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Smith JN, Smolenski J, Lang BH, Blumenthal-Barby J. From Opioid Overdose to LVAD Refusals: Navigating the Spectrum of Decisional Autonomy. Am J Bioeth 2024; 24:8-10. [PMID: 38635427 DOI: 10.1080/15265161.2024.2329496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Affiliation(s)
| | | | - Ben H Lang
- Baylor College of Medicine
- Oxford University
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Smith JN, Dorfman N, Hurley M, Cenolli I, Kostick-Quenet K, Storch EA, Lázaro-Muñoz G, Blumenthal-Barby J. Adolescent OCD Patient and Caregiver Perspectives on Identity, Authenticity, and Normalcy in Potential Deep Brain Stimulation Treatment. Camb Q Healthc Ethics 2024:1-14. [PMID: 38602092 DOI: 10.1017/s0963180124000203] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
The ongoing debate within neuroethics concerning the degree to which neuromodulation such as deep brain stimulation (DBS) changes the personality, identity, and agency (PIA) of patients has paid relatively little attention to the perspectives of prospective patients. Even less attention has been given to pediatric populations. To understand patients' views about identity changes due to DBS in obsessive-compulsive disorder (OCD), the authors conducted and analyzed semistructured interviews with adolescent patients with OCD and their parents/caregivers. Patients were asked about projected impacts to PIA generally due to DBS. All patient respondents and half of caregivers reported that DBS would impact patient self-identity in significant ways. For example, many patients expressed how DBS could positively impact identity by allowing them to explore their identities free from OCD. Others voiced concerns that DBS-related resolution of OCD might negatively impact patient agency and authenticity. Half of patients expressed that DBS may positively facilitate social access through relieving symptoms, while half indicated that DBS could increase social stigma. These views give insights into how to approach decision-making and informed consent if DBS for OCD becomes available for adolescents. They also offer insights into adolescent experiences of disability identity and "normalcy" in the context of OCD.
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Affiliation(s)
- Jared N Smith
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Natalie Dorfman
- Department of Philosophy, University of Washington, Seattle, WA, USA
| | - Meghan Hurley
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Ilona Cenolli
- Center for Bioethics, Harvard Medical School, Boston, MA, USA
| | - Kristin Kostick-Quenet
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Eric A Storch
- Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
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Hurley ME, Sonig A, Herrington J, Storch EA, Lázaro-Muñoz G, Blumenthal-Barby J, Kostick-Quenet K. Ethical considerations for integrating multimodal computer perception and neurotechnology. Front Hum Neurosci 2024; 18:1332451. [PMID: 38435745 PMCID: PMC10904467 DOI: 10.3389/fnhum.2024.1332451] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/30/2024] [Indexed: 03/05/2024] Open
Abstract
Background Artificial intelligence (AI)-based computer perception technologies (e.g., digital phenotyping and affective computing) promise to transform clinical approaches to personalized care in psychiatry and beyond by offering more objective measures of emotional states and behavior, enabling precision treatment, diagnosis, and symptom monitoring. At the same time, passive and continuous nature by which they often collect data from patients in non-clinical settings raises ethical issues related to privacy and self-determination. Little is known about how such concerns may be exacerbated by the integration of neural data, as parallel advances in computer perception, AI, and neurotechnology enable new insights into subjective states. Here, we present findings from a multi-site NCATS-funded study of ethical considerations for translating computer perception into clinical care and contextualize them within the neuroethics and neurorights literatures. Methods We conducted qualitative interviews with patients (n = 20), caregivers (n = 20), clinicians (n = 12), developers (n = 12), and clinician developers (n = 2) regarding their perspective toward using PC in clinical care. Transcripts were analyzed in MAXQDA using Thematic Content Analysis. Results Stakeholder groups voiced concerns related to (1) perceived invasiveness of passive and continuous data collection in private settings; (2) data protection and security and the potential for negative downstream/future impacts on patients of unintended disclosure; and (3) ethical issues related to patients' limited versus hyper awareness of passive and continuous data collection and monitoring. Clinicians and developers highlighted that these concerns may be exacerbated by the integration of neural data with other computer perception data. Discussion Our findings suggest that the integration of neurotechnologies with existing computer perception technologies raises novel concerns around dignity-related and other harms (e.g., stigma, discrimination) that stem from data security threats and the growing potential for reidentification of sensitive data. Further, our findings suggest that patients' awareness and preoccupation with feeling monitored via computer sensors ranges from hypo- to hyper-awareness, with either extreme accompanied by ethical concerns (consent vs. anxiety and preoccupation). These results highlight the need for systematic research into how best to implement these technologies into clinical care in ways that reduce disruption, maximize patient benefits, and mitigate long-term risks associated with the passive collection of sensitive emotional, behavioral and neural data.
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Affiliation(s)
- Meghan E. Hurley
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, United States
| | - Anika Sonig
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, United States
| | - John Herrington
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Eric A. Storch
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Gabriel Lázaro-Muñoz
- Center for Bioethics, Harvard Medical School, Boston, MA, United States
- Department of Psychiatry and Behavioral Sciences, Massachusetts General Hospital, Boston, MA, United States
| | | | - Kristin Kostick-Quenet
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, United States
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Abstract
The concept of personhood has been central to bioethics debates about abortion, the treatment of patients in a vegetative or minimally conscious states, as well as patients with advanced dementia. More recently, the concept has been employed to think about new questions related to human-brain organoids, artificial intelligence, uploaded minds, human-animal chimeras, and human embryos, to name a few. A common move has been to ask what these entities have in common with persons (in the normative sense), and then draw conclusions about what we do (or do not) owe them. This paper argues that at best the concept of "personhood" is unhelpful to much of bioethics today and at worst it is harmful and pernicious. I suggest that we (bioethicists) stop using the concept of personhood and instead ask normative questions more directly (e.g., how ought we to treat this being and why?) and use other philosophical concepts (e.g., interests, sentience, recognition respect) to help us answer them. It is time for bioethics to end talk about personhood.
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Dorfman NJ, Blumenthal-Barby J, Ubel PA, Moore B, Nelson R, Kious BM. What Do Psychiatrists Think About Caring for Patients Who Have Extremely Treatment-Refractory Illness? AJOB Neurosci 2024; 15:51-58. [PMID: 37379054 DOI: 10.1080/21507740.2023.2225467] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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] [Indexed: 06/29/2023]
Abstract
Questions about when to limit unhelpful treatments are often raised in general medicine but are less commonly considered in psychiatry. Here we describe a survey of U.S. psychiatrists intended to characterize their attitudes about the management of suicidal ideation in patients with severely treatment-refractory illness. Respondents (n = 212) received one of two cases describing a patient with suicidal ideation due to either borderline personality disorder or major depressive disorder. Both patients were described as receiving all guideline-based and plausible emerging treatments. Respondents rated the expected helpfulness and likelihood of recommending each of four types of intervention: hospitalization, additional medication changes, additional neurostimulation, and additional psychotherapy. Across both cases, most respondents said they were likely to provide each intervention, except for additional neurostimulation in borderline personality disorder, while fewer thought each intervention would be helpful. Substantial minorities of respondents indicated that they would provide an intervention they did not think was likely to be helpful. Our results suggest that while most psychiatrists recognize the possibility that some patients are unlikely to be helped by available treatments, many would continue to offer such treatments.
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Lang BH, Nyholm S, Blumenthal-Barby J. Responsibility Gaps and Black Box Healthcare AI: Shared Responsibilization as a Solution. Digit Soc 2023; 2:52. [PMID: 38596344 PMCID: PMC11003475 DOI: 10.1007/s44206-023-00073-z] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 09/18/2023] [Indexed: 04/11/2024]
Abstract
As sophisticated artificial intelligence software becomes more ubiquitously and more intimately integrated within domains of traditionally human endeavor, many are raising questions over how responsibility (be it moral, legal, or causal) can be understood for an AI's actions or influence on an outcome. So called "responsibility gaps" occur whenever there exists an apparent chasm in the ordinary attribution of moral blame or responsibility when an AI automates physical or cognitive labor otherwise performed by human beings and commits an error. Healthcare administration is an industry ripe for responsibility gaps produced by these kinds of AI. The moral stakes of healthcare are often life and death, and the demand for reducing clinical uncertainty while standardizing care incentivizes the development and integration of AI diagnosticians and prognosticators. In this paper, we argue that (1) responsibility gaps are generated by "black box" healthcare AI, (2) the presence of responsibility gaps (if unaddressed) creates serious moral problems, (3) a suitable solution is for relevant stakeholders to voluntarily responsibilize the gaps, taking on some moral responsibility for things they are not, strictly speaking, blameworthy for, and (4) should this solution be taken, black box healthcare AI will be permissible in the provision of healthcare.
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Affiliation(s)
- Benjamin H. Lang
- University of Oxford, Oxford, UK
- Baylor College of Medicine, Houston, TX, USA
| | - Sven Nyholm
- LMU Munich, Munich, Germany
- Munich Center for Machine Learning, Munich, Germany
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Torgerson LN, Munoz K, Kostick K, Zuk P, Blumenthal-Barby J, Storch EA, Lázaro-Muñoz G. Clinical and Psychosocial Factors Considered When Deciding Whether to Offer Deep Brain Stimulation for Childhood Dystonia. Neuromodulation 2023; 26:1646-1652. [PMID: 35088744 DOI: 10.1016/j.neurom.2021.10.018] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/20/2021] [Accepted: 10/11/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Childhood dystonia is often nonresponsive to medications, and refractory cases are increasingly being treated with deep brain stimulation (DBS). However, many have noted that there is little consensus about when DBS should be offered, and there has been little examination of clinicians' decision-making process when determining whether to offer DBS for childhood dystonia. OBJECTIVES This study aimed to identify and examine the factors considered by pediatric movement disorder specialists before offering DBS. MATERIALS AND METHODS Semistructured interviews (N = 29) with pediatric dystonia clinicians were conducted, transcribed, and coded. Using thematic content analysis, nine central themes were identified when clinicians were asked about key factors, clinical factors, and psychosocial factors considered before offering pediatric DBS. RESULTS Clinicians identified nine main factors. Five of these were classified primarily as clinical factors: early intervention and younger age (raised by 86% of respondents), disease progression and symptom severity (83%), etiology and genetic status (79%), clinicians' perceived risks and benefits of DBS for the patient (79%), and exhaustion of other treatment options (55%). The remaining four were classified primarily as psychosocial factors: social and family support (raised by 97% of respondents), patient and caregiver expectations about outcomes and understanding of DBS treatment (90%), impact of dystonia on quality of life (69%), and financial resources and access to care (31%). CONCLUSIONS Candidacy determinations, in this context, are complicated by an interrelation of clinical and psychosocial factors that contribute to the decision. There is potential for bias when considering family support and quality of life. Uncertainty of outcomes related to the etiology of dystonia makes candidacy judgments challenging. More systematic examination of the characteristics and criteria used to identify pediatric patients with dystonia who can significantly benefit from DBS is necessary to develop clear guidelines and promote the well-being of these children.
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Affiliation(s)
- Laura N Torgerson
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Katrina Munoz
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Kristin Kostick
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Peter Zuk
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | | | - Eric A Storch
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
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Kostick-Quenet K, Lang BH, Smith J, Hurley M, Blumenthal-Barby J. Trust criteria for artificial intelligence in health: normative and epistemic considerations. J Med Ethics 2023:jme-2023-109338. [PMID: 37979976 DOI: 10.1136/jme-2023-109338] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 11/02/2023] [Indexed: 11/20/2023]
Abstract
Rapid advancements in artificial intelligence and machine learning (AI/ML) in healthcare raise pressing questions about how much users should trust AI/ML systems, particularly for high stakes clinical decision-making. Ensuring that user trust is properly calibrated to a tool's computational capacities and limitations has both practical and ethical implications, given that overtrust or undertrust can influence over-reliance or under-reliance on algorithmic tools, with significant implications for patient safety and health outcomes. It is, thus, important to better understand how variability in trust criteria across stakeholders, settings, tools and use cases may influence approaches to using AI/ML tools in real settings. As part of a 5-year, multi-institutional Agency for Health Care Research and Quality-funded study, we identify trust criteria for a survival prediction algorithm intended to support clinical decision-making for left ventricular assist device therapy, using semistructured interviews (n=40) with patients and physicians, analysed via thematic analysis. Findings suggest that physicians and patients share similar empirical considerations for trust, which were primarily epistemic in nature, focused on accuracy and validity of AI/ML estimates. Trust evaluations considered the nature, integrity and relevance of training data rather than the computational nature of algorithms themselves, suggesting a need to distinguish 'source' from 'functional' explainability. To a lesser extent, trust criteria were also relational (endorsement from others) and sometimes based on personal beliefs and experience. We discuss implications for promoting appropriate and responsible trust calibration for clinical decision-making use AI/ML.
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Affiliation(s)
- Kristin Kostick-Quenet
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
| | - Benjamin H Lang
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
- Department of Philosophy, University of Oxford, Oxford, Oxfordshire, UK
| | - Jared Smith
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
| | - Meghan Hurley
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
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Ryan LF, Blumenthal-Barby J. Reconsidering risk attitudes: why higher-order attitudes hinder medical decision-making. J Med Ethics 2023; 49:742-743. [PMID: 37558405 DOI: 10.1136/jme-2023-109357] [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] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/03/2023] [Indexed: 08/11/2023]
Affiliation(s)
- Liam Francis Ryan
- Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, Illinois, USA
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10
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Opel DJ, Vo HH, Dundas N, Spielvogle H, Mercer A, Wilfond BS, Clark J, Heike CL, Weiss EM, Bryan MA, Shah SK, McCarty CA, Robinson JD, Blumenthal-Barby J, Tilburt J. Validation of a Process for Shared Decision-Making in Pediatrics. Acad Pediatr 2023; 23:1588-1597. [PMID: 36682451 DOI: 10.1016/j.acap.2023.01.007] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/10/2023] [Accepted: 01/16/2023] [Indexed: 01/21/2023]
Abstract
OBJECTIVE We sought to confirm, refute, or modify a 4-step process for implementing shared decision-making (SDM) in pediatrics that involves determining 1) if the decision includes >1 medically reasonable option; 2) if one option has a favorable medical benefit-burden ratio compared to other options; and 3) parents' preferences regarding the options; then 4) calibrating the SDM approach based on other relevant decision characteristics. METHODS We videotaped a purposive sample of pediatric inpatient and outpatient encounters at a single US children's hospital. Clinicians from 7 clinical services (craniofacial, neonatology, oncology, pulmonary, pediatric intensive care, hospital medicine, and sports medicine) were eligible. English-speaking parents of children who participated in inpatient family care conferences or outpatient problem-oriented encounters with participating clinicians were eligible. We conducted individual postencounter interviews with clinician and parent participants utilizing video-stimulated recall to facilitate reflection of decision-making that occurred during the encounter. We utilized direct content analysis with open coding of interview transcripts to determine the salience of the 4-step SDM process and identify themes that confirmed, refuted, or modified this process. RESULTS We videotaped 30 encounters and conducted 53 interviews. We found that clinicians' and parents' experiences of decision-making confirmed each SDM step. However, there was variation in the interpretation of each step and a need for flexibility in implementing the process depending on specific decisional contexts. CONCLUSIONS The 4-step SDM process for pediatrics appears to be salient and may benefit from further guidance about the interpretation of each step and contextual factors that support a modified approach.
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Affiliation(s)
- Douglas J Opel
- Division of Bioethics and Palliative and Division of General Pediatrics, Department of Pediatrics, University of Washington School of Medicine and Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute (DJ Opel), Seattle, Wash.
| | - Holly Hoa Vo
- Division of Pulmonary and Sleep Medicine and Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine and Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute (HH Vo and BS Wilfond), Seattle, Wash
| | - Nicolas Dundas
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute (N Dundas, H Spielvogle, and A Mercer), Seattle, Wash
| | - Heather Spielvogle
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute (N Dundas, H Spielvogle, and A Mercer), Seattle, Wash
| | - Amanda Mercer
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute (N Dundas, H Spielvogle, and A Mercer), Seattle, Wash
| | - Benjamin S Wilfond
- Division of Pulmonary and Sleep Medicine and Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine and Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute (HH Vo and BS Wilfond), Seattle, Wash
| | - Jonna Clark
- Division of Critical Care Medicine and Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine and Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute (J Clark), Seattle, Wash
| | - Carrie L Heike
- Division of Craniofacial Medicine, Department of Pediatrics, University of Washington School of Medicine and Center for Clinical and Translational Research, Seattle Children's Research Institute (CL Heike), Seattle, Wash
| | - Elliott M Weiss
- Division of Neonatology and Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine and Treuman Katz Center for Pediatric Bioethics (EM Weiss), Seattle, Wash
| | - Mersine A Bryan
- Division of Hospital Medicine, Department of Pediatrics, University of Washington School of Medicine and Center for Clinical and Translational Research, Seattle Children's Research Institute (MA Bryan), Seattle, Wash
| | - Seema K Shah
- Department of Pediatrics, Northwestern University Feinberg School of Medicine; Bioethics Program, Lurie Children's Hospital (SK Shah), Chicago, Ill
| | - Carolyn A McCarty
- Division of General Pediatrics, Department of Pediatrics, University of Washington School of Medicine and Center for Child Health, Behavior, and Development, Seattle Children's Research Institute (CA McCarty), Seattle, Wash
| | - Jeffrey D Robinson
- Department of Communication, Portland State University (JD Robinson), Portland, Ore
| | - Jennifer Blumenthal-Barby
- Center for Medical Ethics and Health Policy, Baylor College of Medicine (J Blumenthal-Barby), Houston, Tex
| | - Jon Tilburt
- Division of General Internal Medicine, Department of Internal Medicine, Mayo Clinic (J Tilburt), Scottsdale, Ariz
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Dorfman N, Snellman L, Kerley Y, Kostick-Quenet K, Lazaro-Munoz G, Storch EA, Blumenthal-Barby J. Hope and Optimism in Pediatric Deep Brain Stimulation: Key Stakeholder Perspectives. NEUROETHICS-NETH 2023; 16:17. [PMID: 37905206 PMCID: PMC10615366 DOI: 10.1007/s12152-023-09524-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 06/29/2023] [Indexed: 11/02/2023]
Abstract
Introduction Deep brain stimulation (DBS) is utilized to treat pediatric refractory dystonia and its use in pediatric patients is expected to grow. One important question concerns the impact of hope and unrealistic optimism on decision-making, especially in "last resort" intervention scenarios such as DBS for refractory conditions. Objective This study examined stakeholder experiences and perspectives on hope and unrealistic optimism in the context of decision-making about DBS for childhood dystonia and provides insights for clinicians seeking to implement effective communication strategies. Materials and Methods Semi-structured interviews with clinicians (n = 29) and caregivers (n = 44) were conducted, transcribed, and coded. Results Using thematic content analysis, four major themes from clinician interviews and five major themes from caregiver interviews related to hopes and expectations were identified. Clinicians expressed concerns about caregiver false hopes (86%, 25/29) and desperation (68.9%, 20/29) in light of DBS being a last resort. As a result, 68.9% of clinicians (20/29) expressed that they intentionally tried to lower caregiver expectations about DBS outcomes. Clinicians also expressed concern that, on the flip side, unrealistic pessimism drives away some patients who might otherwise benefit from DBS (34.5%, 10/29). Caregivers viewed DBS as the last option that they had to try (61.3%, 27/44), and 73% of caregivers (32/44) viewed themselves as having high hopes but reasonable expectations. Fewer than half (43%, 19/44) expressed that they struggled setting outcome expectations due to the uncertainty of DBS, and 50% of post-DBS caregivers (14/28) expressed some negative feelings post treatment due to unmet expectations. 43% of caregivers (19/44) had experiences with clinicians who tried to set low expectations about the potential benefits of DBS. Conclusion Thoughtful clinician-stakeholder discussion is needed to ensure realistic outcome expectations.
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Affiliation(s)
- Natalie Dorfman
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | | | | | - Kristin Kostick-Quenet
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | | | - Eric A Storch
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
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Pham MT, Campbell TA, Dorfman N, Torgerson L, Kostick-Quenet K, Blumenthal-Barby J, Storch EA, Lázaro-Muñoz G. Clinician Perspectives on Levels of Evidence and Oversight for Deep Brain Stimulation for Treatment-Resistant Childhood OCD. J Obsessive Compuls Relat Disord 2023; 39:100830. [PMID: 37781644 PMCID: PMC10538479 DOI: 10.1016/j.jocrd.2023.100830] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Approximately 10-20% of children with obsessive-compulsive disorder (OCD) have treatment-resistant presentations, and there is likely interest in developing interventions for this patient group, which may include deep brain stimulation (DBS). The World Society for Stereotactic and Functional Neurosurgery has argued that at least two successful randomized controlled trials should be available before DBS treatment for a psychiatric disorder is considered "established." The FDA approved DBS for adults with treatment-resistant OCD under a humanitarian device exemption (HDE) in 2009, which requires that a device be used to manage or treat a condition impacting 8,000 or fewer patients annually in the United States. DBS is currently offered to children ages 7 and older with treatment-resistant dystonia under an HDE. Ethical and empirical work are needed to evaluate whether and under what conditions it might be appropriate to offer DBS for treatment-resistant childhood OCD. To address this gap, we report qualitative data from semi-structured interviews with 25 clinicians with expertise in this area. First, we report clinician perspectives on acceptable levels of evidence to offer DBS in this patient population. Second, we describe their perspectives on institutional policies or protocols that might be needed to effectively provide care for this patient population.
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Affiliation(s)
- Michelle T Pham
- Center for Bioethics and Social Justice, College of Human Medicine, Michigan State University, East Fee Hall 965 Wilson Road Rm A-126, East Lansing, MI 48824, United States
| | - Tiffany A Campbell
- Center for Bioethics, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, United States
| | - Natalie Dorfman
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza, Suite 326D, Houston, TX, 77030, United States
| | - Laura Torgerson
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza, Suite 326D, Houston, TX, 77030, United States
| | - Kristin Kostick-Quenet
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza, Suite 326D, Houston, TX, 77030, United States
| | - Jennifer Blumenthal-Barby
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza, Suite 326D, Houston, TX, 77030, United States
| | - Eric A Storch
- Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd Suite E4.100, Houston, TX, 77030, United States
| | - Gabriel Lázaro-Muñoz
- Center for Bioethics, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, United States
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, United States
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Kostick-Quenet K, Kalwani L, Torgerson L, Muñoz K, Sanchez C, Storch EA, Blumenthal-Barby J, Lázaro-Muñoz G. Deep Brain Stimulation for Pediatric Dystonia: Clinicians' Perspectives on the Most Pressing Ethical Challenges. Stereotact Funct Neurosurg 2023; 101:301-313. [PMID: 37844562 PMCID: PMC10586720 DOI: 10.1159/000530694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [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: 09/20/2022] [Accepted: 03/30/2023] [Indexed: 10/18/2023]
Abstract
INTRODUCTION Pediatric deep brain stimulation (pDBS) is commonly used to manage treatment-resistant primary dystonias with favorable results and more frequently used for secondary dystonia to improve quality of life. There has been little systematic empirical neuroethics research to identify ethical challenges and potential solutions to ensure responsible use of DBS in pediatric populations. METHODS Clinicians (n = 29) who care for minors with treatment-resistant dystonia were interviewed for their perspectives on the most pressing ethical issues in pDBS. RESULTS Using thematic content analysis to explore salient themes, clinicians identified four pressing concerns: (1) uncertainty about risks and benefits of pDBS (22/29; 72%) that poses a challenge to informed decision-making; (2) ethically navigating decision-making roles (15/29; 52%), including how best to integrate perspectives from diverse stakeholders (patient, caregiver, clinician) and how to manage surrogate decisions on behalf of pediatric patients with limited capacity to make autonomous decisions; (3) information scarcity effects on informed consent and decision quality (15/29; 52%) in the context of patient and caregivers' expectations for treatment; and (4) narrow regulatory status and access (7/29; 24%) such as the lack of FDA-approved indications that contribute to decision-making uncertainty and liability and potentially limit access to DBS among patients who may benefit from it. CONCLUSION These results suggest that clinicians are primarily concerned about ethical limitations of making difficult decisions in the absence of informational, regulatory, and financial supports. We discuss two solutions already underway, including supported decision-making to address uncertainty and further data sharing to enhance clinical knowledge and discovery.
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Affiliation(s)
- Kristin Kostick-Quenet
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Lavina Kalwani
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Laura Torgerson
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Katrina Muñoz
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Clarissa Sanchez
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Eric A. Storch
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | | | - Gabriel Lázaro-Muñoz
- Center for Bioethics, Harvard Medical School, Cambridge, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
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14
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Blumenthal-Barby J. Ethics of speculation. J Med Ethics 2023; 49:525. [PMID: 37487621 DOI: 10.1136/jme-2023-109429] [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] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 07/13/2023] [Indexed: 07/26/2023]
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15
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Smith J, Blumenthal-Barby J. Call for moral recognition as part of paediatric assent. J Med Ethics 2023; 49:481-482. [PMID: 37147114 PMCID: PMC10583811 DOI: 10.1136/jme-2023-109013] [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] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/18/2023] [Indexed: 05/07/2023]
Affiliation(s)
- Jared Smith
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
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16
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Blumenthal-Barby J. An AI Bill of Rights: Implications for Health Care AI and Machine Learning-A Bioethics Lens. Am J Bioeth 2023; 23:4-6. [PMID: 36269302 DOI: 10.1080/15265161.2022.2135875] [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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Abstract
While experience often affords important knowledge and insight that is difficult to garner through observation or testimony alone, it also has the potential to generate conflicts of interest and unrepresentative perspectives. We call this tension the paradox of experience. In this paper, we first outline appeals to experience made in debates about access to unproven medical products and disability bioethics, as examples of how experience claims arise in bioethics and some of the challenges raised by these claims. We then motivate the idea that experience can be an asset by appealing to themes in feminist and moral epistemology, distinguishing between epistemic and justice-based appeals. Next, we explain the concern that experience may be a liability by appealing to empirical work on cognitive biases and theoretical work about the problem of partial representation. We conclude with preliminary recommendations for addressing the paradox and offer several questions for future discussion.
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Affiliation(s)
- Ryan H Nelson
- Baylor College of Medicine, Center for Medical Ethics and Health Policy
| | - Bryanna Moore
- University of Texas Medical Branch, Institute for Bioethics and Health Humanities
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18
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Auckland C, Blumenthal-Barby J, Boyd K, Earp BD, Frith L, Fritz Z, McMillan J, Shahvisi A, Suleman M. Medical ethics and the climate change emergency. J Med Ethics 2022; 48:939-940. [PMID: 36442972 DOI: 10.1136/jme-2022-108738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 11/03/2022] [Indexed: 06/16/2023]
Affiliation(s)
- Cressida Auckland
- Law, The London School of Economics and Political Science, London, UK
| | | | - Kenneth Boyd
- Biomedical Teaching Organisation, Edinburgh University, Edinburgh, Scotland, UK
| | - Brian D Earp
- Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Lucy Frith
- Centre for Social Ethics & Policy, The University of Manchester, Manchester, UK
| | - Zoë Fritz
- THIS institute (The Healthcare Improvement Studies Institute), University of Cambridge School of Clinical Medicine, Cambridge, UK
- Acute Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - John McMillan
- Bioethics Centre, University of Otago, Dunedin, Otago, New Zealand
| | - Arianne Shahvisi
- Ethics, Brighton and Sussex Medical School, Brighton, East Sussex, UK
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Abstract
In some views, philosophy's glory days in bioethics are over. While philosophers were especially important in the early days of the field, so the argument goes, the majority of the work in bioethics today involves the "simple" application of existing philosophical principles or concepts, as well as empirical work in bioethics. Here, we address this view head on and ask: What is the role of philosophy in bioethics today? This paper has three specific aims: (1) to respond to skeptics and make the case that philosophy and philosophers still have a very important and meaningful role to play in contemporary bioethics, (2) to discuss some of the current challenges to the meaningful integration of philosophy and bioethics, and (3) to make suggestions for what needs to happen in order for the two fields to stay richly connected. We outline how bioethics center directors, funders, and philosopher bioethicists can help.
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20
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Blumenthal-Barby J. Looking back and looking forward. J Med Ethics 2022; 48:429. [PMID: 35738679 DOI: 10.1136/medethics-2022-108463] [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] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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21
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Kaplan H, Schoen L, Blumenthal-Barby J, Kostick K, Ubel P, Dang BN. Attitudes and Beliefs of Patients With Left-Ventricular Assist Devices Toward COVID-19 Vaccination and Willingness to Seek Care During the Pandemic. Perm J 2022; 26:64-68. [DOI: 10.7812/tpp/21.207] [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] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Holland Kaplan
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Lauren Schoen
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | | | - Kristin Kostick
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Peter Ubel
- Fuqua School of Business, Duke University, Durham, NC, USA
| | - Bich N Dang
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- VA Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Houston, TX, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
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22
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Abstract
Patients who experience difficulty making medical decisions are often referred to as "ambivalent." However, the current lack of attention to the nuances between a cluster of phenomena that resemble ambivalence means that we are not always recognizing what is really going on with a patient. Importantly, different kinds of "ambivalence" may call for different approaches. In this paper, we present a taxonomy of ambivalence-related phenomena, provide normative analysis of some of the effects of-and common responses to-such mental states, and sketch some practical strategies for addressing ambivalence. In applying lessons from the philosophical literature and decision theory, our aim is to provide ethicists and clinicians with the tools to better understand and effectively intervene in cases of ambivalence.
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23
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Blumenthal-Barby J, Lang B, Dorfman N, Kaplan H, Hooper WB, Kostick-Quenet K. Research on the Clinical Translation of Health Care Machine Learning: Ethicists Experiences on Lessons Learned. Am J Bioeth 2022; 22:1-3. [PMID: 35475968 DOI: 10.1080/15265161.2022.2059199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
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24
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Kostick-Quenet K, Blumenthal-Barby J, Mehra M, Lang B, Dorfman N, Bhimaraj A, Civitello A, Jorde U, Trachtenberg B, Uriel N, Kaplan H, Gilmore-Szott E, Volk R, Estep J. Integrating Personalized Risk Scores in Decision Making About Left Ventricular Assist Device (LVAD) Therapy: Clinician and Patient Perspectives. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1714] [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: 10/18/2022] Open
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25
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Nelson RH, Moore B, Blumenthal-Barby J. Pediatric Authenticity: Hiding in Plain Sight. Hastings Cent Rep 2022; 52:42-50. [PMID: 35143069 DOI: 10.1002/hast.1339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The range of decisions considered permissible in pediatrics is typically understood to involve a balance between patient interests and parental or surrogate authority. In this article, we argue that there is a distinct set of considerations relevant to pediatric decision-making that is often neglected or unacknowledged in pediatrics-namely, considerations related to patient authenticity. The standard of pediatric authenticity asks not what is best for the patient or what the patient would choose but, rather, what is most consistent with who the patient is. We begin the article with an overview of the best interest standard and suggest that authenticity can elucidate considerations that fall between a child's strictly medical interests and broader familial or relational interests. Next, we discuss authenticity in greater detail, noting the limits of applying certain philosophical conceptions of authenticity in pediatrics. We then sketch our own account of pediatric authenticity and distinguish it from the related concepts of subjective interests and assent. We conclude with a discussion of three cases illustrating the normative significance of authenticity in a range of situations arising in pediatric medicine.
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26
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Blumenthal-Barby J, Ubel PA. Supported Decision Making: A Concept at the Margins vs. Center of Autonomy? Am J Bioeth 2021; 21:43-44. [PMID: 34710007 DOI: 10.1080/15265161.2021.1981033] [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: 06/13/2023]
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27
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Blumenthal-Barby J, Ubel P. Payment of COVID-19 challenge trials: underpayment is a bigger worry than overpayment. J Med Ethics 2021; 47:585-586. [PMID: 33046591 PMCID: PMC7551739 DOI: 10.1136/medethics-2020-106901] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/01/2020] [Indexed: 05/27/2023]
Affiliation(s)
| | - Peter Ubel
- Fuqua Business School, Duke University, Durham, North Carolina, USA
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28
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Trenaman L, Jansen J, Blumenthal-Barby J, Körner M, Lally J, Matlock DD, Perestelo-Perez L, Ropka M, Stirling C, Valentine K, Vo H, Wills CE, Thomson R, Sepucha K. Are We Improving? Update and Critical Appraisal of the Reporting of Decision Process and Quality Measures in Trials Evaluating Patient Decision Aids. Med Decis Making 2021; 41:954-959. [PMID: 33966534 PMCID: PMC8474325 DOI: 10.1177/0272989x211011120] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background In 2014, a systematic review found large gaps in the quality of reporting of
measures used in 86 published trials evaluating the effectiveness of patient
decision aids (PtDAs). The purpose of this study was to update that
review. Methods We examined measures of decision making used in 49 randomized controlled
trials included in the 2014 and 2017 Cochrane Collaboration systematic
review of PtDAs. Data on development of the measures, reliability, validity,
responsiveness, precision, interpretability, feasibility, and acceptability
were independently abstracted by 2 paired reviewers. Results Information from 273 measures was abstracted, and 109 of these covered the
core domains of decision processes (n = 55) and decision
quality including informed choice/knowledge (n = 48) and
values-choice concordance (n = 12). Very few studies
reported data on the performance and clinical sensibility of measures, with
reliability (23%) and validity (6%) being the most common. Studies using new
measures were less likely to include information about their psychometric
performance compared with previously published measures. Limitations The review was limited to reporting of measures in studies included in the
Cochrane review and did not consult prior publications. Conclusion There continues to be very little reported about the development or
performance of measures used to evaluate the effectiveness of PtDAs in
published trials. Minimum reporting standards have been published, and
efforts to require investigators to use them are needed.
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Affiliation(s)
- Logan Trenaman
- University of British Columbia, Vancouver, BC, Canada.,Centre for Health Evaluation and Outcome Sciences, Vancouver, Canada
| | - Jesse Jansen
- Maastricht University, Maastricht, The Netherlands
| | | | - Mirjam Körner
- Institute of Medical Psychology and Medical Sociology, Medical Faculty, Albert-Ludwigs- University, Freiburg, Baden-Wurttemberg, Germany
| | - Joanne Lally
- Population Health Sciences Institute, Baddiley Clark Building, Newcastle University, Newcastle upon Tyne, UK
| | - Daniel D Matlock
- University of Colorado, Aurora, CO, USA.,VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO, USA
| | | | - Mary Ropka
- University of Virginia, Charlottesville, VA, USA
| | | | - Kathrene Valentine
- Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital, Boston, MA, USA
| | - Ha Vo
- Massachusetts General Hospital, Boston, MA, USA
| | | | - Richard Thomson
- Population Health Sciences Institute, Baddiley Clark Building, Newcastle University, Newcastle upon Tyne, UK
| | - Karen Sepucha
- Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital, Boston, MA, USA
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29
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Soled D, Dickert NW, Blumenthal-Barby J. When Does Nudging Represent Fraudulent Disclosure? Am J Bioeth 2021; 21:63-66. [PMID: 33945416 DOI: 10.1080/15265161.2021.1906995] [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: 06/12/2023]
Affiliation(s)
- Derek Soled
- Harvard Medical School
- Harvard Business School
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30
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Blumenthal-Barby J, Opel DJ, Dickert NW, Kramer DB, Tucker Edmonds B, Ladin K, Peek ME, Peppercorn J, Tilburt J. Potential Unintended Consequences Of Recent Shared Decision Making Policy Initiatives. Health Aff (Millwood) 2020; 38:1876-1881. [PMID: 31682503 DOI: 10.1377/hlthaff.2019.00243] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Shared decision making (SDM)-when clinicians and patients make medical decisions together-is moving swiftly from an ethical ideal toward widespread clinical implementation affecting millions of patients through recent policy initiatives. We argue that policy initiatives to promote SDM implementation in clinical practice carry the risk of several unintended negative consequences if limitations in defining and measuring SDM are not addressed. We urge policy makers to include prespecified definitions of desired outcomes, offer guidance on the tools used to measure SDM in the multitude of contexts in which it occurs, evaluate the impact of SDM policy initiatives over time, review that impact at regular intervals, and revise SDM measurement tools as needed.
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Affiliation(s)
- Jennifer Blumenthal-Barby
- Jennifer Blumenthal-Barby ( jsswinde@bcm. edu ) is the Cullen Associate Professor and associate director of the Center for Medical Ethics and Health Policy, Baylor College of Medicine, in Houston, Texas
| | - Douglas J Opel
- Douglas J. Opel is an associate professor of pediatrics at the University of Washington School of Medicine and director of clinical ethics at the Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, in Washington
| | - Neal W Dickert
- Neal W. Dickert is an associate professor of cardiology and epidemiology at Emory University, in Atlanta, Georgia
| | - Daniel B Kramer
- Daniel B. Kramer is an assistant professor at Harvard Medical School and faculty at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, both in Boston, Massachusetts
| | - Brownsyne Tucker Edmonds
- Brownsyne Tucker Edmonds is an associate professor of obstetrics and gynecology and assistant dean for diversity affairs at the Indiana University School of Medicine, in Indianapolis
| | - Keren Ladin
- Keren Ladin is an assistant professor of occupational therapy and community health at Tufts University, in Medford, Massachusetts
| | - Monica E Peek
- Monica E. Peek is an associate professor of medicine at the University of Chicago Medical Center, in Illinois
| | - Jeff Peppercorn
- Jeff Peppercorn is an associate professor in and director of the Cancer Survivorship Program, Cancer Center, Massachusetts General Hospital, in Boston
| | - Jon Tilburt
- Jon Tilburt is a professor of internal medicine and biomedical ethics at Mayo Clinic in Rochester, Minnesota
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31
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Muñoz KA, Blumenthal-Barby J, Storch EA, Torgerson L, Lázaro-Muñoz G. Pediatric Deep Brain Stimulation for Dystonia: Current State and Ethical Considerations. Camb Q Healthc Ethics 2020; 29:557-573. [PMID: 32892777 PMCID: PMC9426302 DOI: 10.1017/s0963180120000316] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [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: 12/20/2022]
Abstract
Dystonia is a movement disorder that can have a debilitating impact on motor functions and quality of life. There are 250,000 cases in the United States, most with childhood onset. Due to the limited effectiveness and side effects of available treatments, pediatric deep brain stimulation (pDBS) has emerged as an intervention for refractory dystonia. However, there is limited clinical and neuroethics research in this area of clinical practice. This paper examines whether it is ethically justified to offer pDBS to children with refractory dystonia. Given the favorable risk-benefit profile, it is concluded that offering pDBS is ethically justified for certain etiologies of dystonia, but it is less clear for others. In addition, various ethical and policy concerns are discussed, which need to be addressed to optimize the practice of offering pDBS for dystonia. Strategies are proposed to help address these concerns as pDBS continues to expand.
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Affiliation(s)
- Katrina A. Muñoz
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX
| | | | - Eric A. Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX
| | - Laura Torgerson
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX
| | - Gabriel Lázaro-Muñoz
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX
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32
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Fridman I, Ubel PA, Blumenthal-Barby J, England CV, Currier JS, Eyal N, Freedberg KA, Halpern SD, Kelley CF, Kuritzkes DR, Le CN, Lennox JL, Pollak KI, Zikmund-Fisher BJ, Scherr KA. "Cure" Versus "Clinical Remission": The Impact of a Medication Description on the Willingness of People Living with HIV to Take a Medication. AIDS Behav 2020; 24:2054-2061. [PMID: 31900813 DOI: 10.1007/s10461-019-02769-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Many people living with HIV (PLWHIV) state that they would be willing to take significant risks to be "cured" of the virus. However, how they interpret the word "cure" in this context is not clear. We used a randomized survey to examine whether PLWHIV had a different willingness to take a hypothetical HIV medication if it causes flu-like symptoms, but provides: (a) cure, (b) remission that was labeled "cure", or (c) remission. PLWHIV (n = 454) were more willing to take a medication that provided a "cure" versus a "remission" if the side effects lasted less than 1 year. PLWHIV were more willing to take a medication that provided a remission that was labeled "cure" versus a "remission" (p = 0.01) if the side effects lasted 2 weeks. Clinicians and researchers should be aware of the impact of the word "cure" and ensure that PLWHIV fully understand the possible outcomes of their treatment options.
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33
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34
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Blumenthal-Barby J, Boyd K, Earp BD, Frith L, McDougall RJ, McMillan J, Wall J. Pandemic medical ethics. J Med Ethics 2020; 46:353-354. [PMID: 32471955 DOI: 10.1136/medethics-2020-106431] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 05/11/2020] [Indexed: 06/11/2023]
Affiliation(s)
| | - Kenneth Boyd
- Biomedical Teaching Organisation, Edinburgh University, Edinburgh, UK
| | - Brian D Earp
- Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Lucy Frith
- Health Services Research, University of Liverpool, Liverpool, UK
| | - Rosalind J McDougall
- Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
- Children's Bioethics Centre, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - John McMillan
- Bioethics Centre, University of Otago, Dunedin, New Zealand
| | - Jesse Wall
- Faculty of Law, University of Auckland, Auckland, New Zealand
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35
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Kratka A, Ubel PA, Scherr K, Murray B, Eyal N, Kirby C, Katz MN, Holtzman L, Pollak K, Freedburg K, Blumenthal-Barby J. HIV Cure Research: Risks Patients Expressed Willingness to Accept. Ethics Hum Res 2020; 41:23-34. [PMID: 31743627 DOI: 10.1002/eahr.500035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 01/28/2023]
Abstract
Despite doing well on antiretroviral therapy, many people living with HIV have expressed a willingness to accept substantial risks for an HIV cure. To date, few studies have assessed the specific quantitative maximal risk that future participants might take; probed whether, according to future participants, the risk can be offset by the benefits; and examined whether taking substantial risk is a reasonable decision. In this qualitative study, we interviewed 22 people living with HIV and used standard gamble methodology to assess the maximum chance of death a person would risk for an HIV cure. We probed participants' reasoning behind their risk-taking responses. Conventional inductive content analysis was used to categorize key themes regarding decision-making. We found that some people would be willing to risk even death for an HIV cure, and some of their reasons were plausible and went far beyond the health-related utility of an HIV cure. We contend that people's expressed willingness to take substantial risk for an HIV cure should not be dismissed out of hand.
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Affiliation(s)
- Allison Kratka
- Internal medicine resident at Brigham and Women's Hospital
| | - Peter A Ubel
- Professor in the Fuqua School of Business at Duke University
| | | | | | - Nir Eyal
- Directs the Center for Population-Level Bioethics at Rutgers University
| | - Christine Kirby
- Program coordinator in the Center for Health Equity Research at Northern Arizona University
| | - Madelaine N Katz
- MPH candidate at the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill
| | - Lisa Holtzman
- Program manager in the Department of Global Health and Population at the Harvard T. H. Chan School of Public Health
| | - Kathryn Pollak
- Professor in Population Health Sciences and is the associate director of population sciences in the Duke Cancer Institute at Duke University
| | - Kenneth Freedburg
- Director of the Medical Practice Evaluation Center and is a professor of medicine in the Divisions of General Internal Medicine and Infectious Diseases at Massachusetts General Hospital and Harvard Medical School
| | - Jennifer Blumenthal-Barby
- Associate director and Cullen associate professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine
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36
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Abstract
Objective: To explore the ways in which health care professionals and families understand terms and concepts associated with disorders of consciousness.Methods: Open-ended, semi-structured interviews were conducted with 20 health care professionals and 18 family caregivers affiliated with a disorders of consciousness program within a nationally ranked rehabilitation facility in the United States.Results: Analysis revealed that: (1) disagreement between some health care professionals and family caregivers regarding the presence of consciousness can arise due to differing beliefs about a patient experiencing pain, and differences in the length of time family caregivers spend with patients relative to clinical staff; (2) some health care professionals and family caregivers use nonclinical terms and concepts to describe consciousness; and (3) some family caregivers might attribute complex mental capacities to patients, which extend beyond the clinical evidence.Conclusion: The beliefs of health care professionals and families regarding disorders of consciousness are complex and could be influenced by broader psychological proclivities to "see minds" in patients who have a liminal neurological status. Awareness of these dynamics may assist health care professionals when interacting with family caregivers.
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Affiliation(s)
- Andrew Peterson
- Department of Philosophy and Institute for Philosophy and Public Policy, George Mason University, Fairfax, VA, USA
| | - Kristin M Kostick
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Katherine A O'Brien
- Disorders of Consciousness Rehabilitation Program, TIRR Memorial Herman, Houston, TX, USA.,Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
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37
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Blumenthal-Barby J. How to get your article published as a JME feature article and why they matter for the field. J Med Ethics 2019; 45:755-756. [PMID: 31796561 DOI: 10.1136/medethics-2019-105944] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 11/13/2019] [Indexed: 06/10/2023]
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38
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Lázaro-Muñoz G, Zuk P, Pereira S, Kostick K, Torgerson L, Sierra-Mercado D, Majumder M, Blumenthal-Barby J, Storch EA, Goodman WK, McGuire AL. Neuroethics at 15: Keep the Kant but Add More Bacon. AJOB Neurosci 2019; 10:97-100. [PMID: 31329079 PMCID: PMC6666411 DOI: 10.1080/21507740.2019.1632960] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
| | - Peter Zuk
- b Baylor College of Medicine and Rice University
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39
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Murray BR, Kratka A, Scherr KA, Eyal N, Blumenthal-Barby J, Freedberg KA, Kuritzkes DR, Hammitt JK, Edifor R, Katz MN, Pollak KI, Zikmund-Fisher BJ, Halpern SD, Barks MC, Ubel PA. What risk of death would people take to be cured of HIV and why? A survey of people living with HIV. J Virus Erad 2019. [DOI: 10.1016/s2055-6640(20)30052-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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40
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Murray BR, Kratka A, Scherr KA, Eyal N, Blumenthal-Barby J, Freedberg KA, Kuritzkes DR, Hammitt JK, Edifor R, Katz MN, Pollak KI, Zikmund-Fisher BJ, Halpern SD, Barks MC, Ubel PA. What risk of death would people take to be cured of HIV and why? A survey of people living with HIV. J Virus Erad 2019; 5:109-115. [PMID: 31191914 PMCID: PMC6543487] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
People living with HIV (PLWHIV) can reasonably expect near-normal longevity, yet many express a willingness to assume significant risks to be cured. We surveyed 200 PLWHIV who were stable on antiretroviral therapy (ART) to quantify associations between the benefits they anticipate from a cure and their risk tolerance for curative treatments. Sixty-five per cent expected their health to improve if cured of HIV, 41% predicted the virus would stop responding to medications over the next 20 years and 54% predicted experiencing serious medication side effects in the next 20 years. Respondents' willingness to risk death for a cure varied widely (median 10%, 75th percentile 50%). In multivariate analyses, willingness to risk death was associated with expected long-term side effects of ART, greater financial resources and being employed (all P < 0.05) but was not associated with perceptions of how their health would improve if cured.
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Affiliation(s)
| | | | - Karen A Scherr
- Duke University School of Medicine,
Durham,
NC,
USA,Duke University Fuqua School of Business,
Durham,
NC,
USA
| | - Nir Eyal
- Harvard TH Chan School of Public Health,
Boston,
MA,
USA
| | | | - Kenneth A Freedberg
- Harvard TH Chan School of Public Health,
Boston,
MA,
USA,Medical Practice Evaluation Center,
Divisions of General Internal Medicine and Infectious Diseases,
Massachusetts General Hospital,
Harvard Medical School,
Boston,
MA,
USA,Harvard Medical School,
Boston,
MA,
USA
| | - Daniel R Kuritzkes
- Harvard Medical School,
Boston,
MA,
USA,Division of Infectious Diseases,
Brigham and Women's Hospital,
Harvard Medical School,
Boston,
MA,
USA
| | - James K Hammitt
- Harvard TH Chan School of Public Health,
Boston,
MA,
USA,Toulouse School of Economics,
University of Toulouse Capitole,
Toulouse,
France
| | - Regina Edifor
- University of Massachusetts Medical School,
Worcester,
MA,
USA
| | - Madelaine N Katz
- Duke University Fuqua School of Business,
Durham,
NC,
USA,Duke-Margolis Center for Health Policy,
Duke University,
Durham,
NC,
USA
| | - Kathryn I Pollak
- Duke University School of Medicine,
Durham,
NC,
USA,Population Health Sciences,
Cancer Control and Population Sciences,
Duke Cancer Institute,
Durham,
NC,
USA
| | - Brian J Zikmund-Fisher
- Department of Health Behavior and Health Education,
University of Michigan School of Public Health,
Ann Arbor,
MI,
USA,Center for Bioethics and Social Sciences in Medicine,
University of Michigan School of Medicine,
Ann Arbor,
MI,
USA
| | - Scott D Halpern
- Departments of Medicine and Medical Ethics in Health Policy,
University of Pennsylvania Perelman School of Medicine,
Philadelphia,
PA,
USA
| | - Mary C Barks
- Duke University Fuqua School of Business,
Durham,
NC,
USA,Duke-Margolis Center for Health Policy,
Duke University,
Durham,
NC,
USA
| | - Peter A Ubel
- Duke University School of Medicine,
Durham,
NC,
USA,Duke University Fuqua School of Business,
Durham,
NC,
USA,Duke-Margolis Center for Health Policy,
Duke University,
Durham,
NC,
USA,Corresponding author: Peter A. Ubel
100 Fuqua Drive,
Durham,
NC27708
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Abstract
Richard Thaler and Cass Sunstein define a nudge as "any aspect of the choice architecture that alters people's behavior in a predictable way without forbidding any options or significantly changing their economic incentives." Much has been written about the ethics of nudging competent adult patients. Less has been written about the ethics of nudging surrogates' decision-making and how the ethical considerations and arguments in that context might differ. Even less has been written about nudging surrogate decision-making in the context of pediatrics, despite fundamental differences that exist between the pediatric and adult contexts. Yet, as the field of behavioral economics matures and its insights become more established and well-known, nudges will become more crafted, sophisticated, intentional, and targeted. Thus, the time is now for reflection and ethical analysis regarding the appropriateness of nudges in pediatrics. We argue that there is an even stronger ethical justification for nudging in parental decision-making than with competent adult patients deciding for themselves. We give three main reasons in support of this: (1) child patients do not have autonomy that can be violated (a concern with some nudges), and nudging need not violate parental decision-making authority; (2) nudging can help fulfill pediatric clinicians' obligations to ensure parental decisions are in the child's interests, particularly in contexts where there is high certainty that a recommended intervention is low risk and of high benefit; and (3) nudging can relieve parents' decisional burden regarding what is best for their child, particularly with decisions that have implications for public health.
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Affiliation(s)
| | - Peter A Ubel
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
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de la Garza S, Phuoc V, Throneberry S, Blumenthal-Barby J, McCullough L, Coverdale J. Teaching Medical Ethics in Graduate and Undergraduate Medical Education: A Systematic Review of Effectiveness. Acad Psychiatry 2017; 41:520-525. [PMID: 27644429 DOI: 10.1007/s40596-016-0608-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 08/12/2016] [Indexed: 05/17/2023]
Abstract
OBJECTIVE One objective was to identify and review studies on teaching medical ethics to psychiatry residents. In order to gain insights from other disciplines that have published research in this area, a second objective was to identify and review studies on teaching medical ethics to residents across all other specialties of training and on teaching medical students. METHODS PubMed, EMBASE, and PsycINFO were searched for controlled trials on teaching medical ethics with quantitative outcomes. Search terms included ethics, bioethics, medical ethics, medical students, residents/registrars, teaching, education, outcomes, and controlled trials. RESULTS Nine studies were found that met inclusion criteria, including five randomized controlled trails and four controlled non-randomized trials. Subjects included medical students (5 studies), surgical residents (2 studies), internal medicine house officers (1 study), and family medicine preceptors and their medical students (1 study). Teaching methods, course content, and outcome measures varied considerably across studies. Common methodological issues included a lack of concealment of allocation, a lack of blinding, and generally low numbers of subjects as learners. One randomized controlled trial which taught surgical residents using a standardized patient was judged to be especially methodologically rigorous. CONCLUSIONS None of the trials incorporated psychiatry residents. Ethics educators should undertake additional rigorously controlled trials in order to secure a strong evidence base for the design of medical ethics curricula. Psychiatry ethics educators can also benefit from the findings of trials in other disciplines and in undergraduate medical education.
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44
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Kaplan JA, Kandodo J, Sclafani J, Raine S, Blumenthal-Barby J, Norris A, Norris-Turner A, Chemey E, Beckham JM, Khan Z, Chunda R. An investigation of the relationship between autonomy, childbirth practices, and obstetric fistula among women in rural Lilongwe District, Malawi. BMC Int Health Hum Rights 2017. [PMID: 28629455 PMCID: PMC5477240 DOI: 10.1186/s12914-017-0125-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Obstetric fistula is a childbirth injury caused by prolonged obstructed labor that results in destruction of the tissue wall between the vagina and bladder. Although obstetric fistula is directly caused by prolonged obstructed labor, many other factors indirectly increase fistula risk. Some research suggests that many women in rural Malawi have limited autonomy and decision-making power in their households. We hypothesize that women’s limited autonomy may play a role in reinforcing childbirth practices that increase the risk of obstetric fistula in this setting by hindering access to emergency care and further prolonging obstructed labor. Methods A medical student at Baylor College of Medicine partnered with a Malawian research assistant in July 2015 to conduct in-depth qualitative interviews in Chichewa with 25 women living within the McGuire Wellness Centre’s catchment area (rural Central Lilongwe District) who had received obstetric fistula repair surgery. Results This study assessed whether women’s limited autonomy in rural Malawi reinforces childbearing practices that increase risk of obstetric fistula. We considered four dimensions of autonomy: sexual and reproductive decision-making, decision-making related to healthcare utilization, freedom of movement, and discretion over earned income. We found that participants had limited autonomy in these domains. For example, many women felt pressured by their husbands, families, and communities to become pregnant within three months of marriage; women often needed to seek permission from their husbands before leaving their homes to visit the clinic; and women were frequently prevented from delivering at the hospital by older women in the community. Conclusions Many of the obstetric fistula patients in our sample had limited autonomy in several or all of the aforementioned domains, and their limited autonomy often led both directly and indirectly to an increased risk of prolonged labor and fistula. Reducing the prevalence of fistula in Malawi requires a broad understanding of the causes of fistula, so we recommend that the relationship between women’s autonomy and fistula risk undergo further investigation. Electronic supplementary material The online version of this article (doi:10.1186/s12914-017-0125-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Zara Khan
- , 6100 Main Street, Houston, TX, 77005, USA
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45
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Garmezy B, Worden FP, Blumenthal-Barby J. The oncology prognosis and informed consent: Presentation of a new model to best inform patients. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.e18286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18286 Background: Receiving a malignant diagnosis is challenging and patients must be properly informed of their prognosis to make the best decisions for themselves and their families. The general population has a low degree of statistical literacy and therefore approximations should be considered favorable. However, given that half of patients desire quantitative data, physicians must provide this information within a context that is relevant and comprehensible. Single-point median survival data is less meaningful for patient decision-making. What is preferable is that physicians give experience-based estimations on how a patient might compare to the ‘average’. Including this information leads to more informed consent and best follows the ethical principle of autonomy. Methods: This is a novel framework for providing a prognosis that builds upon the multiples-of-the-mean model established in 2010 by Kiely, Tattersall, and Stockler. This framework was derived from original ethics research involving patient preferences, statistical comprehension, healthcare communication, and medical decision-making. Results: Graphical representation of Kiely’s model provides an intelligible view of quantitative data and allows for the physician to include an experience-based estimation. Steps: (1) Draw a Horizontal line, (2) Calculate from median survival data by using five multiples: 0.25 (Worst-Case, 10% of patients), 0.5 (Lower-Typical, 25%), 1 (Median, 50%), 2 (Upper-Typical, 75%), and 3 (Best-Case, 90%), (3) Label the chart using simple time points in months or years (4) Draw a circle over the region that best represents the patient’s expectation, (5) Provide the diagram alongside easy-to-understand language that clarifies the meaning of the numerical data with written likelihood of the occurrence, such as “almost no chance”, “not likely”, “even chances”, “likely”, and “fairly confident”. Conclusions: Kiely’s model has proven an accurate estimation in colorectal, castration-resistant prostate, non-small-cell lung, and metastatic breast cancer. A graphical representation should provide physicians an easy tool to strengthen informed consent and better aid their patients in decision-making.
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Affiliation(s)
- Benjamin Garmezy
- University of Michigan Comprehensive Cancer Center, Ann Arbor, MI
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46
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Garmezy B, Blumenthal-Barby J. The oncology prognosis and informed consent: Presentation of a new model to best inform patients. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.8_suppl.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
146 Background: Receiving a malignant diagnosis is challenging and patients must be properly informed of their prognosis to make the best decisions for themselves and their families. The general population has a low degree of statistical literacy and therefore approximations should be considered favorable. However, given that half of patients desire quantitative data, physicians must provide this information within a context that is relevant and comprehensible. Single-point median survival data is less meaningful for patient decision-making. What is preferable is that physicians give experience-based estimations on how a patient might compare to the ‘average’. Including this information leads to more informed consent and best follows the ethical principle of autonomy. Methods: This is a novel framework for providing a prognosis that builds upon the multiples-of-the-mean model established in 2010 by Kiely, Tattersall, and Stockler. This framework was derived from original ethics research involving patient preferences, statistical comprehension, healthcare communication, and medical decision-making. Results: Graphical representation of Kiely’s model provides an intelligible view of quantitative data and allows for the physician to include an experience-based estimation. Steps: (1) Draw a Horizontal line, (2) Calculate from median survival data by using five multiples: 0.25 (Worst-Case, 10% of patients), 0.5 (Lower-Typical, 25%), 1 (Median, 50%), 2 (Upper-Typical, 75%), and 3 (Best-Case, 90%), (3) Label the chart using simple time points in months or years (4) Draw a circle over the region that best represents the patient’s expectation, (5) Provide the diagram alongside easy-to-understand language that clarifies the meaning of the numerical data with written likelihood of the occurrence, such as “almost no chance”, “not likely”, “even chances”, “likely”, and “fairly confident”. Conclusions: Kiely’s model has proven an accurate estimation in colorectal, castration-resistant prostate, non-small-cell lung, and metastatic breast cancer. A graphical representation should provide physicians an easy tool to strengthen informed consent and better aid their patients in decision-making.
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47
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Won T, Blumenthal-Barby J, Chacko M. Paid protection? Ethics of incentivised long-acting reversible contraception in adolescents with alcohol and other drug use. J Med Ethics 2017; 43:182-187. [PMID: 27178535 DOI: 10.1136/medethics-2015-103176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Revised: 01/28/2016] [Accepted: 04/21/2016] [Indexed: 06/05/2023]
Abstract
Pregnant adolescents have a higher risk of poor maternal and fetal outcomes, particularly in the setting of concomitant maternal alcohol and other drug (AOD) use. Despite numerous programmes aimed at reducing overall teen pregnancy rates and the recognition of AOD use as a risk factor for unintended pregnancy in adolescents, interventions targeting this specific group have been sparse. In adult drug-using women, financial incentives for contraception have been provided but are ethically controversial. This article explores whether a trial could ethically employ monetary incentives in adolescents with AOD use to promote the use of long-acting reversible contraception (LARC), with special attention to the relevant distinctions between adults and adolescents. We conclude that a trial of incentives to promote LARC in this patient population is ethically permissible if the incentives are small, are tied to completion of an educational activity to minimise the quick fix temptation and potential for non-attendance to the risks and benefits of LARC and are provided only to the adolescent after an assessment of her reasoning to rule out coercion (eg, by guardians) as motivation. Information about treatment for AOD use and follow-up care in case of problems with the contraceptive or desire for removal should also be provided. Before implementing such a trial, qualitative research with input from providers, potential patients and their parents should be conducted to inform the programme's specific structure.
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Affiliation(s)
- Tiana Won
- Center for Medical Ethics, Baylor College of Medicine, Houston, Texas, USA
| | | | - Mariam Chacko
- Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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48
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Jamal L, Robinson JO, Christensen KD, Blumenthal-Barby J, Slashinski MJ, Perry DL, Vassy JL, Wycliff J, Green RC, McGuire AL. When bins blur: Patient perspectives on categories of results from clinical whole genome sequencing. AJOB Empir Bioeth 2017; 8:82-88. [PMID: 28949844 DOI: 10.1080/23294515.2017.1287786] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [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: 10/20/2022]
Abstract
BACKGROUND Clinical genome and exome sequencing (CGES) is being used in an expanding range of clinical settings. Most approaches to offering patients choices about learning CGES results classify results according to expert definitions of clinical actionability. Little is known about how patients conceptualize different categories of CGES results. METHODS The MedSeq Project is a randomized controlled trial studying the use of whole-genome sequencing (WGS) in primary care and cardiology. We surveyed 202 patient-participants about different kinds of WGS results and conducted qualitative interviews with 49 of these participants. Interview data were analyzed both inductively and deductively using thematic content analysis. RESULTS Participants demonstrated high levels of study understanding and genetic literacy. A small majority of participants wanted to learn all of their WGS results (n = 123, 61%). Qualitative data provided a deeper understanding of participants' perspectives about different types of WGS results. Participants did not have the same views about which WGS results would be actionable or upsetting to learn. They conceptualized variants of uncertain significance (VUS) in a variety of different ways. Many participants expressed optimism that the uncertainty associated with VUS results could be reduced over time. CONCLUSIONS Proposals to determine which WGS/CGES results to disclose by soliciting patient preferences may fail to appreciate the complex ways patients think about disease and the information WGS/CGES can produce. Our findings challenge prevailing methods of facilitating patient choice and assessing the benefits and harms related to the return of WGS/CGES results, which mostly rely on expert definitions of clinical utility to categorize the kinds of results patients can learn.
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Affiliation(s)
- Leila Jamal
- a Center for Medical Ethics and Health Policy, Baylor College of Medicine, and Johns Hopkins Berman Institute of Bioethics , Johns Hopkins University
| | - Jill O Robinson
- b Center for Medical Ethics and Health Policy , Baylor College of Medicine
| | | | | | | | | | - Jason L Vassy
- f Division of General Medicine and Primary Care , Brigham and Women's Hospital, Section of General Internal Medicine, VA Boston Healthcare System, and Harvard Medical School
| | - Julia Wycliff
- b Center for Medical Ethics and Health Policy , Baylor College of Medicine
| | - Robert C Green
- g Division of Genetics, Department of Medicine , Brigham and Women's Hospital, and Harvard Medical School
| | - Amy L McGuire
- b Center for Medical Ethics and Health Policy , Baylor College of Medicine
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49
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Loewenstein G, Hagmann D, Schwartz J, Ericson K, Kessler JB, Bhargava S, Blumenthal-Barby J, D'Aunno T, Handel B, Kolstad J, Nussbaum D, Shaffer V, Skinner J, Ubel P, Zikmund-Fisher BJ. A behavioral blueprint for improving health care policy. ACTA ACUST UNITED AC 2017. [DOI: 10.1353/bsp.2017.0005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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50
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Liao K, Blumenthal-Barby J, Sikora AG. Factors Influencing Head and Neck Surgical Oncologists' Transition from Curative to Palliative Treatment Goals. Otolaryngol Head Neck Surg 2016; 156:46-51. [PMID: 27625024 DOI: 10.1177/0194599816667712] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [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: 11/15/2022]
Abstract
Objective The factors influencing head and neck surgical oncologists' goals of care and decisions to initiate conversations about transitioning to palliative-intent treatment for patients with limited curative treatment options are incompletely understood. Lack of guidance for physicians on this topic can lead to inconsistent utilization of palliative services, as well as confusing, upsetting experiences for patients and families. We review the literature investigating the clinical factors, inter- and intrapersonal factors, and financial and health care system considerations that head and neck cancer physicians weigh during this decision-making process. Data Sources PubMed. Review Methods Selected literature on head and neck surgical oncologists' decision making in end-of-life care and palliative therapy was reviewed and analyzed thematically. Conclusions Physicians taking into account patients' clinical trajectories often overestimate the negative impact of head and neck cancer symptoms on their quality of life, suggesting that patients' expectations of quality of life should be discussed early, before communication barriers arise. How head and neck clinicians perceive and are influenced by patients' desired degree of autonomy, which varies greatly depending on the severity of illness, is still unclear. Patients' financial and insurance status affects decision making about hospice care. Finally, physician demographics (eg, age, subspecialization, practice setting), emotions, and philosophical background may exert unconscious biases that have not been fully determined for head and neck surgical oncologists. Implications for Practice A more comprehensive understanding of the head and neck surgical oncologist's approach toward considering a transition to therapy with palliative intent may help guide advancements in this complex counseling process, leading to improvements in patient care, quality of life, and outcomes.
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Affiliation(s)
- Kershena Liao
- 1 Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Andrew G Sikora
- 1 Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
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