain about the future during uncertain societal events. PERSONALITY AND INDIVIDUAL DIFFERENCES 2022. [DOI: 10.1016/j.paid.2022.111606] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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5
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Han PKJ, Scharnetzki E, Anderson E, DiPalazzo J, Strout TD, Gutheil C, Lucas FL, Edelman E, Rueter J. Epistemic Beliefs: Relationship to Future Expectancies and Quality of Life in Cancer Patients. J Pain Symptom Manage 2022; 63:512-521. [PMID: 34952170 PMCID: PMC8930513 DOI: 10.1016/j.jpainsymman.2021.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/08/2021] [Accepted: 12/11/2021] [Indexed: 11/28/2022]
Abstract
CONTEXT Expectations about the future (future expectancies) are important determinants of psychological well-being among cancer patients, but the strategies patients use to maintain positive and cope with negative expectancies are incompletely understood. OBJECTIVES To obtain preliminary evidence on the potential role of one strategy for managing future expectancies: the adoption of "epistemic beliefs" in fundamental limits to medical knowledge. METHODS A sample of 1307 primarily advanced-stage cancer patients participating in a genomic tumor testing study in community oncology practices completed measures of epistemic beliefs, positive future expectancies, and mental and physical health-related quality of life (HRQOL). Descriptive and linear regression analyses were conducted to assess the relationships between these factors and test two hypotheses: 1) epistemic beliefs affirming fundamental limits to medical knowledge ("fallibilistic epistemic beliefs") are associated with positive future expectancies and mental HRQOL, and 2) positive future expectancies mediate this association. RESULTS Participants reported relatively high beliefs in limits to medical knowledge (M = 2.94, s.d.=.67) and positive future expectancies (M = 3.01, s.d.=.62) (range 0-4), and relatively low mental and physical HRQOL. Consistent with hypotheses, fallibilistic epistemic beliefs were associated with positive future expectancies (b = 0.11, SE=.03, P< 0.001) and greater mental HRQOL (b = 0.99, SE=.34, P = 0.004); positive expectancies also mediated the association between epistemic beliefs and mental HRQOL (Sobel Z=4.27, P<0.001). CONCLUSIONS Epistemic beliefs in limits to medical knowledge are associated with positive future expectancies and greater mental HRQOL; positive expectancies mediate the association between epistemic beliefs and HRQOL. More research is needed to confirm these relationships and elucidate their causal mechanisms.
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Affiliation(s)
- Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center (P.K.J.H., E.S., E.A., J.D., C.G., F.L.L.), Portland, Maine; Tufts University School of Medicine (P.K.J.H., E.A., T.D.S., F.L.L.), Boston, Massachusetts.
| | - Elizabeth Scharnetzki
- Center for Outcomes Research and Evaluation, Maine Medical Center (P.K.J.H., E.S., E.A., J.D., C.G., F.L.L.), Portland, Maine
| | - Eric Anderson
- Center for Outcomes Research and Evaluation, Maine Medical Center (P.K.J.H., E.S., E.A., J.D., C.G., F.L.L.), Portland, Maine; Tufts University School of Medicine (P.K.J.H., E.A., T.D.S., F.L.L.), Boston, Massachusetts
| | - John DiPalazzo
- Center for Outcomes Research and Evaluation, Maine Medical Center (P.K.J.H., E.S., E.A., J.D., C.G., F.L.L.), Portland, Maine
| | - Tania D Strout
- Tufts University School of Medicine (P.K.J.H., E.A., T.D.S., F.L.L.), Boston, Massachusetts; Department of Emergency Medicine, Maine Medical Center (T.D.S.), Portland, Maine
| | - Caitlin Gutheil
- Center for Outcomes Research and Evaluation, Maine Medical Center (P.K.J.H., E.S., E.A., J.D., C.G., F.L.L.), Portland, Maine
| | - F Lee Lucas
- Center for Outcomes Research and Evaluation, Maine Medical Center (P.K.J.H., E.S., E.A., J.D., C.G., F.L.L.), Portland, Maine; Tufts University School of Medicine (P.K.J.H., E.A., T.D.S., F.L.L.), Boston, Massachusetts
| | - Emily Edelman
- The Jackson Laboratory (E.E., J.R.), Bar Harbor, Maine
| | - Jens Rueter
- The Jackson Laboratory (E.E., J.R.), Bar Harbor, Maine
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Moral Distress in Healthcare Providers Who Take Care of Critical Pediatric Patients throughout Italy-Cultural Adaptation and Validation of the Italian Pediatric Instrument. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19073880. [PMID: 35409562 PMCID: PMC8997869 DOI: 10.3390/ijerph19073880] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/20/2022] [Accepted: 03/22/2022] [Indexed: 02/04/2023]
Abstract
Background: Although Moral Distress (MD) is a matter of concern within the Pediatric Intensive Care Unit (PICU), there is no validated Italian instrument for measuring the phenomenon in nurses and physicians who care for pediatric patients in Intensive Care. The authors of the Italian Moral Distress Scale-Revised (Italian MDS-R), validated for the adult setting, in 2017, invited further research to evaluate the generalizability of the scale to clinicians working in other fields. Our study aims to reduce this knowledge gap by developing and validating the pediatric version of the Italian MDS-R. Methods: We evaluated the new instrument for construct validity, then we administered it in a multicenter, web-based survey that involved healthcare providers of three PICUs and three adult ICUs admitting children in northern, central, and southern Italy. Finally, we tested it for internal consistency, confirmatory factorial validity, convergent validity, and differences between groups analysis. Results: The 14-item, three-factor model best fit the data. The scale showed good reliability (a = 0.87). Still, it did not correlate with the Emotional Exhaustion and Depersonalization sub-scales of the Maslach Burnout Inventory (MBI) or with the 2-item Connor-Davidson Resilience Scale (CD-RISC 2) or the Satisfaction with Life Scale (SWLS). A mild correlation was found between the Italian Pediatric MDS-R score and intention to resign from the job. No correlation was found between MD and years of experience. Females, nurses, and clinicians who cared for COVID-19 patients had a higher MD score. Conclusions: The Italian Pediatric MDS-R is a valid and reliable instrument for measuring MD among Italian health workers who care for critically ill children. Further research would be helpful in better investigating its applicability to the heterogeneous scenario of Italian Pediatric Critical Care Medicine.
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Bittlinger M, Bicer S, Peppercorn J, Kimmelman J. Ethical Considerations for Phase I Trials in Oncology. J Clin Oncol 2022; 40:3474-3488. [PMID: 35275736 DOI: 10.1200/jco.21.02125] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Phase I trials often represent the first occasion where new cancer strategies are tested in patients. Various developments in cancer biology, methodology, regulation, and medical ethics have altered the ethical landscape of such trials. We provide a narrative review of contemporary ethical challenges in design, conduct, and reporting of phase I cancer trials and outline recommendations for addressing each. We organized our review around four topics, supplementing the first three with scoping reviews: (1) benefit/risk, (2) research biopsies, (3) therapeutic misconception and misestimation, and (4) reporting. The main ethical challenges of conducting phase I trials stem from three issues. First, phase I trials often involve higher research burden and scientific uncertainty compared with other cancer trials. Second, many patients arrive at phase I trials at a transitional point in their illness trajectory where they have exhausted standard survival-extending options. Third, phase I trial results play a major role in informing downstream drug development and regulatory decisions. Together, these issues create distinct pressures for study design, ethical review, informed consent, and reporting. Developments in methodology, regulation, cancer biology, and ethical awareness have helped mitigate some of these challenges, while introducing others. We conclude our review with a series of recommendations regarding trial design, ethical review, consent, and reporting. We also outline several unresolved questions that, if addressed, would strengthen the ethical foundation of phase I cancer trials.
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Affiliation(s)
- Merlin Bittlinger
- Studies of Translation, Ethics and Medicine (STREAM), Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada
| | - Selin Bicer
- Studies of Translation, Ethics and Medicine (STREAM), Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada
| | | | - Jonathan Kimmelman
- Studies of Translation, Ethics and Medicine (STREAM), Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada
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Stout J, Smith C, Buckner J, Adjei AA, Wentworth M, Tilburt JC, Master Z. Oncologists' reflections on patient rights and access to compassionate use drugs: A qualitative interview study from an academic cancer center. PLoS One 2021; 16:e0261478. [PMID: 34919568 PMCID: PMC8682887 DOI: 10.1371/journal.pone.0261478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 12/02/2021] [Indexed: 12/29/2022] Open
Abstract
The U.S. Food and Drug Administration (FDA) allows patients with serious illnesses to access investigational drugs for "compassionate use" outside of clinical trials through expanded access (EA) Programs. The federal Right-to-Try Act created an additional pathway for non-trial access to experimental drugs without institutional review board or FDA approval. This removal of oversight amplifies the responsibility of physicians, but little is known about the role of practicing physicians in non-trial access to investigational drugs. We undertook semi-structured interviews to capture the experiences and opinions of 21 oncologists all with previous EA experience at a major cancer center. We found five main themes. Participants with greater EA experience reported less difficulty accessing drugs through the myriad of administrative processes and drug company reluctance to provide investigational products while newcomers reported administrative hurdles. Oncologists outlined several rationales patients offered when seeking investigational drugs, including those with stronger health literacy and a good scientific rationale versus others who remained skeptical of conventional medicine. Participants reported that most patients had realistic expectations while some had unrealistic optimism. Given the diverse reasons patients sought investigational drugs, four factors-scientific rationale, risk-benefit ratio, functional status of the patient, and patient motivation-influenced oncologists' decisions to request compassionate use drugs. Physicians struggled with a "right-to-try" framing of patient access to experimental drugs, noting instead their own responsibility to protect patients' best interest in the uncertain and risky process of off-protocol access. This study highlights the willingness of oncologists at a major cancer center to pursue non-trial access to experimental treatments for patients while also shedding light on the factors they use when considering such treatment. Our data reveal discrepancies between physicians' sense of patients' expectations and their own internal sense of professional obligation to shepherd a safe process for patients at a vulnerable point in their care.
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Affiliation(s)
- Jeremiah Stout
- Mayo Clinic Alix School of Medicine, Rochester, MN, United States of America
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, United States of America
| | - Cambray Smith
- UNC Chapel Hill School of Medicine, Chapel-Hill, NC, United States of America
| | - Jan Buckner
- Department of Oncology, Mayo Clinic, Rochester, MN, United States of America
| | - Alex A. Adjei
- Department of Oncology, Mayo Clinic, Rochester, MN, United States of America
| | - Mark Wentworth
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Jon C. Tilburt
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, United States of America
- General Internal Medicine, Mayo Clinic, Scottsdale, AZ, United States of America
| | - Zubin Master
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, United States of America
- Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, United States of America
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Wedding U. Palliative care of patients with haematological malignancies: strategies to overcome difficulties via integrated care. THE LANCET HEALTHY LONGEVITY 2021; 2:e746-e753. [DOI: 10.1016/s2666-7568(21)00213-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 12/01/2022]
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Katz NT, Hynson JL, Gillam L. Dissonance in views between parents and clinicians of children with serious illness: How can we bridge the gap? J Paediatr Child Health 2021; 57:1370-1375. [PMID: 34132446 DOI: 10.1111/jpc.15612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/24/2021] [Accepted: 05/29/2021] [Indexed: 10/21/2022]
Abstract
Parents of children with serious illness must find a tolerable way of living each day, while caring for their child and making decisions about their treatments. Sometimes clinicians worry that parents do not understand the seriousness of their child's illness, including possible death. This can lead to tension, disagreement and even conflict. Such situations continue to occur despite expanding literature to help clinicians understand drivers of parental behaviour and decision-making. Some of this literature relates to the role of hope and how parents characterise being a 'good parent'. This article will summarise some of the applications and limitations of the hope and 'good parent' literature, as well as frameworks to understand grief and loss. We propose, however, that there is at least one missing link in understanding potential dissonance in views between parents and clinicians. We will make a case for the importance of a richer understanding about if, and how, parents 'visit' the 'reality' that clinicians wish to convey about their child's diagnosis and prognosis. We propose that clinician understanding about the benefits and burdens of 'visiting' this 'reality' for an individual family may help guide conversations and rapport, which in turn may influence decision-making with benefits for the child, family and clinicians.
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Affiliation(s)
- Naomi T Katz
- Victorian Paediatric Palliative Care Program, Royal Children's Hospital, Parkville, Victoria, Australia.,Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.,Clinical Paediatrics Group, Murdoch Children's Research Group, Melbourne, Victoria, Australia
| | - Jenny L Hynson
- Victorian Paediatric Palliative Care Program, Royal Children's Hospital, Parkville, Victoria, Australia.,Clinical Paediatrics Group, Murdoch Children's Research Group, Melbourne, Victoria, Australia.,Children's Bioethics Centre, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Lynn Gillam
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.,Clinical Paediatrics Group, Murdoch Children's Research Group, Melbourne, Victoria, Australia.,Children's Bioethics Centre, Royal Children's Hospital, Melbourne, Victoria, Australia
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Nayak B, Moon JY, Kim M, Fischhoff B, Haward MF. Optimism bias in understanding neonatal prognoses. J Perinatol 2021; 41:445-452. [PMID: 32778685 DOI: 10.1038/s41372-020-00773-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 07/14/2020] [Accepted: 08/03/2020] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Discrepancies between physician and parent neonatal prognostic expectations are common. Optimism bias is a possible explanation. STUDY DESIGN Parents interpreted hypothetical neonatal prognoses in an online survey. RESULTS Good prognoses tended to be interpreted accurately, while poor prognoses were interpreted as less than the stated value. One-third of participants consistently overstated survival for the three lowest prognoses, compared to the sample as a whole. Three significant predictors of such optimistic interpretations were single-parent status (OR 0.39; 95% CI 0.2-0.75; p = 0.005), African-American descent (OR 3.78; 95% CI 1.63-8.98; p = 0.002) and the belief that physicians misrepresented prognoses (OR 3.11; 95% CI 1.47-6.65; p = 0.003). Participants' explanations echoed research on optimism bias in clinical and decision science studies. CONCLUSION Participants accepted positive prognoses for critically ill neonates, but reinterpreted negative ones as being unduly pessimistic demonstrating optimism bias.
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Affiliation(s)
- Babina Nayak
- Harlem Hospital Medical Center, Columbia University, New York, NY, USA.,Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jee-Young Moon
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mimi Kim
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Baruch Fischhoff
- Department of Engineering and Public Policy and Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Marlyse F Haward
- Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA.
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12
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Muñoz KA, Blumenthal-Barby J, Storch EA, Torgerson L, Lázaro-Muñoz G. Pediatric Deep Brain Stimulation for Dystonia: Current State and Ethical Considerations. Camb Q Healthc Ethics 2020; 29:557-573. [PMID: 32892777 PMCID: PMC9426302 DOI: 10.1017/s0963180120000316] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Dystonia is a movement disorder that can have a debilitating impact on motor functions and quality of life. There are 250,000 cases in the United States, most with childhood onset. Due to the limited effectiveness and side effects of available treatments, pediatric deep brain stimulation (pDBS) has emerged as an intervention for refractory dystonia. However, there is limited clinical and neuroethics research in this area of clinical practice. This paper examines whether it is ethically justified to offer pDBS to children with refractory dystonia. Given the favorable risk-benefit profile, it is concluded that offering pDBS is ethically justified for certain etiologies of dystonia, but it is less clear for others. In addition, various ethical and policy concerns are discussed, which need to be addressed to optimize the practice of offering pDBS for dystonia. Strategies are proposed to help address these concerns as pDBS continues to expand.
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Affiliation(s)
- Katrina A. Muñoz
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX
| | | | - Eric A. Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX
| | - Laura Torgerson
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX
| | - Gabriel Lázaro-Muñoz
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX
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Kane PB, Benjamin DM, Barker RA, Lang AE, Sherer T, Kimmelman J. Comparison of Patient and Expert Perceptions of the Attainment of Research Milestones in Parkinson's Disease. Mov Disord 2020; 36:171-177. [PMID: 33002259 PMCID: PMC7891331 DOI: 10.1002/mds.28319] [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: 04/30/2020] [Revised: 08/28/2020] [Accepted: 09/08/2020] [Indexed: 12/01/2022] Open
Abstract
Background Commentators suggest that patients have unrealistic expectations about the pace of research advances and that such expectations interfere with patient decision‐making. Objective The objective of this study was to compare expert expectations about the timing of research milestone attainment with those of patients who follow Parkinson's disease (PD) research. Methods Patients with PD and experts were asked to provide forecasts about 11 milestones in PD research in an online survey. PD experts were identified from a Michael J. Fox Foundation database, highly ranked neurology centers in the United States and Canada, and corresponding authors of articles on PD in top medical journals. Patients with PD were recruited through the Michael J. Fox Foundation. We tested whether patient forecasts differed on average from expert forecasts. We also tested whether differences between patient forecasts and the average expert forecasts were associated with any demographic factors. Results A total of 256 patients and 249 PD experts completed the survey. For 9 of the 11 milestones, patients' forecasts were on average higher than those of experts. Only exercise therapy met our 10% difference threshold for practical significance. Education was the only demographic that predicted patient deviations from expert forecasts on milestone forecasts. Patients offered significantly higher forecasts than experts that the clinical trials used in milestone queries would report positive primary outcomes. Conclusions Differences between patient and expert expectations about research milestones were generally minor, suggesting that there is little cause for concern that patients who follow PD research are unduly swayed by inaccurate representations of research advancement in the media or elsewhere. © 2020 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society
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Affiliation(s)
- Patrick Bodilly Kane
- Biomedical Ethics Unit, Studies of Translation, Ethics and Medicine (STREAM) Research Group, McGill University, Montreal, Quebec, Canada
| | - Daniel M Benjamin
- Information Sciences Institute, University of Southern California, Marina del Rey, California, USA
| | - Roger A Barker
- John van Geest Centre for Brain Repair, Wellcome Trust/Medical Research Council (WT/MRC) Cambridge Stem Cell Institute, Department of Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Anthony E Lang
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Todd Sherer
- The Michael J. Fox Foundation for Parkinson's Research, New York, New York, USA
| | - Jonathan Kimmelman
- Biomedical Ethics Unit, Studies of Translation, Ethics and Medicine (STREAM) Research Group, McGill University, Montreal, Quebec, Canada
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Cho HL, Miller DG, Kim SYH. Understanding people's 'unrealistic optimism' about clinical research participation. JOURNAL OF MEDICAL ETHICS 2020; 46:172-177. [PMID: 31473653 DOI: 10.1136/medethics-2019-105377] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 07/26/2019] [Accepted: 08/13/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Researchers worry that patients in early-phase research experience unrealistic optimism about benefits and risks of participation. The standard measure of unrealistic optimism is the Comparative Risk/Benefit Assessment (CRBA) questionnaire, which asks people to estimate their chances of an outcome relative to others in similar situations. Such a comparative framework may not be a natural way for research participants to think about their chances. OBJECTIVE To examine how people interpret questions measuring unrealistic optimism and how their interpretations are associated with their responses. METHODS Using an early-phase cancer trial vignette, we administered the CRBA to 297 adults from the general public. They estimated their comparative chances of risk and benefit (7-point scale: -3 less likely to +3 more likely), then provided rationales for their estimates. RESULTS For both CRBA benefit and risk questions, about 50% of respondents chose 0 (the 'correct' response of 'average likelihood'), and 50% chose a non-0 response. Respondents' rationales for their estimates showed that overall only about 40%-44% gave comparative rationales, indicating that they interpreted the CRBA as intended. 68.7% of respondents who gave the 'correct' 0 rating gave comparative rationales, whereas only 11.6% of respondents who gave non-0 ratings did so. A similar trend was seen for chances of risk (p<0.001 for both). CONCLUSION Research participants may not understand comparative benefit and risk questions as intended; attributions of unrealistic optimism may require additional evidence that the respondents' estimates are intended to be comparative.
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Affiliation(s)
- Hae Lin Cho
- Department of Bioethics, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - David Gibbes Miller
- Department of Bioethics, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Scott Y H Kim
- Department of Bioethics, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
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Batten JN, Wong BO, Hanks WF, Magnus D. We Convey More Than We (Literally) Say. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:1-3. [PMID: 30265601 DOI: 10.1080/15265161.2018.1505107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Mukherjee D, Brashler R. In Defense of Common Human Responses. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:20-22. [PMID: 30265598 DOI: 10.1080/15265161.2018.1498945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Michie M, Allyse M, Stoll KA, Master Z. Weaponizing Hope: Sources of Hope, Unrealistic Optimism, and Denial. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:25-27. [PMID: 30265599 PMCID: PMC6314021 DOI: 10.1080/15265161.2018.1498946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Affiliation(s)
- Marsha Michie
- Department of Bioethics, Case Western Reserve University School of
Medicine, 10900 Euclid Avenue, Cleveland, OH 44106-4976
| | - Megan Allyse
- , Biomedical Ethics Research
Program and Department of Obstetrics and Gynecology, Mayo Clinic, Twitter:
@mallyse
| | | | - Zubin Master
- , Biomedical Ethics Research
Program, Mayo Clinic
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Murray D. Hope, Denial, and Third-Party Effects. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:31-33. [PMID: 30265604 DOI: 10.1080/15265161.2018.1498942] [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]
Affiliation(s)
- Dale Murray
- a University of Wisconsin-Platteville Baraboo Sauk County
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Childers JW, Arnold RM. "I Know I'm Going to Beat This": When Patients and Doctors Disagree About Prognosis. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:16-18. [PMID: 30235096 DOI: 10.1080/15265161.2018.1498951] [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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Majumder MA, Scott CT. Off-Target Effects of a Defense of Denial. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:22-24. [PMID: 30265597 DOI: 10.1080/15265161.2018.1498944] [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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Jefferson A, Bortolotti L. Why (Some) Unrealistic Optimism is Permissible in Patient Decision Making. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:27-29. [PMID: 30265602 DOI: 10.1080/15265161.2018.1498940] [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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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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Kondrat A. The Unintended Consequences of Reframing Denial, Unrealistic Optimism, and Self-Deception. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:36-37. [PMID: 30265600 DOI: 10.1080/15265161.2018.1498947] [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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Jerud I, Knowlton S. When Denial Hurts the Children: An Argument for Accountability of Denial in Parental Decision Making. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:33-35. [PMID: 30235104 DOI: 10.1080/15265161.2018.1498950] [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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