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Kostick-Quenet KM, Lang B, Dorfman N, Estep J, Mehra MR, Bhimaraj A, Civitello A, Jorde U, Trachtenberg B, Uriel N, Kaplan H, Gilmore-Szott E, Volk R, Kassi M, Blumenthal-Barby JS. Patients' and physicians' beliefs and attitudes towards integrating personalized risk estimates into patient education about left ventricular assist device therapy. Patient Educ Couns 2024; 122:108157. [PMID: 38290171 DOI: 10.1016/j.pec.2024.108157] [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] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 01/06/2024] [Accepted: 01/14/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Personalized risk (PR) estimates may enhance clinical decision making and risk communication by providing individualized estimates of patient outcomes. We explored stakeholder attitudes toward the utility, acceptability, usefulness and best-practices for integrating PR estimates into patient education and decision making about Left Ventricular Assist Device (LVAD). METHODS AND RESULTS As part of a 5-year multi-institutional AHRQ project, we conducted 40 interviews with stakeholders (physicians, nurse coordinators, patients, and caregivers), analyzed using Thematic Content Analysis. All stakeholder groups voiced positive views towards integrating PR in decision making. Patients, caregivers and coordinators emphasized that PR can help to better understand a patient's condition and risks, prepare mentally and logistically for likely outcomes, and meaningfully engage in decision making. Physicians felt it can improve their decision making by enhancing insight into outcomes, enhance tailored pre-emptive care, increase confidence in decisions, and reduce bias and subjectivity. All stakeholder groups also raised concerns about accuracy, representativeness and relevance of algorithms; predictive uncertainty; utility in relation to physician's expertise; potential negative reactions among patients; and overreliance. CONCLUSION Stakeholders are optimistic about integrating PR into clinical decision making, but acceptability depends on prospectively demonstrating accuracy, relevance and evidence that benefits of PR outweigh potential negative impacts on decision making quality.
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Affiliation(s)
| | - Benjamin Lang
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Natalie Dorfman
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | | | | | | | | | | | | | - Nir Uriel
- Columbia University Irving Medical Center, New York, NY, USA
| | - Holland Kaplan
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Eleanor Gilmore-Szott
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Robert Volk
- University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | | | - J S Blumenthal-Barby
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
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Blumenthal-Barby JS. Theoretical vs Practical Reasons: Derek Parfit and Bioethics. Am J Bioeth 2022; 22:1-3. [PMID: 36040899 DOI: 10.1080/15265161.2022.2107357] [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: 06/15/2023]
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Kostick-Quenet KM, Cohen IG, Gerke S, Lo B, Antaki J, Movahedi F, Njah H, Schoen L, Estep JE, Blumenthal-Barby JS. Mitigating Racial Bias in Machine Learning. J Law Med Ethics 2022; 50:92-100. [PMID: 35243993 DOI: 10.1017/jme.2022.13] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
When applied in the health sector, AI-based applications raise not only ethical but legal and safety concerns, where algorithms trained on data from majority populations can generate less accurate or reliable results for minorities and other disadvantaged groups.
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Kostick-Quenet KM, Lang B, Dorfman N, Blumenthal-Barby JS. A Call for Behavioral Science in Embedded Bioethics. Perspect Biol Med 2022; 65:672-679. [PMID: 36468396 PMCID: PMC10203975 DOI: 10.1353/pbm.2022.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Bioethicists today are taking a greater role in the design and implementation of emerging technologies by "embedding" within the development teams and providing their direct guidance and recommendations. Ideally, these collaborations allow ethical considerations to be addressed in an active, iterative, and ongoing process through regular exchanges between ethicists and members of the technological development team. This article discusses a challenge to this embedded ethics approach-namely, that bioethical guidance, even if embraced by the development team in theory, is not easily actionable in situ. Many of the ethical problems at issue in emerging technologies are associated with preexisting structural, socioeconomic, and political factors, making compliance with ethical recommendations sometimes less a matter of choice and more a matter of feasibility. Moreover, incentive structures within these systemic factors maintain them against reform efforts. The authors recommend that embedded bioethicists utilize principles from behavioral science (such as behavioral economics) to better understand and account for these incentive structures so as to encourage the ethically responsible uptake of technological innovations.
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Kostick KM, Trejo M, Bhimaraj A, Civitello A, Grinstein J, Horstmanshof D, Jorde UP, Loebe M, Mehra MR, Sulemanjee NZ, Thohan V, Trachtenberg BH, Uriel N, Volk RJ, Estep JD, Blumenthal-Barby JS. A principal components analysis of factors associated with successful implementation of an LVAD decision support tool. BMC Med Inform Decis Mak 2021; 21:106. [PMID: 33743685 PMCID: PMC7980808 DOI: 10.1186/s12911-021-01468-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 03/10/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND A central goal among researchers and policy makers seeking to implement clinical interventions is to identify key facilitators and barriers that contribute to implementation success. Despite calls from a number of scholars, empirical insights into the complex structural and cultural predictors of why decision aids (DAs) become routinely embedded in health care settings remains limited and highly variable across implementation contexts. METHODS We examined associations between "reach", a widely used indicator (from the RE-AIM model) of implementation success, and multi-level site characteristics of nine LVAD clinics engaged over 18 months in implementation and dissemination of a decision aid for left ventricular assist device (LVAD) treatment. Based on data collected from nurse coordinators, we explored factors at the level of the organization (e.g. patient volume), patient population (e.g. health literacy; average sickness level), clinician characteristics (e.g. attitudes towards decision aid; readiness for change) and process (how the aid was administered). We generated descriptive statistics for each site and calculated zero-order correlations (Pearson's r) between all multi-level site variables including cumulative reach at 12 months and 18 months for all sites. We used principal components analysis (PCA) to examine any latent factors governing relationships between and among all site characteristics, including reach. RESULTS We observed strongest inclines in reach of our decision aid across the first year, with uptake fluctuating over the second year. Average reach across sites was 63% (s.d. = 19.56) at 12 months and 66% (s.d. = 19.39) at 18 months. Our PCA revealed that site characteristics positively associated with reach on two distinct dimensions, including a first dimension reflecting greater organizational infrastructure and standardization (characteristic of larger, more established clinics) and a second dimension reflecting positive attitudinal orientations, specifically, openness and capacity to give and receive decision support among coordinators and patients. CONCLUSIONS Successful implementation plans should incorporate specific efforts to promote supportive and mutually informative interactions between clinical staff members and to institute systematic and standardized protocols to enhance the availability, convenience and salience of intervention tool in routine practice. Further research is needed to understand whether "core predictors" of success vary across different intervention types.
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Affiliation(s)
- Kristin M Kostick
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza MC: 420, Houston, TX, 77030, USA.
| | - Meredith Trejo
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza MC: 420, Houston, TX, 77030, USA
| | - Arvind Bhimaraj
- Division of Heart Failure, Houston Methodist Hospital, Smith Tower, 6550 Fannin St., Ste 1901, Houston, TX, 77030, USA
| | - Andrew Civitello
- Baylor St. Luke's Medical Center, Texas Heart Institute, 7200 Cambridge Street, Ste 6C, Houston, TX, 77030, USA
| | - Jonathan Grinstein
- Duchossois Center for Advanced Medicine - Hyde Park, University of Chicago Medicine, 5758 S. Maryland Ave., Chicago, IL, 60637, USA
| | - Douglas Horstmanshof
- INTREGIS Advanced Cardiac Care, 3400 N.W. Expressway, Bldg C. Suite 200, Oklahoma City, OK, 73112, USA
| | - Ulrich P Jorde
- Division of Cardiology, Montefiore Medical Center, Bronx, NY, 10467, USA
| | - Matthias Loebe
- Miami Transplant Institute, University of Miami Health System, Miami, FL, 33136, USA
| | - Mandeep R Mehra
- Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
| | - Nasir Z Sulemanjee
- Aurora St. Luke's Medical Center, 2900 W Oklahoma Ave, Milwaukee, WI, 53215, USA
| | - Vinay Thohan
- Asheville Cardiology Associates, 5 Vanderbilt Park Dr., Asheville, NC, 28803, USA
| | - Barry H Trachtenberg
- Division of Heart Failure, Houston Methodist Hospital, Smith Tower, 6550 Fannin St., Ste 1901, Houston, TX, 77030, USA
| | - Nir Uriel
- Columbia Presbyterian Medical Center, Columbia University Irving Medical Center, 622 West 168th St., Room 129, New York, NY, 10032, USA
| | - Robert J Volk
- Department of Health Services Research, Division of Cancer Prevention and Population Services, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1465, Houston, TX, USA
| | - Jerry D Estep
- Miller Family Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA
| | - J S Blumenthal-Barby
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza MC: 420, Houston, TX, 77030, USA
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Ubel PA, Blumenthal-Barby JS. Paying the Right Amount to Challenge Trial Participants - We Need to Use Behavioral Science Insights to Sell What's Right. Am J Bioeth 2021; 21:38-39. [PMID: 33616501 DOI: 10.1080/15265161.2020.1870774] [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)
- Peter A Ubel
- Duke University, Sanford School of Public Policy
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Kostick KM, Blumenthal-Barby JS. Avoiding "toxic knowledge": the importance of framing personalized risk information in clinical decision-making. Per Med 2021; 18:91-95. [PMID: 33616460 DOI: 10.2217/pme-2020-0174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Kristin M Kostick
- Center for Medical Ethics & Health Policy, Baylor College of Medicine, Houston, TX 77030, USA
| | - J S Blumenthal-Barby
- Center for Medical Ethics & Health Policy, Baylor College of Medicine, Houston, TX 77030, USA
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Kostick K, Storch EA, Zuk P, Blumenthal-Barby JS, Torgerson L, Yoshor D, Sheth S, Viswanathan A, Tarakad A, Jimenez-Shahed J, Goodman W, Lázaro-Muñoz G. Strategies to mitigate impacts of the COVID-19 pandemic on patients treated with deep brain stimulation. Brain Stimul 2020; 13:1642-1643. [PMID: 33017673 PMCID: PMC7530624 DOI: 10.1016/j.brs.2020.09.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 09/29/2020] [Accepted: 09/29/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Kristin Kostick
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA.
| | - Eric A Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Peter Zuk
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - J S Blumenthal-Barby
- 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
| | - Daniel Yoshor
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Sameer Sheth
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Ashwin Viswanathan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Arjun Tarakad
- Parkinson's Disease and Movement Disorders Center, Neurology, Movement Disorders, Baylor College of Medicine, Houston, TX, USA
| | - Joohi Jimenez-Shahed
- Movement Disorders Neuromodulation & Brain Circuit Therapeutics, Neurology, Icahn School of Medicine at Mount Sinai, Mount Sinai West, 1000 10th Avenue, Suite 10C, New York, NY, 10019, USA
| | - Wayne Goodman
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Gabriel Lázaro-Muñoz
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
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Kostick KM, Blumenthal-Barby JS, Storch EA, Lázaro-Muñoz G. The Ethics of Getting Ahead When All Heads Are Enhanced. AJOB Neurosci 2020; 11:256-258. [PMID: 33196357 PMCID: PMC9753230 DOI: 10.1080/21507740.2020.1830875] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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10
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Kostick KM, Trejo M, Volk RJ, Estep JD, Blumenthal-Barby JS. Using Nudges to Enhance Clinicians' Implementation of Shared Decision Making With Patient Decision Aids. MDM Policy Pract 2020; 5:2381468320915906. [PMID: 32440570 PMCID: PMC7227151 DOI: 10.1177/2381468320915906] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/15/2020] [Indexed: 01/26/2023] Open
Abstract
Background. Although effective interventions for shared decision making (SDM) exist, there is a lack of uptake of these tools into clinical practice. “Nudges,” which draw on behavioral economics and target automatic thinking processes, are used by policy makers to influence population-level behavior change. Nudges have not been applied in the context of SDM interventions but have potential to influence clinician motivation, a primary barrier to long-term adoption of SDM tools. Objective. Describe, evaluate, and propose recommendations for the use of a behavioral economics framework (MINDSPACE) on clinician motivation and behavior during implementation of a validated decision aid (DA) for left ventricular assist device at nine hospitals. Methods. Qualitative thematic analysis of process notes from stakeholder meetings during the first 6 months of implementation to identify examples of how the MINDSPACE framework was operationalized. Quantitative implementation progress was evaluated using the RE-AIM framework. Results. MINDSPACE components were translated into concrete approaches that leveraged influential stakeholders, fostered ownership over the DA and positive emotional associations, spread desirable norms across sites, and situated the DA within established default processes. DA reach to eligible patients increased from 9.8% in the first month of implementation to 70.0% in the sixth month. Larger gains in reach were observed following meetings using MINDSPACE approaches. Limitations. The MINDSPACE framework does not capture all possible influences on behavior and responses to nudges may differ across populations. Conclusions. Behavioral economics can be applied to implementation science to foster uptake of SDM tools by increasing clinician motivation. Our recommendations can help other researchers effectively apply these approaches in real-world settings when there are often limited incentives and opportunities to change organizational- or structural-level factors.
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Affiliation(s)
- Kristin M Kostick
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas
| | - Meredith Trejo
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas
| | - Robert J Volk
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jerry D Estep
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - J S Blumenthal-Barby
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas
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Kostick K, Trejo M, Blumenthal-Barby JS. Suffering and Healing in the Context of LVAD Treatment. J Clin Med 2019; 8:jcm8050660. [PMID: 31083545 PMCID: PMC6571968 DOI: 10.3390/jcm8050660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 05/03/2019] [Accepted: 05/07/2019] [Indexed: 11/23/2022] Open
Abstract
Background: Illness narratives with meaningful, competent and targeted content have been shown to provide useful guides for patient decision-making and have positive influences on health behaviors. The use of narratives in decision aids can confer a sense of structure, plot and context to illness experiences and help patients make treatment decisions that feel sensible, informed, and transparent. Aim: This paper presents narratives of suffering and healing from patients and their caregivers with advanced heart failure who engaged in decision-making regarding Left Ventricular Device Assist (LVAD) treatment. Methods: Narratives were collected from in-depth interviews with patients who accepted (n = 15) versus declined (n = 15) LVAD implant, LVAD candidates who had received education about LVAD and were in the process of making a decision (n = 15), and caregivers (family or significant others) of LVAD patients (n = 15). Results: Participants shared “restitution” narratives that most commonly conveyed a shift from pre-implant physical suffering and “daily hell,” fatigue so intense it “hurts,” along with emotional suffering from inability to engage with the world, to post-implant improvements in mobility and quality of life, including positivity and family support, adaptation on a “journey,” “getting one’s life back” and becoming “normal” again. Conclusion: For LVAD patients, other patients’ illness narratives can help to give meaning to their own illness and treatment experiences and to more accurately forecast treatment impacts on lifestyle and identity. For clinicians, patient narratives can enhance patient–practitioner communication and understanding by highlighting perspectives and values that structure patients’ clinical experiences.
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Affiliation(s)
- Kristin Kostick
- Baylor College of Medicine, Center for Medical Ethics and Health Policy, Houston, TX 77030, USA.
| | - Meredith Trejo
- Baylor College of Medicine, Center for Medical Ethics and Health Policy, Houston, TX 77030, USA.
| | - J S Blumenthal-Barby
- Baylor College of Medicine, Center for Medical Ethics and Health Policy, Houston, TX 77030, USA.
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Blumenthal-Barby JS. On the Ethical Criteria for Health-Promoting Nudges: The Importance of Conceptual Clarity. Am J Bioeth 2019; 19:66-68. [PMID: 31090531 DOI: 10.1080/15265161.2019.1588412] [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: 06/09/2023]
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Affiliation(s)
- J S Blumenthal-Barby
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas (J.B.)
| | - Bernard Lo
- The Greenwall Foundation, New York, New York (B.L.)
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Blumenthal-Barby JS, Ubel PA. Response to Open Peer Commentaries on ''In Defense of 'Denial': Difficulty Knowing When Beliefs Are Unrealistic and Whether Unrealistic Beliefs Are Bad". Am J Bioeth 2018; 18:W3-W5. [PMID: 30235100 DOI: 10.1080/15265161.2018.1509154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Abstract
Bioethicists often draw sharp distinctions between hope and states like denial, self-deception, and unrealistic optimism. But what, exactly, is the difference between hope and its more suspect cousins? One common way of drawing the distinction focuses on accuracy of belief about the desired outcome: Hope, though perhaps sometimes misplaced, does not involve inaccuracy in the way that these other states do. Because inaccurate beliefs are thought to compromise informed decision making, bioethicists have considered these states to be ones where intervention is needed either to correct the person's mental state or to persuade the person to behave differently, or even to deny the person certain options (e.g., another round of chemotherapy). In this article, we argue that it is difficult to determine whether a patient is really in denial, self-deceived, or unrealistically optimistic. Moreover, even when we are confident that beliefs are unrealistic, they are not always as harmful as critics contend. As a result, we need to be more permissive in our approach to patients who we believe are unrealistically optimistic, in denial, or self-deceived-that is, unless patients significantly misunderstand their situation and thus make decisions that are clearly bad for them (especially in light of their own values and goals), we should not intervene by trying to change their mental states or persuade them to behave differently, or by paternalistically denying them certain options (e.g., a risky procedure).
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Arora NS, Davis JK, Kirby C, McGuire AL, Green RC, Blumenthal-Barby JS, Ubel PA. Communication challenges for nongeneticist physicians relaying clinical genomic results. Per Med 2017; 14:423-431. [PMID: 29181085 DOI: 10.2217/pme-2017-0008] [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] [Received: 02/10/2017] [Accepted: 05/16/2017] [Indexed: 02/07/2023]
Abstract
Aim Identify the behavioral challenges to the use of genome sequencing (GS) in a clinical setting. Materials & methods We observed how general internists and nongenetic specialists delivered GS results to patients enrolled in the MedSeq Project. Using transcripts of such disclosure interactions, we made qualitative observations of communication behaviors that could limit the usefulness of GS results until reaching the point of thematic saturation. Results Findings included confusion regarding genomic terminology, difficulty with the volume or complexity of information and difficulties communicating complex risk information to patients. We observed a broad dismissal of clinical value of GS by some physicians and sometimes ineffective communication regarding health behavior change. Conclusion Overcoming these behavioral challenges is necessary to make full use of clinical GS results.
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Affiliation(s)
- Nonie S Arora
- University of Michigan Medical School, Ann Arbor, MI 48109, USA.,University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - J Kelly Davis
- Duke-Margolis Health Policy Center, Durham, NC 27708, USA.,Fuqua School of Business, Duke University, Durham, NC 27708, USA.,Duke-Margolis Health Policy Center, Durham, NC 27708, USA.,Fuqua School of Business, Duke University, Durham, NC 27708, USA
| | - Christine Kirby
- Duke-Margolis Health Policy Center, Durham, NC 27708, USA.,Fuqua School of Business, Duke University, Durham, NC 27708, USA.,Duke-Margolis Health Policy Center, Durham, NC 27708, USA.,Fuqua School of Business, Duke University, Durham, NC 27708, USA
| | - Amy L McGuire
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX 77030, USA.,Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX 77030, USA
| | - Robert C Green
- Division of Genetics, Department of Medicine, Brigham & Women's Hospital, Boston, MA 02115, USA.,Harvard Medical School, Boston, MA 02115, USA.,Partners Healthcare Personalized Medicine, Boston, MA 02139, USA.,Division of Genetics, Department of Medicine, Brigham & Women's Hospital, Boston, MA 02115, USA.,Harvard Medical School, Boston, MA 02115, USA.,Partners Healthcare Personalized Medicine, Boston, MA 02139, USA
| | - J S Blumenthal-Barby
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX 77030, USA.,Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX 77030, USA
| | - Peter A Ubel
- Duke-Margolis Health Policy Center, Durham, NC 27708, USA.,Fuqua School of Business, Duke University, Durham, NC 27708, USA.,Sanford School of Public Policy, Duke University, Durham, NC 27708, USA.,Duke University School of Medicine, Durham, NC 27710, USA.,Duke-Margolis Health Policy Center, Durham, NC 27708, USA.,Fuqua School of Business, Duke University, Durham, NC 27708, USA.,Sanford School of Public Policy, Duke University, Durham, NC 27708, USA.,Duke University School of Medicine, Durham, NC 27710, USA
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Blumenthal-Barby JS. 'That's the doctor's job': Overcoming patient reluctance to be involved in medical decision making. Patient Educ Couns 2017; 100:14-17. [PMID: 27423179 DOI: 10.1016/j.pec.2016.07.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [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: 07/01/2016] [Accepted: 07/02/2016] [Indexed: 05/20/2023]
Abstract
OBJECTIVE To review the barriers to patient engagement and techniques to increase patients' engagement in their medical decision-making and care. DISCUSSION Barriers exist to patient involvement in their decision-making and care. Individual barriers include education, language, and culture/attitudes (e.g., deference to physicians). Contextual barriers include time (lack of) and timing (e.g., lag between test results being available and patient encounter). Clinicians should gauge patients' interest in being involved and their level of current knowledge about their condition and options. Framing information in multiple ways and modalities can enhance understanding, which can empower patients to become more engaged. Tools such as decision aids or audio recording of conversations can help patients remember important information, a requirement for meaningful engagement. Clinicians and researchers should work to create social norms and prompts around patients asking questions and expressing their values. Telehealth and electronic platforms are promising modalities for allowing patients to ask questions on in a non-intimidating atmosphere. CONCLUSION Researchers and clinicians should be motivated to find ways to engage patients on the ethical imperative that many patients prefer to be more engaged in some way, shape, or form; patients have better experiences when they are engaged, and engagement improves health outcomes.
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Affiliation(s)
- J S Blumenthal-Barby
- Baylor College of Medicine, Center for Medical Ethics & Health Policy, One Baylor Plaza, MS: BCM 420, Houston, TX, USA.
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18
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Blumenthal-Barby JS, Loftis L, Cummings CL, Meadow W, Lemmon M, Ubel PA, McCullough L, Rao E, Lantos JD. Should Neonatologists Give Opinions Withdrawing Life-sustaining Treatment? Pediatrics 2016; 138:peds.2016-2585. [PMID: 27940720 DOI: 10.1542/peds.2016-2585] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2016] [Indexed: 11/24/2022] Open
Abstract
An infant has a massive intracranial hemorrhage. She is neurologically devastated and ventilator-dependent. The prognosis for pulmonary or neurologic recovery is bleak. The physicians and parents face a choice: withdraw the ventilator and allow her to die or perform a tracheotomy? The parents cling to hope for recovery. The physician must decide how blunt to be in communicating his own opinions and recommendations. Should the physician try to give just the facts? Or should he also make a recommendation based on his own values? In this article, experts in neonatology, decision-making, and bioethics discuss this situation and the choice that the physician faces.
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Affiliation(s)
| | | | - Christy L Cummings
- Boston Children's Hospital, Harvard School of Medicine, Boston, Massachusetts
| | | | | | | | | | - Emily Rao
- Rice University, Houston, Texas; and
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Blumenthal-Barby JS, Ubel PA. Gunmen and Ice Cream Cones: Harm to Autonomy and Harm to Persons. Am J Bioeth 2016; 16:13-14. [PMID: 27749180 DOI: 10.1080/15265161.2016.1222021] [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: 06/06/2023]
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Blumenthal-Barby JS, Lazaridis C. A Woman in Her 30s Whose Family Becomes Distrustful After an Initial Prognosis Proves Inaccurate. Chest 2016; 149:e115-7. [PMID: 27055715 DOI: 10.1016/j.chest.2015.09.021] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 09/10/2015] [Accepted: 09/16/2015] [Indexed: 11/30/2022] Open
Abstract
A woman in her 30s with alcoholic liver disease presented with an intracerebral hemorrhage with intraventricular extension, hydrocephalus, and an intracerebral hemorrhage score of 3. In the ICU, she was comatose with a flexion withdrawal as a best motor response. The ICU team, after 6 days of care, informed the family that the prognosis for any recovery of meaningful neurological function was dismal and that the family should consider withdrawal of life support. The family resisted any consideration of limitation of care, citing religious beliefs.
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Affiliation(s)
- J S Blumenthal-Barby
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza Houston, TX.
| | - Christos Lazaridis
- Department of Neurology-Neuro Critical Care, Baylor College of Medicine, Houston, TX
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Abstract
Cognitive scientists have identified a wide range of biases and heuristics in human decision making over the past few decades. Only recently have bioethicists begun to think seriously about the implications of these findings for topics such as agency, autonomy, and consent. This article aims to provide an overview of biases and heuristics that have been identified and a framework in which to think comprehensively about the impact of them on the exercise of autonomous decision making. I analyze the impact that these biases and heuristics have on the following dimensions of autonomy: understanding, intentionality, absence of alienating or controlling influence, and match between formally autonomous preferences or decisions and actual choices or actions.
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Kostick KM, Minard CG, Wilhelms LA, Delgado E, Abraham M, Bruce CR, Estep JD, Loebe M, Volk RJ, Blumenthal-Barby JS. Development and validation of a patient-centered knowledge scale for left ventricular assist device placement. J Heart Lung Transplant 2016; 35:768-76. [PMID: 26922278 DOI: 10.1016/j.healun.2016.01.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 12/21/2015] [Accepted: 01/10/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND A central tenet of patient-centered health care advocated by the Institute of Medicine and the American Medical Association is to enhance informed decision-making in a way that incorporates patient values, knowledge and beliefs. Achievement of this goal is constrained by a lack of validated measures of patients' knowledge needs. METHODS In this study we present a comprehensive and valid methodology for developing a clinically informed and patient-centered measure of knowledge about left ventricular assist device (LVAD) therapy to facilitate discussion and measure candidate understanding of treatment options. Using structured interviews with patients, caregivers, candidates for LVAD treatment (New York Heart Association Class III and IV) and expert clinicians (n = 71), we identified top patient decisional needs and perspectives on essential knowledge needs for informed decision-making. From this list, we generated 20 knowledge scale question items to refine in cognitive interviews (n = 5) with patients and patient consultants. RESULTS Good internal consistency and reliability of the knowledge scale (Cronbach's α = 0.81) was seen in 30 LVAD patients and candidates. Knowledge was higher among patients currently with LVADs than candidates, regardless of receiving standard education (with education: 69.9 vs 50.1, adjusted p = 0.02; without education: 69.9 vs 37.6, adjusted p < 0.001). CONCLUSION The LVAD knowledge scale may be useful in clinical settings to identify gaps in knowledge among patient candidates considering LVAD treatment, and to better tailor education and discussion with patients and their caregivers, and to enhance informed decision-making before treatment decisions are made.
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Affiliation(s)
- Kristin M Kostick
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA.
| | - Charles G Minard
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas, USA
| | - L A Wilhelms
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
| | - Estevan Delgado
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
| | - Mackenzie Abraham
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
| | - Courtenay R Bruce
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
| | - Jerry D Estep
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Matthias Loebe
- Miami Transplant Institute, University of Miami, Miami, Florida, USA
| | - Robert J Volk
- Department of Health Services Research, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - J S Blumenthal-Barby
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
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Blumenthal-Barby JS, Robinson E, Cantor SB, Naik AD, Russell HV, Volk RJ. The neglected topic: presentation of cost information in patient decision AIDS. Med Decis Making 2015; 35:412-8. [PMID: 25583552 DOI: 10.1177/0272989x14564433] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Accepted: 11/21/2014] [Indexed: 11/16/2022]
Abstract
Costs are an important component of patients' decision making, but a comparatively underemphasized aspect of formal shared decision making. We hypothesized that decision aids also avoid discussion of costs, despite their being tools designed to facilitate shared decision making about patient-centered outcomes. We sought to define the frequency of cost-related information and identify the common modes of presenting cost and cost-related information in the 290 decision aids catalogued in the Ottawa Hospital Research Institute's Decision Aid Library Inventory (DALI) system. We found that 56% (n = 161) of the decision aids mentioned cost in some way, but only 13% (n = 37) gave a specific price or range of prices. We identified 9 different ways in which cost was mentioned. The most common approach was as a "pro" of one of the treatment options (e.g., "you avoid the cost of medication"). Of the 37 decision aids that gave specific prices or ranges of prices for treatment options, only 2 were about surgery decisions despite the fact that surgery decision aids were the most common. Our findings suggest that presentation of cost information in decision aids is highly variable. Evidence-based guidelines should be developed by the International Patient Decision Aid Standards (IPDAS) Collaboration.
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Affiliation(s)
- J S Blumenthal-Barby
- Department of Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas (JSB-B)
| | - Emily Robinson
- Department of Organizational Behavior, INSEAD, Fontainebleau, France (ER)
| | - Scott B Cantor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas (SBC, RJV)
| | - Aanand D Naik
- Department of Medicine, Baylor College of Medicine, Houston, Texas (ADN)
| | | | - Robert J Volk
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas (SBC, RJV)
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Affiliation(s)
| | - Aanand D Naik
- b Michael E. DeBakey VA Med Center and Baylor College of Medicine
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Blumenthal-Barby JS, McGuire AL, Ubel PA. Why information alone is not enough: behavioral economics and the future of genomic medicine. Ann Intern Med 2014; 161:605-6. [PMID: 25329206 DOI: 10.7326/m14-2074] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Blumenthal-Barby JS, Krieger H. Cognitive biases and heuristics in medical decision making: a critical review using a systematic search strategy. Med Decis Making 2014; 35:539-57. [PMID: 25145577 DOI: 10.1177/0272989x14547740] [Citation(s) in RCA: 274] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 07/26/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND The role of cognitive biases and heuristics in medical decision making is of growing interest. The purpose of this study was to determine whether studies on cognitive biases and heuristics in medical decision making are based on actual or hypothetical decisions and are conducted with populations that are representative of those who typically make the medical decision; to categorize the types of cognitive biases and heuristics found and whether they are found in patients or in medical personnel; and to critically review the studies based on standard methodological quality criteria. METHOD Data sources were original, peer-reviewed, empirical studies on cognitive biases and heuristics in medical decision making found in Ovid Medline, PsycINFO, and the CINAHL databases published in 1980-2013. Predefined exclusion criteria were used to identify 213 studies. During data extraction, information was collected on type of bias or heuristic studied, respondent population, decision type, study type (actual or hypothetical), study method, and study conclusion. RESULTS Of the 213 studies analyzed, 164 (77%) were based on hypothetical vignettes, and 175 (82%) were conducted with representative populations. Nineteen types of cognitive biases and heuristics were found. Only 34% of studies (n = 73) investigated medical personnel, and 68% (n = 145) confirmed the presence of a bias or heuristic. Each methodological quality criterion was satisfied by more than 50% of the studies, except for sample size and validated instruments/questions. Limitations are that existing terms were used to inform search terms, and study inclusion criteria focused strictly on decision making. CONCLUSIONS Most of the studies on biases and heuristics in medical decision making are based on hypothetical vignettes, raising concerns about applicability of these findings to actual decision making. Biases and heuristics have been underinvestigated in medical personnel compared with patients.
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Affiliation(s)
- J S Blumenthal-Barby
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX (JSBB)
| | - Heather Krieger
- Department of Social Psychology, University of Houston, Houston, TX (HK)
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Abstract
The introduction of the Diagnostic and statistical manual of mental disorders (DSM-5) in May 2013 is being hailed as the biggest event in psychiatry in the last 10 years. In this paper I examine three important issues that arise from the new manual:(1) Expanding nosology: Psychiatry has again broadened its nosology to include human experiences not previously under its purview (eg, binge eating disorder, internet gaming disorder, caffeine use disorder, hoarding disorder, premenstrual dysphoric disorder). Consequence-based ethical concerns about this expansion are addressed, along with conceptual concerns about a confusion of "construct validity" and "conceptual validity" and a failure to distinguish between "disorder" and "non disordered conditions for which we help people."(2) The role of claims about societal impact in changes in nosology: Several changes in the DSM-5 involved claims about societal impact in their rationales. This is due in part to a new online open comment period during DSM development. Examples include advancement of science, greater access to treatment, greater public awareness of condition, loss of identify or harm to those with removed disorders, stigmatization, offensiveness, etc. I identify and evaluate four importantly distinct ways in which claims about societal impact might operate in DSM development. (3) Categorisation nosology to spectrum nosology: The move to "degrees of severity" of mental disorders, a major change for DSM-5, raises concerns about conceptual clarity and uniformity concerning what it means to have a severe form of a disorder, and ethical concerns about communication.
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Affiliation(s)
- Courtenay R Bruce
- 1 Center for Medical Ethics and Health Policy Baylor College of Medicine Houston, Texas and Houston Methodist Hospital System Houston Methodist Hospital System Biomedical Ethics Program Houston, Texas
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Blumenthal-Barby JS, Cantor SB, Russell HV, Naik AD, Volk RJ. Decision aids: when 'nudging' patients to make a particular choice is more ethical than balanced, nondirective content. Health Aff (Millwood) 2013; 32:303-10. [PMID: 23381523 DOI: 10.1377/hlthaff.2012.0761] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Patient decision aids, such as instructional leaflets describing treatment options for prostate cancer, are designed to help educate patients so that they can share in decisions about their care. Developers of these decision aids strive for balance, aiming to be as neutral, unbiased, and nondirective as possible. We argue that balance should not always be a goal, and we identify three situations where it should not be. For example, men diagnosed with early-stage prostate cancer frequently are not advised by their physicians that active surveillance is a reasonable alternative to immediate surgery or radiation. It may be desirable to design decision aids that promote active surveillance as an option. We recognize that the arguments put forth in this article are controversial. But they are also justified. We challenge medical decision makers and decision aid developers to determine if and when patients should be "nudged" toward one option or another.
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Affiliation(s)
- J S Blumenthal-Barby
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA.
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Affiliation(s)
- J S Blumenthal-Barby
- From the Center for Medical Ethics & Health Policy (Drs. Blumenthal-Barby and McCullough, and Ms. Krieger) and Department of Psychiatry (Dr. Coverdale), Baylor College of Medicine
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Abstract
The American Board of Internal Medicine (ABIM) Foundation has recently initiated a campaign called "Choosing Wisely," which is aimed at reducing "low-value" care services. Lists of low-value care services are being developed and the ABIM Foundation is urging the American Medical Association and other organizations to get behind the lists, disseminate them, and implement them. Yet, there are many ethical questions that remain about the development, dissemination, and implementation of these low-value care lists. In this paper I argue for conceptual clarity with respect to the label "low-value care." Thus far it has not been precisely defined, and I argue that there are actually 10 distinct categories of low-value care. I discuss the ethical challenges and considerations associated with each category. I also provide arguments that can be used to justify the reduction of some of these categories of low-value care. These arguments rely on Rawlsian and Hegelian notions of justice, as well as on concepts about the fiduciary obligations of physicians. Finally, I outline the various mechanisms that could be utilized for the reduction of low-value care (i.e., incentives, punishments, nonrational influences such as appeals to social norms, emotions, or ego, and creation of conditions that make avoidance easy such as defaults and reminders). I provide normative guidelines for the use of each.
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Affiliation(s)
- J S Blumenthal-Barby
- *Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030 USA.
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Blumenthal-Barby JS. Between reason and coercion: ethically permissible influence in health care and health policy contexts. Kennedy Inst Ethics J 2012; 22:345-366. [PMID: 23420941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
In bioethics, the predominant categorization of various types of influence has been a tripartite classification of rational persuasion (meaning influence by reason and argument), coercion (meaning influence by irresistible threats-or on a few accounts, offers), and manipulation (meaning everything in between). The standard ethical analysis in bioethics has been that rational persuasion is always permissible, and coercion is almost always impermissible save a few cases such as imminent threat to self or others. However, many forms of influence fall into the broad middle terrain-and this terrain is in desperate need of conceptual refining and ethical analysis in light of recent interest in using principles from behavioral science to influence health decisions and behaviors. This paper aims to address the neglected space between rational persuasion and coercion in bioethics. First, I argue for conceptual revisions that include removing the "manipulation" label and relabeling this space "nonargumentative influence," with two subtypes: "reason-bypassing" and "reason-countering." Second, I argue that bioethicists have made the mistake of relying heavily on the conceptual categories themselves for normative work and instead should assess the ethical permissibility of a particular instance of influence by asking several key ethical questions, which I elucidate, that relate to (1) the impact of the form of influence on autonomy and (2) the relationship between the influencer and the influenced. Finally, I apply my analysis to two examples of nonargumentative influence in health care and health policy: (1) governmental agencies such as the Food and Drug Administration (FDA) trying to influence the public to be healthier using nonargumentative measures such as vivid images on cigarette packages to make more salient the negative effects of smoking, and (2) a physician framing a surgery in terms of survival rates instead of mortality rates to influence her patient to consent to the surgery.
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Braverman JA, Blumenthal-Barby JS. Assessment of the sunk-cost effect in clinical decision-making. Soc Sci Med 2012; 75:186-92. [PMID: 22503839 DOI: 10.1016/j.socscimed.2012.03.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Revised: 02/14/2012] [Accepted: 03/06/2012] [Indexed: 10/28/2022]
Abstract
Despite the current push toward the practice of evidence-based medicine and comparative effectiveness research, clinicians' decisions may be influenced not only by evidence, but also by cognitive biases. A cognitive bias describes a tendency to make systematic errors in certain circumstances based on cognitive factors rather than evidence. Though health care providers have been shown in several studies to be susceptible to a variety of types of cognitive biases, research on the role of the sunk-cost bias in clinical decision-making is extremely limited. The sunk-cost bias is the tendency to pursue a course of action, even after it has proved to be suboptimal, because resources have been invested in that course of action. This study explores whether health care providers' medical treatment recommendations are affected by prior investments in a course of treatment. Specifically, we surveyed 389 health care providers in a large urban medical center in the United States during August 2009. We asked participants to make a treatment recommendation based on one of four hypothetical clinical scenarios that varied in the source and type of prior investment described. By comparing recommendations across scenarios, we found that providers did not demonstrate a sunk-cost effect; rather, they demonstrated a significant tendency to over-compensate for the effect. In addition, we found that more than one in ten health care providers recommended continuation of an ineffective treatment.
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Abstract
Policymakers, employers, insurance companies, researchers, and health care providers have developed an increasing interest in using principles from behavioral economics and psychology to persuade people to change their health-related behaviors, lifestyles, and habits. In this article, we examine how principles from behavioral economics and psychology are being used to nudge people (the public, patients, or health care providers) toward particular decisions or behaviors related to health or health care, and we identify the ethically relevant dimensions that should be considered for the utilization of each principle.
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