Dr. Sandberg is a pediatric psychologist and clinical researcher. As a pediatric psychologist, he delivers psychoeducational and behavioral health services to persons with endocrine disorders and their families, in particular, conditions affecting linear growth or disorders of sex development (DSD), i.e., congenital conditions in which development of sex chromosomes, gonads or sex anatomy is atypical.
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Carl Schneider, JD -- “Can Informed-Consent Laws Work? Evaluating Compelled Disclosure as a Method of Regulation”
Abstract: The law of informed consent is an example of a form of legal regulation called mandated disclosure. In such regulation, one party to a transaction is required to give the other party to the transaction information to use in making decisions about the parties’ relationship. There are hundreds of examples of such legal rules besides medical informed consent. This talk asks how well these rules have worked outside medicine. It concludes that there is little evidence that those rules ever work, explores some of the reasons for this surprising failure, and asks what the failure of mandated disclosure outside medicine tells us about the success of informed-consent laws in medicine.
Paul Lichter, MD
The Medical-Industrial Complex is alive and well and has been that way for decades. The Complex depends on strong cooperation from physicians. Not only do physicians help industry to develop drugs and devices, they then take part in selling them to their fellow physicians. The physician-as-drug-rep is driven by money and by the culture of reciprocity in our society. This talk will review the foundations of the Medical-Industrial Complex and the reasons why it is able to control a great deal of medical practice in our country. Physicians rarely if ever believe they are biased and Industry works hard to enforce that belief. Money provided by Industry to physicians in essence creates a contract, however subtle, whereby physicians will sell drugs and devices for Industry. We will discuss the ethical issues surrounding physician-industry relationships as part of the Medical-Industrial Complex.
Anna Kirkland, JD, PhD Title – "The Vaccine Injury Compensation Court and Its Critics"
Presenter – Anna Kirkland, JD, PhD, Arthur F. Thurnau Professor of Women's Studies and Political Science, University of Michigan
Abstract: The so-called vaccine court is a small special court in the United States Court of Federal Claims that handles controversial claims that a vaccine has harmed someone. The government steps in as the defendant and vaccine manufacturers are protected from liability. In this court, lawyers, activists, judges, doctors, and scientists come together, sometimes arguing bitterly, trying to figure out whether a vaccine really caused a person’s medical problem. Drawing on her recently published book, Vaccine Court: The Law and Politics of Injury (NYU Press, 2016), Prof. Anna Kirkland will discuss the ethical controversies surrounding the vaccine court, from the perspective of anti-vaccine movement activists as well as from the mainstream.
Systematizing the Teaching of Medical Ethics in the Undergraduate Medical Years
Medical students at the University of Michigan encounter ethical issues throughout their four years of training. Some are obvious – decisions at the end of life, the allocation of scarce of medical resources, challenges to patient autonomy – others are less obvious – relationships between medical residents and medical students, problems with the “hidden curriculum,” and systemic discrimination in the provision of care. Our goal is to make students aware of the variety of ethical problems in medical care and to equip them to respond to these problems in a wise and responsible manner.
To that end, our curriculum efforts focus on extending the existing curriculum and on making the medical ethics curriculum for undergraduate medical students at UM more systematic and explicit. Because we want students to become well-versed in thinking through ethical dilemmas before they encounter them in their clinical work we weave ethics into the curriculum throughout the 4 years of their undergraduate training. We use the expertise of our CBSSM faculty to create novel curricular components that incorporate our empirical work in bioethics with our particular expertise in decision science.
Increasing Opportunities for Ethics Teaching in the Clerkship Years
We facilitate regular ethics discussions for medical students at the end of their required clinical rotations in Obstetrics and Gynecology (in the third year) and Emergency Medicine (in the fourth year). To facilitate these discussions, students prepare short essays on ethical dilemmas encountered in these clerkships. Students are given a summary of all the issues that came up that rotation, which is used as a starting point for a discussion facilitated by a clinical faculty member trained in ethics. In addition, the Internal Medicine subinternship (an option for fourth year students) includes an ethics discussion at the end of the rotation.
These discussions allow medical students to bring up concerns with ethical dilemmas in a safe environment, teach the students about approaches to ethics, and embed training in ethical decision-making in clinical practice. This is often the first time students learn about the role of the hospital ethics committee and how they can contact them if desired.
“That was unexpectedly awesome!"
-- Medical student after Ob/Gyn ethics discussion
Advanced Medical Therapeutics Ethics Module
All fourth year medical students are required to take an online Advanced Medical Therapeutics course. As part of the course, we created an ethics module that includes multiple cases that present ethical dilemmas. Each case includes pre-recorded videos of faculty discussing the ethical aspects of the case and interactive components requiring students to choose possible solutions to the problem, after which they receive explanations of the pros and cons of their choice.
Medical Ethics Path of Excellence
CBSSM faculty work closely with the medical school to strengthen the medical ethics curriculum for Michigan medical students. Our goal is to make students aware of the broad range of ethical challenges facing 21st century medicine – challenges in clinical care, medical research and the design of health care delivery. Most recently, a team of CBSSM faculty developed the Medical Ethics Pathway of Excellence, an opportunity for students to receive mentored training in ethics throughout their four years of medical school.
Overview of Medical Ethics Pathway to Excellence:
- Introduced in September 2013, the first 10 students were accepted in 2014. Twelve students joined in 2015.
- Students apply to the Ethics Path of Excellence at the end of February during their M1 year, and continue their studies through their M4 year. Students in the POE learn to:
- Identify ethical issues in the organization and delivery of health care
- Implement tools and strategies to address ethical issues
- Continue their professional education and development of the skills required for leadership
- Before applying to the Ethics Path of Excellence, students have the opportunity to attend fourteen interactive lunchtime lectures that review various aspects of ethics in a healthcare setting. Applicants must attend a minimum of five of these lectures.
- Students who want to serve on ethics committees and/or include ethics as part of an academic career are provided with specialized training.
- All students participate in an individualized, independent study, culminating in a capstone project in the M4 year. Often this work includes field work at CBSSM.
Beginning in 2015, the Path of Excellence has been responsible for administering the core ethics curriculum for all of the M1 students. The Ethics Path of Excellence will continue to be a co-curricular activity until 2017 when all students will be required to choose one of the paths offered in the medical school.
“We really want to educate people to be the ethics committee consultants of the future. I think it's pretty unique to have the option of pursuing this extracurricular program because essentially it teaches you leadership skills and how to be a self-directed learner. These are skills you'll really need when you become faculty. Students can take their interest in ethics and pursue it further.”
Lauren Smith, M.D., Associate Professor of Pathology
Lauren Smith is the Director of the Path of Excellence. Andrew Barnosky, Christian Vercler, Ed Goldman, Kathryn Moseley, Janice Firn, Sacha Montas, and Raymond De Vries are core faculty members.
Start Seeing Ethics Lunch Discussions
As part of the Medical Ethics Path of Excellence, we offer lunch time discussions of cutting-edge topics in ethics. The content of these discussions includes topics such as conscientious objection, mandatory vs. optional vaccinations, patient centered care and shared decision making. We have also used these discussions to hold mock ethics committee meetings with discussion of a specific case. Facilitators provide a relaxed atmosphere in which students can feel comfortable asking questions and voicing opinions.
"It is exciting to see medical students engage with the ethical issues that arise in the clinic and the classroom. With encouragement from us they are beginning to see that there is more to medical ethics than just the well-known issues at the beginning and end of life. While these ethical issues are important, there are also moral consequences associated with the mundane aspects of being a student and working with patients." Raymond De Vries, PhD, Director, Ethics Education Initiative
What's the difference between opting in and opting out of an activity? Who decides if people will be put automatically into one category or another? Click this interactive decision to learn how default options work.
Imagine that you're a US Senator and that you serve on the Senate's Committee on Health, Education, Labor, and Pensions. The Infectious Diseases Society of America has come before your committee because they believe that too many health care workers are getting sick with influenza ("flu") each year and infecting others. As a result, your Senate committee is now considering a new bill that would require that all health care workers get annual influenza vaccinations ("flu shots") unless the worker specifically refuses this vaccination in writing.
Do you think you would support this bill for mandatory flu shots for health care workers?
Imagine that you're the human resources director at a mid-sized company that's initiating an employee retirement plan. Management is concerned that many employees are not saving enough for retirement. They're considering a policy that would automatically deduct retirement contributions from all employees' wages unless the employee fills out and submits a form requesting exemption from the automatic deductions.
Do you think a policy of automatic retirement deductions is reasonable for your company to follow?
Organ transplants save many lives each year, but there are always too many deserving patients and too few organs available. To try to improve the number of organs available for donation, the state legislature in your state is considering a new policy that all people who die under certain well-defined circumstances will have their organs donated to others. The system would start in three years, after an information campaign. People who do not want to have their organs donated would be given the opportunity to sign a refusal of organ donation when they renewed their drivers' licenses or state ID cards, which expire every three years. Citizens without either of these cards could also sign the refusal at any drivers' license office in the state. This is a policy similar to ones already in place in some European countries.
Does this seem like an appropriate policy to you?
How do your answers compare?
For many decisions in life, people encounter default options-that is, events or conditions that will be set in place if they don't actively choose an alternative. Some default options have clear benefits and are relatively straightforward to implement, such as having drug prescriptions default to "generic" unless the physician checks the "brand necessary" box. Others are more controversial, such as the automatic organ donation issue that you made a decision about.
Default options can strongly influence human behavior. For example, employees are much more likely to participate in a retirement plan if they're automatically enrolled (and must ask to be removed, or opt out) than if they must actively opt in to the plan. Researchers have found a number of reasons for this influence of default options, including people's aversion to change.
But default options can seem coercive also. So, an Institute of Medicine committee recently recommended against making organ donation automatic in the US. One reason was the committee's concern that Americans might not fully understand that they could opt out of donation or exactly how they could do so.
The policy scenarios presented to you here have been excerpted from a 2007 article in the New England Journal of Medicine titled "Harnessing the Power of Default Options to Improve Health Care," by Scott D. Halpern, MD, PhD, Peter A. Ubel, MD, and David A. Asch, MD, MBA. Dr. Ubel is the Director of the Center for Behavioral and Decision Sciences in Medicine.
This article provides guidance for policy-makers in setting default options, specifically in health care. Generally, default options in health care are intended to promote the use of interventions that improve care, reduce the use of interventions that put patients at risk, or serve broader societal agendas, such as cost containment.
In this NEJM article, the researchers argue that default options are often unavoidable-otherwise, how would an emergency-room physician decide on care for an uninsured patient? Many default options already exist but are hidden. Without either returning to an era of paternalism in medicine or adopting a laissez-faire approach, the authors present ways to use default options wisely but actively, based on clear findings in the medical literature.
Some examples of default policies that may improve health care quality:
- routine HIV testing of all patients unless they opt out.
- removal of urinary catheters in hospital patients after 72 hours unless a nurse or doctor documents why the catheter should be retained.
- routine ventilation of all newly intubated patients with lung-protective settings unless or until other settings are ordered.
Drs. Halpern, Ubel, and Asch conclude, "Enacting policy changes by manipulating default options carries no more risk than ignoring such options that were previously set passively, and it offers far greater opportunities for benefit."
Read the article:
Harnessing the power of default options to improve health care.
Halpern SD, Ubel PA, Asch DA. New England Journal of Medicine 2007;357:1340-1344.
It is with both sadness and joy that we announce that CBSSM Co-Director Dr. Angela Fagerlin will be assuming a new position as the inaugural Chair ofPopulation Health Sciences at the University of Utah. While we are very sad to see Angie leave, we congratulate her on this well-deserved opportunity and are thrilled to see her enter this new stage in her career.
Dr. Fagerlin has been with the University of Michigan for 15 years and Co-Director of CBSSM for the last 5 years. She has been an integral member of CBSSM and all its precursors—the Program for Improving Health Care Decisions and The Center for Behavioral and Decision Sciences in Medicine. Dr. Fagerlin will be greatly missed for her friendship, collegiality, mentorship, and the great science she has produced over the years.
As of January 2016, current Co-Director of CBSSM Dr. Raymond De Vries will be joined by Dr. Brian Zikmund-Fisher, who will serve as an Interim Co-Director. Dr. Zikmund-Fisher is an Associate Professor of Health Behavior and Health Education at the School of Public Health, as well as a Research Associate Professor of Internal Medicine. He has been actively involved with CBSSM and its precursors for over 13 years and has many research collaborations and mentoring relationships with CBSSM faculty, fellows, and affiliates. Dr. Zikmund-Fisher looks forward to helping to grow CBSSM's many research and educational initiatives in the future.
Paul A. Lombardo, PhD, JD
Regents' Professor and Bobby Lee Cook Professor of Law
Georgia State University College of Law
"From Psycographs to FMRI: Historical Context for the Claims of Neuroscience"
Abstract: In the U.S., announcement of the Presidential “Brain Initiative” has focused attention on “revolutionizing our understanding of the human brain” And neuroscience has begun to replace genetics as the field most likely to fill press headlines. The promise of more research funding for the field has led to extraordinary claims that research will soon lead to mind reading, lie detection, and unlocking the brain-based foundations of virtue and character. But these claims echo similar assertions from a century ago, many of which were eventually discarded as quackery, eugenics or misguided pseudoscience. Then the power of phrenology was touted, and machines like the “Psycograph” were offered to “thoroughly and accurately” measure “the powers of intellect, affect and will.” Today similarly expansive claims are being made for color-coded functional magnetic resonance imagery. Are we facing true scientific triumph or mere recycled hyperbole? This presentation will explore the historical echoes of today’s most extravagant claims in the field of neuroscience, and analyze how our actual understanding of mental functioning compares to the hopeful assertions that are filling both the lay press and scientific journals.
Jeff Kullgren, MD, MS, MPH
Assistant Professor, Internal Medicine
Consumer Behaviors among Americans in High-Deductible Health Plans
More than 1 in 3 Americans with private health insurance now face high out-of-pocket expenditures for their care because they are enrolled in high-deductible health plans (HDHPs), which have annual deductibles of at least $1,300 for an individual or $2,600 for a family before most services are covered. Though it is well known that HDHPs lead patients to use fewer health services, what is less known is the extent to which Americans who are enrolled in HDHPs are currently using strategies to optimize the value of their out-of-pocket health care spending such as (1) budgeting for necessary care, (2) accessing tools to select providers and facilities based on their prices and quality, (3) engaging clinicians in shared decision making which considers cost of care, and (4) negotiating prices for services. Such strategies could be particularly helpful for people living with chronic conditions, who are even more likely to delay or forego necessary care when enrolled in an HDHP. In this seminar we will examine these issues and review preliminary results from a recent national survey of US adults enrolled in HDHPs that aimed to determine how often these strategies are being utilized and how helpful patients have found them to be, which patients choose to use or not use these strategies and why, and identify opportunities for policymakers, health plans, and employers to better support the growing number of Americans enrolled in HDHPs.