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Felder RM, Luenprakansit K, Pope TM, Magnus D. Making Medical Treatment Decisions for Unrepresented Hospitalized Patients. Am J Med 2024:S0002-9343(24)00064-0. [PMID: 38336083 DOI: 10.1016/j.amjmed.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024]
Affiliation(s)
- Ryan Marshall Felder
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Calif.
| | - Kate Luenprakansit
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Calif
| | | | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Calif
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Mittal V, Hakes NA, Magnus D, Batten JN. Vagueness in Goals-of-Care Conferences for Critically Ill Patients: Types of Hedge Language Used by Physicians. Crit Care Med 2023; 51:1538-1546. [PMID: 37358354 DOI: 10.1097/ccm.0000000000005974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
OBJECTIVES Hedge language is a category of language that refers to words or phrases that make statements "fuzzier." We sought to understand how physicians use hedge language during goals-of-care conferences in the ICU. DESIGN Secondary analysis of transcripts of audio-recorded goals-of-care conferences in the ICU. SETTING Thirteen ICUs at six academic and community medical centers in the United States. PATIENTS Conferences were between clinicians and surrogates of incapacitated, critically ill adults. INTERVENTIONS Four investigators performed a qualitative content analysis of transcripts using deductive followed by inductive methods to identify types of hedge language used by physicians, then coded all instances of hedge language across 40 transcripts to characterize general patterns in usage. MEASUREMENTS AND MAIN RESULTS We identified 10 types of hedge language: numeric probabilistic statement ("there's an 80% chance"), qualitative probabilistic statement ("there's a good chance"), nonprobabilistic uncertainty statement ("hard to say for her"), plausibility shield ("we expect"), emotion-based statement ("we're concerned"), attribution shield ("according to Dr. X"), adaptor ("sort of"), metaphor ("the chips are stacking up against her"), time reference ("too soon to tell"), and contingency statement ("if we are lucky"). For most types of hedge language, we identified distinct subtypes. Physicians used hedge language frequently in every transcript (median: 74 hedges per transcript) to address diagnosis, prognosis, and treatment. We observed large variation in how frequently each type and subtype of hedge language was used. CONCLUSIONS Hedge language is ubiquitous in physician-surrogate communication during goals-of-care conferences in the ICU and can be used to introduce vagueness to statements in ways beyond expressing uncertainty. It is not known how hedge language impacts decision-making or clinician-surrogate interactions. This study prioritizes specific types of hedge language for future research based on their frequency and novelty.
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Affiliation(s)
- Vaishali Mittal
- Center for Biomedical Ethics, Stanford University, Stanford, CA
- Department of Dermatology, Stanford University, Stanford, CA
| | - Nicholas A Hakes
- Center for Biomedical Ethics, Stanford University, Stanford, CA
- University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - David Magnus
- Center for Biomedical Ethics, Stanford University, Stanford, CA
- Department of Medicine, Stanford University, Stanford, CA
- Department of Pediatrics, Stanford University, Stanford, CA
| | - Jason N Batten
- Center for Biomedical Ethics, Stanford University, Stanford, CA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA
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Youssef A, Stein S, Clapp J, Magnus D. The Importance of Understanding Language in Large Language Models. Am J Bioeth 2023; 23:6-7. [PMID: 37812091 DOI: 10.1080/15265161.2023.2256614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Affiliation(s)
| | - Samantha Stein
- Stanford School of Medicine
- UCLA Department of Anthropology
| | - Justin Clapp
- University of Pennsylvania Perelman School of Medicine
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Trotsyuk AA, Federico CA, Cho MK, Altman RB, Magnus D. Stronger regulation of AI in biomedicine. Sci Transl Med 2023; 15:eadi0336. [PMID: 37703349 PMCID: PMC10977140 DOI: 10.1126/scitranslmed.adi0336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Regulatory agencies need to ensure the safety and equity of AI in biomedicine, and the time to do so is now.
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Affiliation(s)
- Artem A. Trotsyuk
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, USA
| | - Carole A. Federico
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, USA
| | - Mildred K. Cho
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, USA
| | - Russ B. Altman
- Department of Genetics, Stanford University, Stanford, USA
- Departments of Bioengineering, Stanford University, Stanford, USA
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, USA
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Shearer E, Blythe J, Magnus D, Batten JN. Recognizing Choice Architecture in the Design of Hospital Code Status Orders. Resuscitation 2023; 188:109824. [PMID: 37169274 DOI: 10.1016/j.resuscitation.2023.109824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 05/03/2023] [Indexed: 05/13/2023]
Affiliation(s)
- Emily Shearer
- Department of Emergency Medicine, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital. 55 Claverick Street, 1(st) Floor. Providence, RI, USA; Stanford Center for Biomedical Ethics, 1215 Welch Road Modular A, Stanford, CA, USA.
| | - Jacob Blythe
- Stanford Center for Biomedical Ethics, 1215 Welch Road Modular A, Stanford, CA, USA; Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - David Magnus
- Stanford Center for Biomedical Ethics, 1215 Welch Road Modular A, Stanford, CA, USA
| | - Jason N Batten
- Stanford Center for Biomedical Ethics, 1215 Welch Road Modular A, Stanford, CA, USA; Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, 300 N Pasteur Drive #H3647, Stanford, CA, USA
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Batten JN, Blythe JA, Wieten SE, Dzeng E, Kruse KE, Cotler MP, Porter-Williamson K, Kayser JB, Harman SM, Magnus D. "No Escalation of Treatment" Designations: A Multi-institutional Exploratory Qualitative Study. Chest 2023; 163:192-201. [PMID: 36007596 PMCID: PMC9993335 DOI: 10.1016/j.chest.2022.08.2211] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/26/2022] [Accepted: 08/09/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND No Escalation of Treatment (NoET) designations are used in ICUs internationally to limit treatment for critically ill patients. However, they are the subject of debate in the literature and have not been qualitatively studied. RESEARCH QUESTION How do physicians understand and perceive NoET designations, especially regarding their usefulness and associated challenges? What mechanisms do hospitals provide to facilitate the use of NoET designations? STUDY DESIGN AND METHODS Qualitative study at seven US hospitals, employing semistructured interviews with 30 physicians and review of relevant institutional records (eg, hospital policies, screenshots of ordering menus in the electronic health record). RESULTS At all hospitals, participants reported the use of NoET designations, which were understood to mean that providers should withhold new or higher-intensity interventions ("escalations") but not withdraw ongoing interventions. Three hospitals provided a specific mechanism for designating a patient as NoET (eg, a DNR/Do Not Escalate code status order); at the remaining hospitals, a variety of informal methods (eg, verbal hand-offs) were used. We identified five functions of NoET designations: (1) Defining an intermediate point of treatment limitation, (2) helping physicians navigate prearrest clinical decompensations, (3) helping surrogate decision-makers transition toward comfort care, (4) preventing patient harm from invasive measures, and (5) conserving critical care resources. Across hospitals, participants reported implementation challenges related to the ambiguity in meaning of NoET designations. INTERPRETATION Despite ongoing debate, NoET designations are used in a varied sample of hospitals and are perceived as having multiple functions, suggesting they may fulfill an important need in the care of critically ill patients, especially at the end of life. The use of NoET designations can be improved through the implementation of a formal mechanism that encourages consistency across providers and clarifies the meaning of "escalation" for each patient.
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Affiliation(s)
- Jason N Batten
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA; Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA.
| | - Jacob A Blythe
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA; Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Sarah E Wieten
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA; Department of Philosophy, Durham University, Durham, England
| | - Elizabeth Dzeng
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Katherine E Kruse
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA; Department of Critical Care, Children's Minnesota, Minneapolis, MN
| | - Miriam P Cotler
- Department of Health Sciences, California State University Northridge, Northridge, CA
| | | | - Joshua B Kayser
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
| | | | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA
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Felder RM, Magnus D. A Rejection of "Applied Ethics": Philosophy's Real Contributions to Bioethics Found Elsewhere. Am J Bioeth 2022; 22:1-2. [PMID: 36416420 DOI: 10.1080/15265161.2022.2140539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
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Federico CA, Heagerty PJ, Lantos J, O'Rourke P, Rahimzadeh V, Sugarman J, Weinfurt K, Wendler D, Wilfond BS, Magnus D. Ethical and epistemic issues in the design and conduct of pragmatic stepped-wedge cluster randomized clinical trials. Contemp Clin Trials 2022; 115:106703. [PMID: 35176501 PMCID: PMC9272561 DOI: 10.1016/j.cct.2022.106703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/27/2022] [Accepted: 02/02/2022] [Indexed: 11/27/2022]
Abstract
Stepped-wedge cluster randomized trial (SW-CRT) designs are increasingly employed in pragmatic research; they differ from traditional parallel cluster randomized trials in which an intervention is delivered to a subset of clusters, but not to all. In a SW-CRT, all clusters receive the intervention under investigation by the end of the study. This approach is thought to avoid ethical concerns about the denial of a desired intervention to participants in control groups. Such concerns have been cited in the literature as a primary motivation for choosing SW-CRT design, however SW-CRTs raise additional ethical concerns related to the delayed implementation of an intervention and consent. Yet, PCT investigators may choose SW-CRT designs simply because they are concerned that other study designs are infeasible. In this paper, we examine justifications for the use of SW-CRT study design, over other designs, by drawing on the experience of the National Institutes of Health's Health Care Systems Research Collaboratory (NIH Collaboratory) with five pragmatic SW-CRTs. We found that decisions to use SW-CRT design were justified by practical and epistemic reasons rather than ethical ones. These include concerns about feasibility, the heterogeneity of cluster characteristics, and the desire for simultaneous clinical evaluation and implementation. In this paper we compare the potential benefits of SW-CRTs against the ethical and epistemic challenges brought forth by the design and suggest that the choice of SW-CRT design must balance epistemic, feasibility and ethical justifications. Moreover, given their complexity, such studies need rigorous and informed ethical oversight.
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Affiliation(s)
- Carole A Federico
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, WA 98185, USA
| | - John Lantos
- Children's Mercy Hospital Bioethics Center, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | | | - Vasiliki Rahimzadeh
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Kevin Weinfurt
- Center for Health Measurement, Duke University, Durham, NC 27701, USA
| | - David Wendler
- Department of Bioethics, NIH Clinical Center, Bethesda, MD 20892, USA
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA 98185, USA
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA.
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Omelianchuk A, Bernat J, Caplan A, Greer D, Lazaridis C, Lewis A, Pope T, Ross LF, Magnus D. Revise the UDDA to Align the Law with Practice through Neuro-Respiratory Criteria. Neurology 2022; 98:532-536. [PMID: 35078943 PMCID: PMC8967425 DOI: 10.1212/wnl.0000000000200024] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/06/2022] [Indexed: 11/15/2022] Open
Abstract
Although the Uniform Determination of Death Act (UDDA) has served as a model statute for 40 years, there is a growing recognition that the law must be updated. One issue being considered by the Uniform Law Commission's Drafting Committee to revise the UDDA is whether the text “all functions of the entire brain, including the brainstem” should be changed. Some argue that the absence of diabetes insipidus indicates that some brain functioning continues in many individuals who otherwise meet the “accepted medical standards” like the American Academy of Neurology's. The concern is that the legal criteria and the medical standards used to determine death by neurologic criteria are not aligned. We argue for the revision of the UDDA to more accurately specify legal criteria that align with the medical standards: brain injury leading to permanent loss of the capacity for consciousness, the ability to breathe spontaneously, and brainstem reflexes. We term these criteria neurorespiratory criteria and show that they are well-supported in the literature for physiologic and social reasons justifying their use in the law.
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Affiliation(s)
- Adam Omelianchuk
- From the Stanford Center for Biomedical Ethics (A.O., D.M.), CA; Dartmouth Geisel School of Medicine (J.B.), Hanover, NH; NYU Grossman School of Medicine (A.C.), New York; Boston University School of Medicine (D.G.), MA; University of Chicago Medical Center (C.L.), IL; NYU Langone Medical Center (A.L.), New York; Mitchell Hamline School of Law (T.P.), St. Paul, MN; Institute for Translational Medicine (L.F.R.), Chicago; and University of Chicago (L.F.R.), IL
| | - James Bernat
- From the Stanford Center for Biomedical Ethics (A.O., D.M.), CA; Dartmouth Geisel School of Medicine (J.B.), Hanover, NH; NYU Grossman School of Medicine (A.C.), New York; Boston University School of Medicine (D.G.), MA; University of Chicago Medical Center (C.L.), IL; NYU Langone Medical Center (A.L.), New York; Mitchell Hamline School of Law (T.P.), St. Paul, MN; Institute for Translational Medicine (L.F.R.), Chicago; and University of Chicago (L.F.R.), IL
| | - Arthur Caplan
- From the Stanford Center for Biomedical Ethics (A.O., D.M.), CA; Dartmouth Geisel School of Medicine (J.B.), Hanover, NH; NYU Grossman School of Medicine (A.C.), New York; Boston University School of Medicine (D.G.), MA; University of Chicago Medical Center (C.L.), IL; NYU Langone Medical Center (A.L.), New York; Mitchell Hamline School of Law (T.P.), St. Paul, MN; Institute for Translational Medicine (L.F.R.), Chicago; and University of Chicago (L.F.R.), IL
| | - David Greer
- From the Stanford Center for Biomedical Ethics (A.O., D.M.), CA; Dartmouth Geisel School of Medicine (J.B.), Hanover, NH; NYU Grossman School of Medicine (A.C.), New York; Boston University School of Medicine (D.G.), MA; University of Chicago Medical Center (C.L.), IL; NYU Langone Medical Center (A.L.), New York; Mitchell Hamline School of Law (T.P.), St. Paul, MN; Institute for Translational Medicine (L.F.R.), Chicago; and University of Chicago (L.F.R.), IL
| | - Christos Lazaridis
- From the Stanford Center for Biomedical Ethics (A.O., D.M.), CA; Dartmouth Geisel School of Medicine (J.B.), Hanover, NH; NYU Grossman School of Medicine (A.C.), New York; Boston University School of Medicine (D.G.), MA; University of Chicago Medical Center (C.L.), IL; NYU Langone Medical Center (A.L.), New York; Mitchell Hamline School of Law (T.P.), St. Paul, MN; Institute for Translational Medicine (L.F.R.), Chicago; and University of Chicago (L.F.R.), IL
| | - Ariane Lewis
- From the Stanford Center for Biomedical Ethics (A.O., D.M.), CA; Dartmouth Geisel School of Medicine (J.B.), Hanover, NH; NYU Grossman School of Medicine (A.C.), New York; Boston University School of Medicine (D.G.), MA; University of Chicago Medical Center (C.L.), IL; NYU Langone Medical Center (A.L.), New York; Mitchell Hamline School of Law (T.P.), St. Paul, MN; Institute for Translational Medicine (L.F.R.), Chicago; and University of Chicago (L.F.R.), IL
| | - Thaddeus Pope
- From the Stanford Center for Biomedical Ethics (A.O., D.M.), CA; Dartmouth Geisel School of Medicine (J.B.), Hanover, NH; NYU Grossman School of Medicine (A.C.), New York; Boston University School of Medicine (D.G.), MA; University of Chicago Medical Center (C.L.), IL; NYU Langone Medical Center (A.L.), New York; Mitchell Hamline School of Law (T.P.), St. Paul, MN; Institute for Translational Medicine (L.F.R.), Chicago; and University of Chicago (L.F.R.), IL
| | - Lainie Friedman Ross
- From the Stanford Center for Biomedical Ethics (A.O., D.M.), CA; Dartmouth Geisel School of Medicine (J.B.), Hanover, NH; NYU Grossman School of Medicine (A.C.), New York; Boston University School of Medicine (D.G.), MA; University of Chicago Medical Center (C.L.), IL; NYU Langone Medical Center (A.L.), New York; Mitchell Hamline School of Law (T.P.), St. Paul, MN; Institute for Translational Medicine (L.F.R.), Chicago; and University of Chicago (L.F.R.), IL
| | - David Magnus
- From the Stanford Center for Biomedical Ethics (A.O., D.M.), CA; Dartmouth Geisel School of Medicine (J.B.), Hanover, NH; NYU Grossman School of Medicine (A.C.), New York; Boston University School of Medicine (D.G.), MA; University of Chicago Medical Center (C.L.), IL; NYU Langone Medical Center (A.L.), New York; Mitchell Hamline School of Law (T.P.), St. Paul, MN; Institute for Translational Medicine (L.F.R.), Chicago; and University of Chicago (L.F.R.), IL.
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Spector-Bagdady K, Lynch HF, Bierer BE, Gelinas L, Hull SC, Magnus D, Meyer MN, Sharp RR, Sugarman J, Wilfond BS, Yearby R, Mohapatra S. Allocation of Opportunities to Participate in Clinical Trials during the Covid-19 Pandemic and Other Public Health Emergencies. Hastings Cent Rep 2022; 52:51-58. [PMID: 34908169 PMCID: PMC9414770 DOI: 10.1002/hast.1297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Covid-19 raised many novel ethical issues including regarding the allocation of opportunities to participate in clinical trials during a public health emergency. In this article, we explore how hospitals that have a scarcity of trial opportunities, either overall or in a specific trial, can equitably allocate those opportunities in the context of an urgent medical need with limited therapeutic interventions. We assess the three main approaches to allocating trial opportunities discussed in the literature: patient choice, physician referral, and randomization/lottery. As, we argue, none of the three typical approaches are ethically ideal for allocating trial opportunities in the pandemic context, many hospitals have instead implemented hybrid solutions. We offer practical guidance to support those continuing to face these challenges, and we analyze options for the future.
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Affiliation(s)
- Kayte Spector-Bagdady
- Associate Director of the Center for Bioethics & Social Sciences in Medicine and Assistant Professor of Obstetrics and Gynecology at the University of Michigan Medical School
| | - Holly Fernandez Lynch
- John Russell Dickson, MD Presidential Assistant Professor of Medical Ethics and Assistant Professor of Law at the University of Pennsylvania
| | - Barbara E. Bierer
- Professor of Medicine at Harvard Medical School and the Brigham and Women’s Hospital
| | - Luke Gelinas
- IRB Chair at Advarra and a Senior Advisor for the Multi-Regional Clinical Trials Center of Brigham and Women’s Hospital and Harvard
| | - Sara Chandros Hull
- Director of the NHGRI Bioethics Core and member of the Department of Bioethics faculty at the National Institutes of Health
| | - David Magnus
- Thomas A. Raffin Professor of Medicine and Biomedical Ethics and Professor of Pediatrics at Stanford University
| | - Michelle N. Meyer
- Assistant professor and the associate director of research ethics in the Center for Translational Bioethics and Health Care Policy at Geisinger Health System
| | | | - Jeremy Sugarman
- Harvey M. Meyerhoff Professor of Bioethics and Medicine and deputy director for medicine of the Berman Institute of Bioethics at the Johns Hopkins University
| | - Benjamin S. Wilfond
- Professor in the Department of Pediatrics, University of Washington School of Medicine and investigator at the Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute
| | - Ruqaiijah Yearby
- Full professor and member of the Center for Health Law Studies at Saint Louis University School of Law and co-founder and Executive Director of Saint Louis University’s Institute for Healing Justice and Equity
| | - Seema Mohapatra
- Murray Visiting Professor of Law at SMU Dedman School of Law
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Wong BO, Blythe JA, Batten JN, Turner BE, Lau JN, Hosamani P, Hanks WF, Magnus D. Recognizing the Role of Language in the Hidden Curriculum of Undergraduate Medical Education: Implications for Equity in Medical Training. Acad Med 2021; 96:842-847. [PMID: 32769473 DOI: 10.1097/acm.0000000000003657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Medical education involves a transition from "outsider" to "insider" status, which entails both rigorous formal training and an inculturation of values and norms via a hidden curriculum. Within this transition, the ability to "talk the talk" designates an individual as an insider, and learning to talk this talk is a key component of professional socialization. This Article uses the framework of "patterns of medical language" to explore the role of language in the hidden curriculum of medical education, exploring how students must learn to recognize and participate fluently within patterns of medical language to be acknowledged and evaluated as competent trainees. The authors illustrate this by reframing the Association of American Medical Colleges' Core Entrustable Professional Activities for Entering Residency as a series of overlapping patterns of medical language that students are expected to master before residency. The authors propose that many of these patterns of medical language are learned through trial and error, taught via a hidden curriculum rather than through explicit instruction. Medical students come from increasingly diverse backgrounds and therefore begin medical training further from or closer to insider status. Thus, evaluative practices based on patterns of medical language, which are not explicitly taught, may exacerbate and perpetuate existing inequities in medical education. This Article aims to bring awareness to the importance of medical language within the hidden curriculum of medical education, to the role of medical language as a marker of insider status, and to the centrality of medical language in evaluative practices. The authors conclude by offering possible approaches to ameliorate the inequities that may exist due to current evaluative practices.
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Affiliation(s)
- Bonnie O Wong
- B.O. Wong is a medical student, Stanford University School of Medicine, researcher, Stanford Center for Biomedical Ethics, Stanford, California, and PhD candidate, Department of Anthropology, University of California, Berkeley, Berkeley, California
| | - Jacob A Blythe
- J.A. Blythe is a medical student, Stanford University School of Medicine, and researcher, Stanford Center for Biomedical Ethics, Stanford, California
| | - Jason N Batten
- J.N. Batten is resident physician, Internal Medicine and Anesthesia Combined Program, Stanford University, and researcher, Stanford Center for Biomedical Ethics, Stanford, California
| | - Brandon E Turner
- B.E. Turner is resident physician, Harvard Radiation Oncology Residency Program, Boston, Massachusetts
| | - James N Lau
- J.N. Lau is clinical professor of surgery and assistant dean for clerkship education, Stanford University School of Medicine, and director, Stanford Surgery ACS Education Institute, Surgical Education Fellowship, and core clerkship in surgery, Stanford University, Stanford, California
| | - Poonam Hosamani
- P. Hosamani is clinical assistant professor of medicine, director, Practice of Medicine course, and codirector, Transition to Clerkships, Stanford University School of Medicine, Stanford, California
| | - William F Hanks
- W.F. Hanks is distinguished chair of linguistic anthropology, professor of anthropology, affiliated professor of linguistics, and founding director, Social Science Matrix, University of California, Berkeley, Berkeley, California
| | - David Magnus
- D. Magnus is Thomas A. Raffin Professor of Medicine and Biomedical Ethics, and professor, Pediatrics and Medicine, Stanford University School of Medicine, and director, Stanford Center for Biomedical Ethics, Stanford, California
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Meyer MN, Gelinas L, Bierer BE, Hull SC, Joffe S, Magnus D, Mohapatra S, Sharp RR, Spector-Bagdady K, Sugarman J, Wilfond BS, Lynch HF. An ethics framework for consolidating and prioritizing COVID-19 clinical trials. Clin Trials 2021; 18:226-233. [PMID: 33530721 PMCID: PMC8009845 DOI: 10.1177/1740774520988669] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Given the dearth of established safe and effective interventions to respond to COVID-19, there is an urgent ethical imperative to conduct meaningful clinical research. The good news is that interventions to be tested are not in short supply. Unfortunately, the human and material resources needed to conduct these trials are finite. It is essential that trials be robust and meet enrollment targets and that lower-quality studies not be permitted to displace higher-quality studies, delaying answers to critical questions. Yet, with few exceptions, existing research review bodies and processes are not designed to ensure these conditions are satisfied. To meet this challenge, we offer guidance for research institutions about how to ethically consolidate and prioritize COVID-19 clinical trials, while recognizing that consolidation and prioritization should also take place upstream (among manufacturers and funders) and at a higher level (e.g. nationally). In our proposed three-stage process, trials must first meet threshold criteria. Those that do are evaluated in a second stage to determine whether the institution has sufficient capacity to support all proposed trials. If it does not, the third stage entails evaluating studies against two additional sets of comparative prioritization criteria: those specific to the study and those that aim to advance diversification of an institution's research portfolio. To implement these criteria fairly, we propose that research institutions form COVID-19 research prioritization committees. We briefly discuss some important attributes of these committees, drawing on the authors' experiences at our respective institutions. Although we focus on clinical trials of COVID-19 therapeutics, our guidance should prove useful for other kinds of COVID-19 research, as well as non-pandemic research, which can raise similar challenges due to the scarcity of research resources.
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Affiliation(s)
- Michelle N Meyer
- Center for Translational Bioethics and Health Care Policy and The Steele Institute for Health Innovation, Geisinger Health System, Danville, PA, USA
| | | | - Barbara E Bierer
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sara Chandros Hull
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Steven Joffe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - David Magnus
- Center for Biomedical Ethics, Stanford University, Stanford, CA, USA
| | - Seema Mohapatra
- Indiana University Robert H. McKinney School of Law, Indiana University, Indianapolis, IN, USA
| | - Richard R Sharp
- Biomedical Ethics Program, Division of Health Care Policy Research, Mayo Clinic, Rochester, MN, USA
| | - Kayte Spector-Bagdady
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics and Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA, USA
| | - Holly Fernandez Lynch
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Martinez-Martin N, Luo Z, Kaushal A, Adeli E, Haque A, Kelly SS, Wieten S, Cho MK, Magnus D, Fei-Fei L, Schulman K, Milstein A. Ethical issues in using ambient intelligence in health-care settings. Lancet Digit Health 2021; 3:e115-e123. [PMID: 33358138 PMCID: PMC8310737 DOI: 10.1016/s2589-7500(20)30275-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/26/2020] [Accepted: 11/11/2020] [Indexed: 12/16/2022]
Abstract
Ambient intelligence is increasingly finding applications in health-care settings, such as helping to ensure clinician and patient safety by monitoring staff compliance with clinical best practices or relieving staff of burdensome documentation tasks. Ambient intelligence involves using contactless sensors and contact-based wearable devices embedded in health-care settings to collect data (eg, imaging data of physical spaces, audio data, or body temperature), coupled with machine learning algorithms to efficiently and effectively interpret these data. Despite the promise of ambient intelligence to improve quality of care, the continuous collection of large amounts of sensor data in health-care settings presents ethical challenges, particularly in terms of privacy, data management, bias and fairness, and informed consent. Navigating these ethical issues is crucial not only for the success of individual uses, but for acceptance of the field as a whole.
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Affiliation(s)
| | - Zelun Luo
- Department of Computer Science, Stanford University, Stanford, CA, USA
| | - Amit Kaushal
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Ehsan Adeli
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA; Department of Computer Science, Stanford University, Stanford, CA, USA
| | - Albert Haque
- Department of Computer Science, Stanford University, Stanford, CA, USA
| | - Sara S Kelly
- Clinical Excellence Research Center, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Sarah Wieten
- Center for Biomedical Ethics, Stanford University, Stanford, CA, USA
| | - Mildred K Cho
- Center for Biomedical Ethics, Stanford University, Stanford, CA, USA
| | - David Magnus
- Center for Biomedical Ethics, Stanford University, Stanford, CA, USA
| | - Li Fei-Fei
- Stanford Institute for Human-Centered Artificial Intelligence, Stanford University, Stanford, CA, USA
| | - Kevin Schulman
- Clinical Excellence Research Center, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Arnold Milstein
- Clinical Excellence Research Center, Department of Medicine, Stanford University, Stanford, CA, USA
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15
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Panagiotou OA, Högg LH, Hricak H, Khleif SN, Levy MA, Magnus D, Murphy MJ, Patel B, Winn RA, Nass SJ, Gatsonis C, Cogle CR. Clinical Application of Computational Methods in Precision Oncology: A Review. JAMA Oncol 2021; 6:1282-1286. [PMID: 32407443 DOI: 10.1001/jamaoncol.2020.1247] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance There is an enormous and growing amount of data available from individual cancer cases, which makes the work of clinical oncologists more demanding. This data challenge has attracted engineers to create software that aims to improve cancer diagnosis or treatment. However, the move to use computers in the oncology clinic for diagnosis or treatment has led to instances of premature or inappropriate use of computational predictive systems. Objective To evaluate best practices for developing and assessing the clinical utility of predictive computational methods in oncology. Evidence Review The National Cancer Policy Forum and the Board on Mathematical Sciences and Analytics at the National Academies of Sciences, Engineering, and Medicine hosted a workshop to examine the use of multidimensional data derived from patients with cancer and the computational methods used to analyze these data. The workshop convened diverse stakeholders and experts, including computer scientists, oncology clinicians, statisticians, patient advocates, industry leaders, ethicists, leaders of health systems (academic and community based), private and public health insurance carriers, federal agencies, and regulatory authorities. Key characteristics for successful computational oncology were considered in 3 thematic areas: (1) data quality, completeness, sharing, and privacy; (2) computational methods for analysis, interpretation, and use of oncology data; and (3) clinical infrastructure and expertise for best use of computational precision oncology. Findings Quality control was found to be essential across all stages, from data collection to data processing, management, and use. Collecting a standardized parsimonious data set at every cancer diagnosis and restaging could enhance reliability and completeness of clinical data for precision oncology. Data completeness refers to key data elements such as information about cancer diagnosis, treatment, and outcomes, while data quality depends on whether appropriate variables have been measured in valid and reliable ways. Collecting data from diverse populations can reduce the risk of creating invalid and biased algorithms. Computational systems that aid clinicians should be classified as software as a medical device and thus regulated according to the potential risk posed. To facilitate appropriate use of computational methods that interpret high-dimensional data in oncology, treating physicians need access to multidisciplinary teams with broad expertise and deep training among a subset of clinical oncology fellows in clinical informatics. Conclusions and Relevance Workshop discussions suggested best practices in demonstrating the clinical utility of predictive computational methods for diagnosing or treating cancer.
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Affiliation(s)
- Orestis A Panagiotou
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Lori Hoffman Högg
- National Center for Health Promotion and Disease Prevention, Veterans Health Administration, Durham, North Carolina.,Office of Nursing Services, Veterans Health Administration, Washington, DC
| | - Hedvig Hricak
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Samir N Khleif
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
| | - Mia A Levy
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee.,Division of Hematology and Oncology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - David Magnus
- Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California
| | | | - Bakul Patel
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland
| | - Robert A Winn
- University of Illinois at Chicago Cancer Center, University of Illinois Hospital and Health Sciences System, Chicago
| | - Sharyl J Nass
- Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine, Washington, DC
| | - Constantine Gatsonis
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island
| | - Christopher R Cogle
- Division of Hematology & Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville
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16
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Shearer E, Cho M, Magnus D. Regulatory, social, ethical, and legal issues of artificial intelligence in medicine. Artif Intell Med 2021. [DOI: 10.1016/b978-0-12-821259-2.00023-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Alvarez JB, Bibault JE, Burgun A, Cai J, Cao Z, Chang K, Chen JH, Chen WC, Cho M, Cho PJ, Cornish TC, Costa A, Dekker A, Drukker K, Dunn J, Eminaga O, Erickson BJ, Fournier L, Gambhir SS, Gennatas ED, Giger ML, Halilaj I, Harrison AP, He B, Hong JC, Jin D, Jin MC, Jochems A, Kalpathy-Cramer J, Kapp DS, Karimzadeh M, Karnes W, Lambin P, Langlotz CP, Lee J, Li H, Liao JC, Lin AL, Lin RY, Liu Y, Lu L, Magnus D, McIntosh C, Miao S, Min JK, Neill DB, Oermann EK, Ouyang D, Peng L, Phene S, Poirot MG, Quon JL, Ranti D, Rao A, Raskar R, Rombaoa C, Rubin DL, Samarasena J, Seekins J, Seetharam K, Shearer E, Sibley A, Singh K, Singh P, Sordo M, Suraweera D, Valliani AAA, van Wijk Y, Vepakomma P, Wang B, Wang G, Wang N, Wang Y, Warner E, Welch M, Wong K, Wu Z, Xing F, Xing L, Yan K, Yan P, Yang L, Yeom KW, Zachariah R, Zeng D, Zhang L, Zhang L, Zhang X, Zhou L, Zou J. List of contributors. Artif Intell Med 2021. [DOI: 10.1016/b978-0-12-821259-2.00035-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Wall A, Lee GH, Maldonado J, Magnus D. Genetic disease and intellectual disability as contraindications to transplant listing in the United States: A survey of heart, kidney, liver, and lung transplant programs. Pediatr Transplant 2020; 24:e13837. [PMID: 32997378 DOI: 10.1111/petr.13837] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/21/2020] [Accepted: 08/13/2020] [Indexed: 01/01/2023]
Abstract
Discrimination based on disability is prohibited in organ transplantation, yet studies suggest it continues in listing practices for intellectual disability and genetic diseases. It is not known if this differs between adult and pediatric programs, or by organ type. We performed an online, forced-choice survey of psychosocial listing criteria for adult and pediatric heart, kidney, liver, and lung transplant programs in the United States. Of 650 programs contacted, 343 (52.8%) submitted complete. A minority of programs had formal listing guidelines for any condition considered (Down Syndrome, Duchenne Muscular Dystrophy, Becker Muscular Dystrophy, DiGeorge Syndrome, and Wolf Hirschhorn Syndrome; and mild [IQ < 70] and severe [IQ < 35] intellectual disability), although a majority had encountered most. Pediatric programs were significantly (P < .02) more lenient in the level of contraindication to listing for all genetic conditions considered except Duchenne Muscular Dystrophy, and for mild and severe intellectual disability. Level of contraindication differed significantly by organ type (heart, lung, liver, and kidney) for Duchenne Muscular dystrophy (P = <.001), Becker Muscular Dystrophy (P < .001), DiGeorge Syndrome (P < .001), Wolf-Hirschhorn syndrome (P = .0012), and severe intellectual disability (P < .001). There is significant variation among transplant programs in availability of guidelines for as well as listing practices regarding genetic diseases and intellectual disability, differing by both adult vs pediatric program, and organ type. Programs with absolute contraindications to listing for specific genetic diseases or intellectual disability should reframe their approach, ensuring individualized assessments and avoiding elimination of patients based on membership in a particular group.
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Affiliation(s)
- Anji Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Gun Ho Lee
- School of Medicine, Stanford University, Stanford, California, USA
| | - Jose Maldonado
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA
| | - David Magnus
- Departments of Pediatrics and Medicine and Center for Biomedical Ethics, Stanford University, Stanford, California, USA
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Batten JN, Blythe JA, Wieten S, Cotler MP, Kayser JB, Porter-Williamson K, Harman S, Dzeng E, Magnus D. Variation in the design of Do Not Resuscitate orders and other code status options: a multi-institutional qualitative study. BMJ Qual Saf 2020; 30:668-677. [PMID: 33082165 DOI: 10.1136/bmjqs-2020-011222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/01/2020] [Accepted: 08/14/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND US hospitals typically provide a set of code status options that includes Full Code and Do Not Resuscitate (DNR) but often includes additional options. Although US hospitals differ in the design of code status options, this variation and its impacts have not been empirically studied. DESIGN AND METHODS Multi-institutional qualitative study at 7 US hospitals selected for variability in geographical location, type of institution and design of code status options. We triangulated across three data sources (policy documents, code status ordering menus and in-depth physician interviews) to characterise the code status options available at each hospital. Using inductive qualitative methods, we investigated design differences in hospital code status options and the perceived impacts of these differences. RESULTS The code status options at each hospital varied widely with regard to the number of code status options, the names and definitions of code status options, and the formatting and capabilities of code status ordering menus. DNR orders were named and defined differently at each hospital studied. We identified five key design characteristics that impact the function of a code status order. Each hospital's code status options were unique with respect to these characteristics, indicating that code status plays differing roles in each hospital. Physician participants perceived that the design of code status options shapes communication and decision-making practices about resuscitation and life-sustaining treatments, especially at the end of life. We identified four potential mechanisms through which this may occur: framing conversations, prompting decisions, shaping inferences and creating categories. CONCLUSIONS There are substantive differences in the design of hospital code status options that may contribute to known variability in end-of-life care and treatment intensity among US hospitals. Our framework can be used to design hospital code status options or evaluate their function.
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Affiliation(s)
- Jason N Batten
- Department of Medicine, Stanford University, Stanford, California, USA .,Department of Anesthesia, Stanford University, Stanford, California, USA.,Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Jacob A Blythe
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Sarah Wieten
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Miriam Piven Cotler
- Department of Health Sciences, California State University Northridge, Northridge, California, USA
| | - Joshua B Kayser
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Karin Porter-Williamson
- Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Stephanie Harman
- Department of Medicine, Stanford University, Stanford, California, USA.,Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Elizabeth Dzeng
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
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21
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Abstract
Digital contact tracing, in combination with widespread testing, has been a focal point for many plans to “reopen” economies while containing the spread of Covid‐19. Most digital contact tracing projects in the United States and Europe have prioritized privacy protections in the form of local storage of data on smartphones and the deidentification of information. However, in the prioritization of privacy in this narrow form, there is not sufficient attention given to weighing ethical trade‐offs within the context of a public health pandemic or to the need to evaluate safety and effectiveness of software‐based technology applied to public health.
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22
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Shearer E, Magnus D. Using Implementation Science to Enact Specific Ethical Norms: The Case of Code Status Policy. Am J Bioeth 2020; 20:6-7. [PMID: 32208071 DOI: 10.1080/15265161.2020.1735874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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23
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Shearer E, Martinez N, Magnus D. Dimensions of Research-Participant Interaction: Engagement is Not a Replacement for Consent. J Law Med Ethics 2020; 48:183-184. [PMID: 32342787 DOI: 10.1177/1073110520917008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Emily Shearer
- Emily Shearer, M.P.P., M.Sc., is with the Stanford Center for Biomedical Ethics. Nicole Martinez, J.D., Ph.D., is with the Stanford Center for Biomedical Ethics. David Magnus, Ph.D., is with the Stanford Center for Biomedical Ethics
| | - Nicole Martinez
- Emily Shearer, M.P.P., M.Sc., is with the Stanford Center for Biomedical Ethics. Nicole Martinez, J.D., Ph.D., is with the Stanford Center for Biomedical Ethics. David Magnus, Ph.D., is with the Stanford Center for Biomedical Ethics
| | - David Magnus
- Emily Shearer, M.P.P., M.Sc., is with the Stanford Center for Biomedical Ethics. Nicole Martinez, J.D., Ph.D., is with the Stanford Center for Biomedical Ethics. David Magnus, Ph.D., is with the Stanford Center for Biomedical Ethics
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25
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Graf M, Char D, Hanson-Kahn A, Magnus D. Use of genetic risks in pediatric organ transplantation listing decisions: A national survey. Pediatr Transplant 2019; 23:e13402. [PMID: 31012250 PMCID: PMC6836721 DOI: 10.1111/petr.13402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/04/2018] [Accepted: 01/14/2019] [Indexed: 01/02/2023]
Abstract
There is a limited supply of organs for all those who need them for survival. Thus, careful decisions must be made about who is listed for transplant. Studies show that manifesting genetic disease can impact listing eligibility. What has not yet been studied is the impact genetic risks for future disease have on a patient's chance to be listed. Surveys were emailed to 163 pediatric liver, heart, and kidney transplant programs across the United States to elicit views and experiences of key clinicians regarding each program's use of genetic risks (ie, predispositions, positive predictive testing) in listing decisions. Response rate was 42%. Sixty-four percent of programs have required genetic testing for specific indications prior to listing decisions. Sixteen percent have required it without specific indications, suggesting that genetic testing may be used to screen candidates. Six percent have chosen not to list patients with secondary findings or family histories of genetic conditions. In hypothetical scenarios, programs consider cancer predispositions and adult-onset neurological conditions to be relative contraindications to listing (61%, 17%, and 8% depending on scenario), and some consider them absolute contraindications (5% and 3% depending on scenario). Only 3% of programs have formal policies for these scenarios, but all consult genetic specialists at least "sometimes" for results interpretation. Our study reveals that pediatric transplant programs are using future onset genetic risks in listing decisions. As genetic testing is increasingly adopted into pediatric medicine, further study is needed to prevent possible inappropriate use of genetic information from impacting listing eligibility.
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Affiliation(s)
- Madeline Graf
- Department of Genetics, Stanford University School of Medicine, Stanford University, Stanford, California
| | - Danton Char
- Department of Anesthesiology, Perioperative and Pain Management, Stanford University School of Medicine, Stanford University, Stanford, California
| | - Andrea Hanson-Kahn
- Department of Genetics, Stanford University School of Medicine, Stanford University, Stanford, California
- Division of Medical Genetics, Department of Pediatrics, Stanford University Medical Center, Stanford University, Stanford, California
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford University, Stanford, California
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26
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Affiliation(s)
- Sarah Wieten
- a Stanford University Center for Biomedical Ethics
| | | | - David Magnus
- a Stanford University Center for Biomedical Ethics
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Abstract
INTRODUCTION Next-generation sequencing (NGS) is expected to revolutionize health care. NGS allows for sequencing of the whole genome more cheaply and quickly than previous techniques. NGS offers opportunities to advance medical diagnostics and treatments, but also raises complicated ethical questions that need to be addressed. AREAS CONSIDERED This article draws from the literature on research and clinical ethics, as well as next-generation sequencing, in order to provide an overview of the ethical challenges involved in next-generation sequencing. This article includes a discussion of the ethics of NGS in research and clinical contexts. EXPERT OPINION The use of NGS in clinical and research contexts has features that pose challenges for traditional ethical frameworks for protecting research participants and patients. NGS generates massive amounts of data and results that vary in terms of known clinical relevance. It is important to determine appropriate processes for protecting, managing and communicating the data. The use of machine learning for sequencing and interpretation of genomic data also raises concerns in terms of the potential for bias and potential implications for fiduciary obligations. NGS poses particular challenges in three main ethical areas: privacy, informed consent, and return of results.
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Affiliation(s)
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA, USA
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28
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D’Angelo A, Ormond KE, Magnus D, Tabor HK. Assessing genetic counselors’ experiences with physician aid-in-dying and practice implications. J Genet Couns 2019; 28:164-173. [DOI: 10.1002/jgc4.1047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 10/04/2018] [Accepted: 10/05/2018] [Indexed: 12/29/2022]
Affiliation(s)
- Abby D’Angelo
- Department of Genetics; Stanford School of Medicine; Stanford California
| | - Kelly E. Ormond
- Stanford Center for Biomedical Ethics; Stanford University; Stanford California
- Department of Pediatrics; Stanford University; Stanford California
| | - David Magnus
- Stanford Center for Biomedical Ethics; Stanford University; Stanford California
- Department of Pediatrics; Stanford University; Stanford California
- Department of Medicine; Stanford University; Stanford California
| | - Holly K. Tabor
- Stanford Center for Biomedical Ethics; Stanford University; Stanford California
- Department of Medicine; Stanford University; Stanford California
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Lee SSJ, Cho MK, Kraft SA, Varsava N, Gillespie K, Ormond KE, Wilfond BS, Magnus D. "I don't want to be Henrietta Lacks": diverse patient perspectives on donating biospecimens for precision medicine research. Genet Med 2018; 21:107-113. [PMID: 29887604 PMCID: PMC6289900 DOI: 10.1038/s41436-018-0032-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/21/2018] [Indexed: 01/12/2023] Open
Abstract
Purpose To determine whether patients distinguish between biospecimens and electronic health records (EHRs) when considering research participation to inform research protections. Methods We conducted 20 focus groups with individuals who identified as African American, Hispanic, Chinese, South Asian and non-Hispanic White on the collection of biospecimens and EHR data for research. Results Our study found that many participants did not distinguish between biospecimens and EHR data. However, some participants identified specific concerns about biospecimens. These included the need for special care and respect for biospecimens due to enduring connections between the body and identity; the potential for unacceptable future research, specifically the prospect of human cloning; heightened privacy risks; and the potential for unjust corporate profiteering. Among those who distinguished biospecimens from EHR data, many supported separate consent processes and would limit their own participation to EHR data. Conclusion Considering that the potential misuse of EHR data is as great, if not greater than for biospecimens, more research is needed to understand how attitudes differ between biospecimens and EHR data across diverse populations. Such research should explore mechanisms beyond consent that can address diverse values, perspectives and misconceptions about sources of patient information to build trust in research relationships.
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Affiliation(s)
- Sandra S-J Lee
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA, USA.
| | - Mildred K Cho
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA, USA
| | - Stephanie A Kraft
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA, USA.,Division of Bioethics, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Nina Varsava
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA, USA
| | - Katie Gillespie
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | - Kelly E Ormond
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA, USA.,Division of Bioethics, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA, USA
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34
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Affiliation(s)
- Danton S Char
- From the Department of Anesthesiology, Division of Pediatric Cardiac Anesthesia (D.S.C.), the Center for Biomedical Ethics (D.S.C., D.M.), and the Center for Biomedical Informatics Research (N.S.), Stanford University School of Medicine, Stanford, CA
| | - Nigam H Shah
- From the Department of Anesthesiology, Division of Pediatric Cardiac Anesthesia (D.S.C.), the Center for Biomedical Ethics (D.S.C., D.M.), and the Center for Biomedical Informatics Research (N.S.), Stanford University School of Medicine, Stanford, CA
| | - David Magnus
- From the Department of Anesthesiology, Division of Pediatric Cardiac Anesthesia (D.S.C.), the Center for Biomedical Ethics (D.S.C., D.M.), and the Center for Biomedical Informatics Research (N.S.), Stanford University School of Medicine, Stanford, CA
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35
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Burgart AM, Magnus D, Tabor HK, Paquette EDT, Frader J, Glover JJ, Jackson BM, Harrison CH, Urion DK, Graham RJ, Brandsema JF, Feudtner C. Ethical Challenges Confronted When Providing Nusinersen Treatment for Spinal Muscular Atrophy. JAMA Pediatr 2018; 172:188-192. [PMID: 29228163 DOI: 10.1001/jamapediatrics.2017.4409] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The US Food and Drug Administration's December 2016 approval of nusinersen for the treatment of patients with all subtypes of spinal muscular atrophy ushered in a new era for patients with spinal muscular atrophy, their families, and all those involved in their care. The extreme cost of the medication and the complicated logistical requirements for administering nusinersen via lumbar puncture have created practical challenges that raise important ethical considerations. We discuss 6 challenges faced at the institutional level in the United States: cost, limited evidence, informed consent, treatment allocation, fair distribution of responsibilities, and transparency with stakeholders. These challenges must be understood to ensure that patients with spinal muscular atrophy benefit from treatment, are protected from harm, and are treated fairly.
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Affiliation(s)
- Alyssa M Burgart
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, California
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, California
| | - Holly K Tabor
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, California
| | | | - Joel Frader
- Center for Biomedical Ethics and Humanities, Northwestern University, Chicago, Illinois
| | - Jaqueline J Glover
- Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus, Aurora
| | - Brian M Jackson
- Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus, Aurora
| | - Charlotte H Harrison
- Center for Bioethics, Harvard Medical School, Boston, Massachusetts.,Office of Ethics, Boston Children's Hospital, Boston, Massachusetts
| | - David K Urion
- Office of Ethics, Boston Children's Hospital, Boston, Massachusetts.,Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Robert J Graham
- Department of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - John F Brandsema
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chris Feudtner
- Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Burgart AM, Magnus D. Managing Expectations: Delivering the Worst News in the Best Way? Am J Bioeth 2018; 18:1-2. [PMID: 29313792 DOI: 10.1080/15265161.2017.1414494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Cho MK, Varsava N, Kraft SA, Ashwal G, Gillespie K, Magnus D, Ormond KE, Thomas A, Wilfond BS, Lee SSJ. Metaphors matter: from biobank to a library of medical information. Genet Med 2017; 20:802-805. [PMID: 29267267 DOI: 10.1038/gim.2017.204] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 10/10/2017] [Indexed: 11/09/2022] Open
Affiliation(s)
- Mildred K Cho
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA.
| | - Nina Varsava
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Stephanie A Kraft
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, Washington, USA.,Division of Bioethics, Department of Pediatrics, University of Washington School of Medicine, Seattle, USA
| | - Gary Ashwal
- Booster Shot Media, Santa Monica, California, USA
| | - Katie Gillespie
- Palo Alto Medical Foundation Research Institute, Palo Alto, California, USA
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Kelly E Ormond
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA.,Department of Genetics, Stanford University School of Medicine, Stanford, California, USA
| | - Alex Thomas
- Booster Shot Media, Santa Monica, California, USA
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, Washington, USA.,Division of Bioethics, Department of Pediatrics, University of Washington School of Medicine, Seattle, USA
| | - Sandra S-J Lee
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
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Abstract
Objectives In the context of serious or life-limiting illness, pediatric patients and their families are faced with difficult decisions surrounding appropriate resuscitation efforts in the event of a cardiopulmonary arrest. Code status orders are one way to inform end-of-life medical decision making. The objectives of this study are to evaluate the extent to which pediatric providers have knowledge of code status options and explore the association of provider role with (1) knowledge of code status options, (2) perception of timing of code status discussions, (3) perception of family receptivity to code status discussions, and (4) comfort carrying out code status discussions. Design Nurses, trainees (residents and fellows), and attending physicians from pediatric units where code status discussions typically occur completed a short survey questionnaire regarding their knowledge of code status options and perceptions surrounding code status discussions. Setting Single center, quaternary care children’s hospital. Measurements and main results 203 nurses, 31 trainees, and 29 attending physicians in 4 high-acuity pediatric units responded to the survey (N = 263, 90% response rate). Based on an objective knowledge measure, providers demonstrate poor understanding of available code status options, with only 22% of providers able to enumerate more than two of four available code status options. In contrast, provider groups self-report high levels of familiarity with available code status options, with attending physicians reporting significantly higher levels than nurses and trainees (p = 0.0125). Nurses and attending physicians show significantly different perception of code status discussion timing, with majority of nurses (63.4%) perceiving discussions as occurring “too late” or “much too late” and majority of attending physicians (55.6%) perceiving the timing as “about right” (p<0.0001). Attending physicians report significantly higher comfort having code status discussions with families than do nurses or trainees (p≤0.0001). Attending physicians and trainees perceive families as more receptive to code status discussions than nurses (p<0.0001 and p = 0.0018, respectively). Conclusions Providers have poor understanding of code status options and differ significantly in their comfort having code status discussions and their perceptions of these discussions. These findings may reflect inherent differences among providers, but may also reflect discordant visions of appropriate care and function as a potential source of moral distress. Lack of knowledge of code status options and differences in provider perceptions are likely barriers to quality communication surrounding end-of-life options.
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Affiliation(s)
- Katherine E. Kruse
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, United States of America
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America
- * E-mail:
| | - Jason Batten
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, United States of America
| | - Melissa L. Constantine
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota, United States of America
| | - Saraswati Kache
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, United States of America
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Kraft SA, Porter KM, Korngiebel DM, James C, Constantine M, Kelley M, Capron AM, Diekema D, Lee SSJ, Cho MK, Magnus D, Wilfond BS. Research on Medical Practices: Why Patients Consider Participating and the Investigational Misconception. IRB 2017; 39:10-16. [PMID: 30387977 PMCID: PMC7374557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Understanding how patients decide whether to enroll in research can help improve educational materials, protocols, and recruitment rates. However, little is known about patients' willingness to participate in research on medical practices (ROMP), or studies comparing interventions within usual care. We assessed willingness to consider participating in ROMP by surveying 1095 adults in the United States, of whom 834 answered at least one open-ended question about their reasons for being willing or unwilling to consider participating in two scenarios involving ROMP. Most respondents were willing to consider participating in the research scenarios. The most commonly cited reasons for being willing to consider participating included benefit to others and oneself; the top reasons for being unwilling to consider participating included belief that the research was unsafe and an unfavorable view of experimentation. Responses also revealed misconceptions about ROMP among both those who were willing and unwilling to consider participating. Because these misconceptions may present an obstacle to recruiting participants in ROMP, there may be a need for educational initiatives to clarify the nature of these types of studies.
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Affiliation(s)
| | | | | | | | | | | | | | - Douglas Diekema
- University of Washington
- Seattle Children's Research Institute
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Harman SM, Magnus D. Early Experience With the California End of Life Option Act: Balancing Institutional Participation and Physician Conscientious Objection. JAMA Intern Med 2017; 177:907-908. [PMID: 28531248 DOI: 10.1001/jamainternmed.2017.1485] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Stephanie M Harman
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - David Magnus
- Center for Biomedical Ethics, Stanford University School of Medicine, Palo Alto, California
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Abstract
Genome sequencing raises new ethical challenges. Decoding the genome produces new forms of diagnostic and prognostic information; however, the information is often difficult to interpret. The connection between most genetic variants and their phenotypic manifestations is not understood. This scenario is particularly true for disorders that are not associated with an autosomal genetic variant. The analytic uncertainty is compounded by moral uncertainty about how, exactly, the results of genomic testing should influence clinical decisions. In this Ethics Rounds, we present a case in which genomic findings seemed to play a role in deciding whether a patient was to be listed as a transplant candidate. We then asked experts in bioethics and cardiology to discuss the implications of such decisions.
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Affiliation(s)
- Danton S. Char
- Department of Anesthesiology, and,Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California;,Division of Pediatric Cardiac Anesthesia, Stanford University Medical Center, Stanford, California
| | - Gabriel Lázaro-Muñoz
- Center for Genomics and Society, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina;,Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas
| | | | - David Magnus
- Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California
| | - Michael J. Deem
- Department of Multidisciplinary Studies, The Center for Genomic Advocacy, Indiana State University, Terre Haute, Indiana
| | - John D. Lantos
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri; and
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Kraft SA, Constantine M, Magnus D, Porter KM, Lee SSJ, Green M, Kass NE, Wilfond BS, Cho MK. A randomized study of multimedia informational aids for research on medical practices: Implications for informed consent. Clin Trials 2017; 14:94-102. [PMID: 27625314 PMCID: PMC5300898 DOI: 10.1177/1740774516669352] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND/AIMS Participant understanding is a key element of informed consent for enrollment in research. However, participants often do not understand the nature, risks, benefits, or design of the studies in which they take part. Research on medical practices, which studies standard interventions rather than new treatments, has the potential to be especially confusing to participants because it is embedded within usual clinical care. Our objective in this randomized study was to compare the ability of a range of multimedia informational aids to improve participant understanding in the context of research on medical practices. METHODS We administered a web-based survey to members of a proprietary online panel sample selected to match national US demographics. Respondents were randomized to one of five arms: four content-equivalent informational aids (animated videos, slideshows with voice-over, comics, and text) and one no-intervention control. We measured knowledge of research on medical practices using a summary knowledge score from 10 questions based on the content of the informational aids. We used analysis of variance and paired t-tests to compare knowledge scores between arms. RESULTS There were 1500 completed surveys (300 in each arm). Mean knowledge scores were highest for the slideshows with voice-over (65.7%), followed by the animated videos (62.7%), comics (60.7%), text (57.2%), and control (50.3%). Differences between arms were statistically significant except between the slideshows with voice-over and animated videos and between the animated videos and comics. Informational aids that included an audio component (animated videos and slideshows with voice-over) had higher knowledge scores than those without an audio component (64.2% vs 59.0%, p < .0001). There was no difference between informational aids with a character-driven story component (animated videos and comics) and those without. CONCLUSION Our results show that simple multimedia aids that use a dual-channel approach, such as voice-over with visual reinforcement, can improve participant knowledge more effectively than text alone. However, the relatively low knowledge scores suggest that targeted informational aids may be needed to teach some particularly challenging concepts. Nonetheless, our results demonstrate the potential to improve informed consent for research on medical practices using multimedia aids that include simplified language and visual metaphors.
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Affiliation(s)
- Stephanie A Kraft
- Seattle Children’s Research Institute – Treuman Katz Center for Pediatric Bioethics, Seattle, WA USA
| | - Melissa Constantine
- University of Minnesota, Division of Health Policy and Management, Minneapolis, MN USA
| | - David Magnus
- Stanford University School of Medicine – Center for Biomedical Ethics, Stanford, CA USA
| | - Kathryn M. Porter
- Seattle Children’s Research Institute – Treuman Katz Center for Pediatric Bioethics, Seattle, WA USA
| | - Sandra Soo-Jin Lee
- Stanford University School of Medicine – Center for Biomedical Ethics, Stanford, CA USA
| | - Michael Green
- Penn State Milton S Hershey Medical Center – College of Medicine, Hershey, PA USA
| | - Nancy E Kass
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD USA
| | - Benjamin S. Wilfond
- Seattle Children’s Research Institute – Treuman Katz Center for Pediatric Bioethics, Seattle, WA USA
| | - Mildred K Cho
- Stanford University School of Medicine – Center for Biomedical Ethics, Stanford, CA USA
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Porter KM, Cho MK, Kraft SA, Korngiebel DM, Constantine M, Lee SSJ, Kelley M, James C, Kuwana E, Meyer A, Diekema D, Capron AM, Magnus D, Wilfond BS. Research on Medical Practices (ROMP): Attitudes of IRB Personnel about Randomization and Informed Consent. IRB 2017; 39:10-16. [PMID: 30146866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Char DS, Lee SSJ, Ikoku AA, Rosenthal D, Magnus D. Can Destination Therapy be implemented in children with heart failure? A study of provider perceptions. Pediatr Transplant 2016; 20:819-24. [PMID: 27357389 DOI: 10.1111/petr.12747] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/02/2016] [Indexed: 11/29/2022]
Abstract
DT is an established final therapeutic choice in adult patients with severe heart failure who do not meet criteria for cardiac transplantation. Patients are given VADs, without the prospect of care escalation to transplantation. VADs are now established therapy for children and are currently used as a bridge until transplantation can be performed or heart failure improves. For children who present in severe heart failure but do not meet transplantation criteria, the question has emerged whether DT can be offered. This qualitative study aimed to elicit the perspectives of early adopters of DT at one of the few institutions where DT has been provided for children. Responses were recorded and coded and themes extracted using grounded theory. Interviewees discussed: envisioning of the DT candidate; approach to evaluation for DT; contraindications to choosing DT; and concerns about choosing DT. Providers articulated two frameworks for conceptualizing DT: as a long bridge through resolution of problems that would initially contraindicate transplantation or, alternatively, as a true destination instead of transplantation. True destination, however, may not be the lasting concept for long-term VAD use in children given improvement in prognosis for current medical contraindications and improving VAD technology.
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Affiliation(s)
- Danton S Char
- Division of Pediatric Anesthesia, Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA, USA.,Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA, USA
| | - Sandra S-J Lee
- Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA, USA
| | - Alvan A Ikoku
- Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA, USA
| | - David Rosenthal
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - David Magnus
- Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA, USA
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Samuel JP, Burgart A, Wootton SH, Magnus D, Lantos JD, Tyson JE. Randomized n-of-1 Trials: Quality Improvement, Research, or Both? Pediatrics 2016; 138:peds.2016-1103. [PMID: 27385811 PMCID: PMC4960733 DOI: 10.1542/peds.2016-1103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2016] [Indexed: 11/24/2022] Open
Abstract
The regulatory demarcations between clinical research and quality improvement (QI) are ambiguous and controversial. Some projects that were undertaken as a form of QI were deemed by regulatory agencies to be research and thus to require institutional review board approval. In the era of personalized medicine, some physicians may ask some patients to participate in n-of-1 trials in an effort to personalize and optimize each patient's medical treatment. Should such activities be considered research, QI, or just excellent personalized medicine? Experts in research, research regulation, and bioethics analyze these issues.
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Affiliation(s)
- Joyce P. Samuel
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Alyssa Burgart
- Center for Bioethics, Stanford University, Palo Alto, California; and
| | - Susan H. Wootton
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - David Magnus
- Center for Bioethics, Stanford University, Palo Alto, California; and
| | - John D. Lantos
- Bioethics Center, Children’s Mercy Hospital, Kansas City, Missouri
| | - Jon E. Tyson
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
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Kraft SA, Cho MK, Constantine M, Lee SSJ, Kelley M, Korngiebel D, James C, Kuwana E, Meyer A, Porter K, Diekema D, Capron AM, Alicic R, Wilfond BS, Magnus D. A comparison of institutional review board professionals' and patients' views on consent for research on medical practices. Clin Trials 2016; 13:555-65. [PMID: 27257125 DOI: 10.1177/1740774516648907] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND/AIMS In the context of research on medical practices, which includes comparative effectiveness research and pragmatic clinical trials, empirical studies have begun to raise questions about the extent to which institutional review boards' interpretations and applications of research regulations align with patients' values. To better understand the similarities and differences between these stakeholder groups, we compare and contrast two surveys: one of institutional review board professionals and one of patients, which examine views on consent for research on medical practices. METHODS We conducted online surveys of two target populations between July 2014 and March 2015. We surveyed 601 human subjects research professionals out of 1500 randomly selected from the Public Responsibility in Medicine and Research membership list (40.1% response rate), limiting analysis to 537 respondents who reported having had institutional review board experience. We also surveyed 120 adult patients out of 225 approached at subspecialty clinics in Spokane, Washington (53.3% response rate). Our survey questions probed attitudes about consent in the context of research on medical practices using medical record review and randomization. The patient survey included three embedded animated videos to explain these concepts. RESULTS A majority of institutional review board professionals distinguished between consent preferences for medical record review and randomization, ranked clinicians as the least preferred person to obtain participant consent (54.6%), and viewed written or verbal permission as the minimum acceptable consent approach for research on medical practices using randomization (87.3%). In contrast, most patients had similar consent preferences for research on medical practices using randomization and medical record review, most preferred to have consent conversations with their doctors rather than with researchers for studies using randomization (72.6%) and medical record review (67.0%), and only a few preferred to see research involving randomization (16.8%) or medical record review (13.8%) not take place if obtaining written or verbal permission would make the research too difficult to conduct. Limitations of our post hoc analysis include differences in framing, structure, and language between the two surveys and possible response bias. CONCLUSION Our findings highlight a need to identify appropriate ways to integrate patient preferences into prevailing regulatory interpretations as institutional review boards increasingly apply research regulations in the context of research on medical practices. Dialogue between institutional review boards and research participants will be an important part of this process and should inform future regulatory guidance.
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Affiliation(s)
| | - Mildred K Cho
- Stanford Center for Biomedical Ethics, Stanford, CA, USA
| | - Melissa Constantine
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA
| | | | - Maureen Kelley
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Diane Korngiebel
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, USA
| | - Cyan James
- Institute for Public Health Genetics, University of Washington, Seattle, WA, USA
| | - Ellen Kuwana
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA
| | - Adrienne Meyer
- Human Subjects Division, University of Washington, Seattle, WA, USA
| | - Kathryn Porter
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA
| | - Douglas Diekema
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA
| | - Alexander M Capron
- USC Gould School of Law, University of Southern California, Los Angeles, CA, USA
| | - Radica Alicic
- Providence Medical Research Center, Spokane, WA, USA
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford, CA, USA
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Hollander SA, Axelrod DM, Bernstein D, Cohen HJ, Sourkes B, Reddy S, Magnus D, Rosenthal DN, Kaufman BD. Compassionate deactivation of ventricular assist devices in pediatric patients. J Heart Lung Transplant 2016; 35:564-7. [PMID: 27197773 DOI: 10.1016/j.healun.2016.03.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/14/2016] [Accepted: 03/23/2016] [Indexed: 10/22/2022] Open
Abstract
Despite greatly improved survival in pediatric patients with end-stage heart failure through the use of ventricular assist devices (VADs), heart failure ultimately remains a life-threatening disease with a significant symptom burden. With increased demand for donor organs, liberalizing the boundaries of case complexity, and the introduction of destination therapy in children, more children can be expected to die while on mechanical support. Despite this trend, guidelines on the ethical and pragmatic issues of compassionate deactivation of VAD support in children are strikingly absent. As VAD support for pediatric patients increases in frequency, the pediatric heart failure and palliative care communities must work toward establishing guidelines to clarify the complex issues surrounding compassionate deactivation. Patient, family and clinician attitudes must be ascertained and education regarding the psychological, legal and ethical issues should be provided. Furthermore, pediatric-specific planning documents for use before VAD implantation as well as deactivation checklists should be developed to assist with decision-making at critical points during the illness trajectory. Herein we review the relevant literature regarding compassionate deactivation with a specific focus on issues related to children.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Palo Alto, California, USA.
| | - David M Axelrod
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Palo Alto, California, USA
| | - Daniel Bernstein
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Palo Alto, California, USA
| | - Harvey J Cohen
- Department of Pediatrics (Palliative Care Services), Stanford University Medical Center, Palo Alto, California, USA
| | - Barbara Sourkes
- Department of Pediatrics (Palliative Care Services), Stanford University Medical Center, Palo Alto, California, USA
| | - Sushma Reddy
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Palo Alto, California, USA
| | - David Magnus
- Center for Biomedical Ethics, Stanford University, Palo Alto, California, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Palo Alto, California, USA
| | - Beth D Kaufman
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Palo Alto, California, USA
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Lee SSJ, Kelley M, Cho MK, Kraft SA, James C, Constantine M, Meyer AN, Diekema D, Capron AM, Wilfond BS, Magnus D. Adrift in the Gray Zone: IRB Perspectives on Research in the Learning Health System. AJOB Empir Bioeth 2016; 7:125-134. [PMID: 27917391 DOI: 10.1080/23294515.2016.1155674] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Human subjects protection in healthcare contexts rests on the premise that a principled boundary distinguishes clinical research and clinical practice. However, growing use of evidence-based clinical practices by health systems makes it increasingly difficult to disentangle research from a wide range of clinical activities that are sometimes called "research on medical practice" (ROMP), including quality improvement activities and comparative effectiveness research. The recent growth of ROMP activities has created an ethical and regulatory gray zone with significant implications for the oversight of human subjects research. METHODS We conducted six semi-structured, open-ended focus group discussions with IRB members to understand their experiences and perspectives on ethical oversight of ROMP, including randomization of patients to standard treatments. RESULTS Our study revealed that IRB members are unclear or divided on the central questions at stake in the current policy debate over ethical oversight of ROMP: IRB members struggle to make a clear distinction between clinical research and medical practice improvement, lack consensus on when ROMP requires IRB review and oversight, and are uncertain about what constitutes incremental risk when patients are randomized to different treatments, any of which may be offered in usual care. They characterized the central challenge as a balancing act, between, on the one hand, making information fully transparent to patients and providing adequate oversight, and on the other hand, avoiding a chilling effect on the research process or harming the physician-patient relationship. CONCLUSIONS Evidence-based guidance that supports IRB members in providing adequate and effective oversight of ROMP without impeding the research process or harming the physician-patient relationship is necessary to realize the full benefits of the learning health system.
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