Dr. Jeff Kullgren is a Research Scientist in the Center for Clinical Management Research at the VA Ann Arbor Healthcare System and an Assistant Professor in the Department of Internal Medicine at the University of Michigan Medical School and Institute for Healthcare Policy and Innovation. Dr.
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A special issue of Learning Health Systems is now out with guest commentary by CBSSM faculty, Jodyn Platt, Kayte Spector-Bagdady, Raymond De Vries, Dorene Markel, and colleagues.
Article can be found here.
Dr. Naomi T. Laventhal joined the University of Michigan in August 2009, after completing her residency in pediatrics, fellowships in neonatology and clinical medical ethics, and a master’s degree in public policy at the University of Chicago. She is a Clinical Associate Professor in the Department of Pediatrics and Communicable Diseases in the Division of Neonatal-Perinatal Medicine, and in the Center for Bioethics and Social Sciences in Medicine (CBSSM).
Click to decide between death and living with a colostomy. Which would you choose? Are you sure?
Given the choice, would you choose immediate death,or living with a colostomy (where part of your bowel is removed and you have bowel movements into a plastic pouch attached to your belly)?
- Immediate Death
Think about what it would be like if you were diagnosed with colon cancer. You are given the option of choosing between two surgical treatments.The first is a surgery that could result in serious complications and the second has no chance of complications but has a higher mortality rate.
|Possible outcome||Surgery 1
|Cure without complication||80%||80%|
|Cure with colostomy||1%|
|Cure with chronic diarrhea||1%|
|Cure with intermittent bowel obstruction||1%|
|Cure with wound infection||1%|
|No cure (death)||16%||20%|
If you had the type of colon cancer described above, which surgery do you think you would choose?
- Surgery 1
- Surgery 2
How do your answers compare?
Are you saying what you really mean?
CBDSM investigators Brian Zikmund-Fisher, Angela Fagerlin, Peter Ubel, teamed up with Jennifer Amsterlaw, to see if they could reduce the number of people choosing the surgery with the higher rate of death and therefore reducing the discrepancy. A large body of past research has shown that people are notoriously averse to uncertainty. The investigators had a hunch that uncertainty could account for some of the discrepancy. Surgery 1 has a greater number of ambiguous outcomes, perhaps causing people to be averse to it. In an effort to minimize this uncertainty, the investigators laid out a series of scenarios outlining different circumstances and presentations of the two surgeries. For example the research presented some of the participants with a reframing of the surgery information, such as:
|Possible outcome||Surgery 1
|Cured without complication||80%||80%|
|Cured, but with one of the following complications: colostomy, chronic diarrhea, intermittent bowl obstruction, or wound infection||4%|
|No cure (death)||16%||20%|
The investigators believed by grouping all of the complications together that people would be more apt to chose the surgery with the lower mortality rate, because seeing a single group of undesirable outcomes, versus a list, may decrease some of the ambiguity from previous research.
Although none of the manipulations significantly reduced the percentage of participants selecting Surgery 2, the versions that yielded the lowest preference for this surgery all grouped the risk of the four possible complications into a single category, as in the example shown above.
Why these findings are important
Over the past several decades there has been a push to give patients more information so they can make decisions that are consistent with their personal preferences. On the other hand there is a growing psychological literature revealing people's tendency to make choices that are in fact inconsistent with their own preferences; this is a dilemma. Because the present research suggests that the discrepancy between value and surgery choice is extremely resilient, much research still needs to be done in order to understand what underlies the discrepancy, with the goal of eliminating it.
The research reported in this decision of the month is currently in press. Please come back to this page in the near future for a link to the article.
Read the article:
Can avoidance of complications lead to biased healthcare decisions?
Amsterlaw J, Zikmund-Fisher BJ, Fagerlin A, Ubel PA. Judgment and Decision Making 2006;1(1):64-75.
Kayte Spector-Bagdady is an Assistant Professor in the Department of Obstetrics and Gynecology at the University of Michigan Medical School and is also the Chief of the Research Ethics Service in the Center for Bioethics and Social Sciences in Medicine (CBSSM). At UM she also serves as Chair of the Research Ethics Committee, a clinical ethicist through CBSSM’s Clinical Ethics Service, and a member of IRB Council. Her current work focuses on the intersection of human subjects research law and ethics with a concentration on genetics, reproduction, and data sharing partnerships.
Kathryn Moseley served as one of the judges at "The Big Ethical Question Slam 5" hosted by a2ethics.org. In addition, Naomi Laventhal, Michele Gornick, Christian Vercler, Lauren Smith, and Lauren Wancata served as judges at the "Michigan Highschool Ethics Bowl 2."
Thanks to all the CBSSM folks who contributed their time!
For more information about these events and other great ethics-related activites, go to a2ethics.org.
A short video about the Highschool Ethics Bowl can be found here.
Scott Roberts, PhD, is Professor of Health Behavior & Health Education at the University of Michigan’s School of Public Health (U-M SPH), where he directs the School’s Public Health Genetics program and teaches a course on public health ethics. A clinical psychologist by training, Dr. Roberts conducts research on the psychosocial implications of genetic testing for adult-onset diseases.
I serve as Professor of Family Medicine, Director of Japanese Family Health Program, and Co-Director of the Michigan Mixed Methods Research and Scholarship Program at the University of Michigan. In addition to being a family/general doctor fluent in Japanese, I have long been interested in the influence of culture on medical decision making and ethics, and have conducted numerous health research projects, and published numerous papers in English and Japanese.