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Announcement of Position: Faculty Ethicist

Announcement of Position: Faculty Ethicist


Background
The Clinical Ethics Service within the Center for Bioethics and Social Sciences in Medicine (CBSSM) promotes a culture of patient-centered excellence by performing a comprehensive set of ethics-related activities. The aims of this service are to: liaise with and provide support to the adult and pediatric ethics committees; provide clinical ethics consultation and engage in preventative ethics endeavors; assist with ethics-related policy development on a regular and proactive basis; organize and administer structured educational programs in clinical ethics; and coordinate empiric research with relevance to clinical ethics within CBSSM.

Program Organization
The Clinical Ethics Service is led by Christian J. Vercler, MD MA and Andrew G. Shuman, MD. A dedicated clinical ethicist will manage the program on a daily basis. A cadre of faculty ethicists will rotate on service throughout the year and work closely with the clinical ethicist. Trainees and students will rotate as well. Dedicated administrative support is organized through CBSSM.


Position
The Clinical Ethics Service employs a roster of faculty ethicists who are responsible for staffing ethics consultations arising from any of the clinical venues (inpatient and outpatient; adult and pediatric) within Michigan Medicine during their time on service. They will supervise and participate in the institutional educational endeavors and preventative ethics rounds in a regular and on-going manner. Faculty ethicists will also develop and provide clinical rotations for medical students and house officers on a cohesive ethics service. Each faculty member will be expected to rotate on service for four to six weeks per year, and attend/participate in committee meetings and other events throughout the academic year (this will not necessarily require suspension of other activities when on-service). Depending on the total number appointed, each faculty ethicist will receive $15,000-$20,000 of direct salary support annually, to be distributed and allocated in conjunction with their home department. The initial appointment will last two and a half years and is renewable. Additional appointments will last two years.


Qualifications
Candidates are expected to have faculty appointments at University of Michigan and be in good academic standing; any professional background is acceptable. Candidates are expected to have qualifications that meet the standards outlined by The American Society for Bioethics and Humanities (ASBH) for accreditation for clinical ethics consultants. Direct experience with clinical ethics consultation is required. Familiarity with ethics education and related clinical research would be helpful. Excellent organizational and communication skills across multidisciplinary medical fields are required.


Application Process
Candidates will be vetted and chosen by a selection committee. Candidates are asked to submit:

  • Curriculum vitae or resume
  • One page maximum summary of (1) education/training related to ethics consultation; (2) clinical ethics consultation experience; and (3) motivation/interest in the position
  • Letter of support from Department Chair/Division Head/Center Director or equivalent
  • Submit formal application via email to: lynnam@med.umich.edu


Timeline

  • Application is due September 25, 2017
  • Appointment will take effect January 1, 2018

Contacts

  • Leaders of the Clinical Ethics Service: Christian J. Vercler, MD MA & Andrew G. Shuman, MD
  • Administrative contact: Valerie Kahn – valkahn@med.umich.edu 734 615 5371

Adult Ethics Committee

The Michigan Medicine Committee advisory groups are appointed by the Hospital's Office of Clinical Affairs. They review ethical or moral questions that may come up during an adult patient's care. The consultants facilitate communication among adult patients, their families and the treatment team to assist everyone in making appropriate choices when difficult decisions need to be made. The Committee's goal is to help everyone decide the right thing to do. The Michigan Medicine Adult Ethics Committee is a sub-committee of the Executive Committee on Clinical Affairs as determined by the Medical Staff Bylaws.

About Us

Sometimes patients, families and staff have very difficult choices and ethical questions they need to talk about. Discussions with the Ethics Committee can be helpful and reassuring when a difficult choice must be made (for example, questions on end-of-life care, or issues of confidentiality). The goal of the Committee is to facilitate communication among adult patients, their families and the treatment team to assist everyone in making appropriate choices, as well as to assist Michigan Medicine in complying with ethical regulatory standards, when difficult decisions need to be made. The Committee provides consultation to the treatment team, patients and families on ethical, moral or philosophical problems and issues encountered in the course of managing inpatient and outpatient care.

Committee members include physicians, residents, nurses and social workers, as well as medical students, an attorney/compliance officer, a chaplain, a medical ethics professor and members from the community.

The Adult Ethics Committee meets on the third Tuesday of the month, form 12-1:30pm, at University Hospital in dining room D, if you would like to attend as a guest, please contact Amy Lynn @ lynnam@med.umich.edu

What happens when a meeting with the Ethics Committee is requested?

The consultants on call review the patient's medical situation and treatment options. In addition, concerns and feelings of the patient, family members, and the health care team are discussed. Members of the committee may visit with patients, families and medical personnel to discuss these concerns.

Ethics Committee members discuss the information which has been gathered. The Ethics Committee makes suggestions about the best course of action. Often there are a number of options available in the course of a patient's care. Final decisions are made by the patient, family and the health care team.

Request a Consult

Monday-Friday
8:00 a.m. - 5:00 p.m. Call 734-615-1379
After normal business hours, please call 936-6267 and ask for the clinical ethicist on call to be paged.

Resources

Financial Assistance

Non-Beneficial Treatment

Advance Directives

Committee Bylaws

 

For upcoming Bioethics Grand Rounds see Events

Pediatric Ethics Committee

The Michigan Medicine Committee advisory groups are appointed by the Hospital's Office of Clinical Affairs. They review ethical or moral questions that may come up during a pediatrics patient's care. The consultants facilitate communication among patients, their families and the treatment team to assist everyone in making appropriate choices when difficult decisions need to be made. The Committee's goal is to help everyone decide the right thing to do. The Michigan Medicine Ethics Committee is a sub-committee of the Executive Committee on Clinical Affairs as determined by the Medical Staff Bylaws. 

About Us


The committee is available for consultation to family members, patients, staff, and health care providers. The committee may help you and your child’s medical team clarify facts, examine ethical issues, and assist in the resolution of disagreements about your child’s care. The committee includes people with additional training in medical ethics, doctors, nurses, social workers, a lawyer, a chaplain, an administrator, and members of the community
The University of Michigan has a Pediatric Ethics Committee because the best medical care requires not only medical skill but good moral judgment. The Committee’s main purpose is to offer help and guidance on moral and ethical questions, such as:

  • Should treatment be started or stopped?
  • How much should a child be told about his or her disease?
  • Is the promise of treatment worth the suffering it may cause?
  • What is the best thing to do when we must face the end of life?
  • What happens when a meeting with the Ethics Committee is requested?

The consultants on call review the patient's medical situation and treatment options. In addition, concerns and feelings of the patient, family members, and the health care team are discussed. Members of the committee may visit with patients, families and medical personnel to discuss these concerns.

Ethics Committee members discuss the information which has been gathered. The Ethics Committee makes suggestions about the best course of action. Often there are a number of options available in the course of a patient's care. Final decisions are made by the patient, family and the health care team.

The Pediatric Ethics Committee meets on the first Tuesday of the month from 12-1:30pm at University Hospital in dining rooms C&D. If you would like to attend as a guest, please contact Amy Lynn @ lynnam@med.umich.edu

Request a Consult

Monday-Friday
8:00 a.m. - 5:00 p.m. Call 734-615-1379
After normal business hours, please call 936-6267 and ask for the clinical ethicist on call to be paged.

Resources

Financial Assistance

Non-Beneficial Treatment

Committee Bylaws

 

For upcoming Bioethics Grand Rounds see Events

 

Funded by VA Health Services Research and Development Career Development Award

Funding Years: 2015-2019

Heart attack and stroke, which together are called cardiovascular disease, cause over 1/3 of all deaths in VA patients. The current guidelines for the prevention of these conditions focus on lowering patients'blood pressure and cholesterol levels. A new treatment strategy, which I call benefit-based tailored treatment, that instead guides treatment decisions based on the likelihood that a medication would prevent a heart attack or stroke could prevent more cardiovascular disease, with lower medication use, and be more patient centered. The purpose of this Career Development Award is to develop and assess tools and approaches that could enable the implementation of benefit-based tailored treatment of cardiovascular disease, in particular a decision support tool and educational program for clinicians and a performance profiling system. The decision support tool will enable better care by showing clinicians patient-specific estimates of the likelihood that their medication decisions will prevent a cardiovascular disease event. The performance profiling system will encourage better care by assessing the quality of care provided at VA sites and in PACT teams based on how well the medical care provided follows this treatment strategy. The project will have three aims:
Aim 1 : In the first aim, I will seek to understand clinicians' and patients' perceptions of and receptivity to the use of benefit-based tailored treatment for cardiovascular disease. Information gained from qualitative research with clinicians will help assess and improve the usability and effectiveness of the decision support tool and educational program for clinicians, along with the acceptability of the treatment strategies in general. Information gained from focus groups with patients will help learn their priorities in cardiovascular disease prevention, to help identify ways to make the interventions and their assessments more patient-centered.
Aim 2 : In the second aim, the decision support tool and educational program will be assessed in a real-world randomized pilot study involving thirty clinicians. Half of the clinicians will be provided the decision support tool and education intervention for ten patients each, the other half will receive a traditional quality improvement program and treatment reminders. The study will have formative goals of ensuring that clinicians and patients believe the tool is valuable and does not disrupt care processes or workflow for anyone in the PACT team. This will be studied with qualitative and survey assessments. The primary summative outcome will be the influence of the intervention on clinicians'treatment decisions. Secondary outcomes will assess patients'satisfaction with their visits and their clinicians.
Aim 3 : The third aim will develop and evaluate a novel performance measurement system based on benefit- based tailored treatment. First, the performance profiling system will be developed. Then the profiling system's ability to reliably differentiate high quality from low-quality care will be evaluated.

PI: Jeremy Sussman

David Sandberg, PhD

Faculty

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.

Last Name: 
Sandberg

Investigator(s)

Conference

Title of Talk/Poster

Ray De Vries

Lisa Harris

et al.

American Society for Bioethics & Humanities (ASBH)

Annual Meeting

 

“Mundane Reproductive Ethics: Beyond the Sensational Lie"

 

"Everyday Ethical Problems in Abortion, In Vitro Fertilization, Pregnancy Planning, and Birth"

 

Ray De Vries

Susan Goold

et al.

American Society for Bioethics & Humanities (ASBH)

Annual Meeting

 

“Learning about Learning from the Public: A Workshop about Methods of Public Engagement on Ethical Issues in Biomedical Research, Health, and Health Care"

 

Angela Fagerlin

et al.

Society for Medical Decision Making (SMDM) Annual Meeting

 

“Minority Cancer Survivors' Perceptions and Experience with Cancer Clinical Trials Participation"

Angela Fagerlin

Andrea Fuhrel-Forbis

Sarah Hawley

Holly Witteman

et al.

 

Society for Medical Decision Making (SMDM) Annual Meeting

“Preferences for Breast Cancer Chemoprevention"

Angela Fagerlin

Andrea Fuhrel-Forbis

Brian Zikmund-Fisher

et al.

Society for Medical Decision Making (SMDM) Annual Meeting

 

“Informed Decision Making About Breast Cancer Chemoprevention: RCT of an Online Decision Aid Intervention"

Angela Fagerlin

Valerie Kahn

et al.

Society for Medical Decision Making (SMDM) Annual Meeting

 

“Literacy and Numeracy in Veterans and Their Impact on Cancer Treatment Perceptions and Anxiety"

Angela Fagerlin

Laura Scherer

et al.

Society for Medical Decision Making (SMDM) Annual Meeting

 

“Anxiety as an Impetus for Action: On the Relative Influence of Breast Cancer Risk and Breast Cancer Anxiety on Chemoprevention Decisions"

Angela Fagerlin

Laura Scherer

et al.

Society for Medical Decision Making (SMDM) Annual Meeting

 

“Literacy and Irrational Decisions: Bias From Beliefs, Not From Comprehension"

Angela Fagerlin

Holly Witteman

Brian Zikmund-Fisher

et al.

Society for Medical Decision Making (SMDM) Annual Meeting

 

“Integers Are Better: Adding Decimals to Risk Estimates Makes Them Less Believable and Harder to Remember"

Andrea Fuhrel-Forbis

Holly Witteman

Brian Zikmund-Fisher

et al.

Society for Medical Decision Making (SMDM) Annual Meeting

 

“Avatars and Animation of Risk Graphics Help People Better Understand Their Risk of Cardiovascular Disease"

Holly Witteman

Brian Zikmund-Fisher

et al.

Society for Medical Decision Making (SMDM) Annual Meeting

 

 

“If I'm Not High Risk, Then That's Not My Risk: Tailoring Estimates for Low-risk Patients May Undermine Perceived Relevance"

 

Brian Zikmund-Fisher

et al.

Society for Medical Decision Making (SMDM) Annual Meeting

“The Effect of Narrative Content and Emotional Valence on Decision About Treatments for Early Stage Breast Cancer"

 

2018 Bishop Lecture featuring Barbara Koenig, PhD

Tue, May 01, 2018, 11:15am
Location: 
Henderson Room, Michigan League, 911 N. University Avenue, Ann Arbor, MI

The 2018 Bishop Lecture in Bioethics was presented by Barbara Koenig, PhD, Professor of Bioethics and Medical Anthropology and Director of UCSF Bioethics at the University of California, San Francisco. Professor Koenig presented a talk entitled, " Does Enhancing Individual Choice and Control Promote Freedom? Challenges in Contemporary Bioethics." The Bishop Lecture serves as the keynote address during the CBSSM Research Colloquium.

Abstract: Over the past three decades, the discipline of bioethics has advocated for enhanced patient choice and control over a range of medical decisions, from care near the end of life to participation in clinical research. Using two current policy challenges in California—1) the advent of legally sanctioned medical aid in dying and, 2) efforts to share UC Health “big data” from the electronic health record in research with private sector partners—Professor Koenig will explore how current bioethics practices may unintentionally and ironically impede our shared goals of promoting human freedom.

Barbara A. Koenig, PhD is Professor of Bioethics and Medical Anthropology, based at the Institute for Health & Aging, University of California, San Francisco. She is the Director of “UCSF Bioethics,” a nascent program that spans ethics research, clinical ethics, and ethics education across the university’s four professional schools. Prof. Koenig pioneered the use of empirical methods in the study of ethical questions in science, medicine, and health. Prof. Koenig’s current focus is emerging genomic technologies, including biobanking policy and using deliberative democracy to engage communities about research governance. Her work has been continuously funded by the National Institutes of Health since 1991. Currently, she: 1) directs the ELSI component of a NICHD award focused on newborn screening in an era of whole genome analysis, 2) is P.I. of UCSF’s Program in Prenatal and Pediatric Genomic Sequencing (P3EGS), part of the CSER2 national network, and, 3) is supported by NCI to conduct an “embedded ethics” study of the Athena “Wisdom” PCORI-funded clinical trial of genomic risk-stratified breast cancer prevention. Previously, she directed an NHGRI-funded “Center of Excellence” in ELSI Research. Prof. Koenig was the founding executive director of the Center for Biomedical Ethics at Stanford University; she created and led the Bioethics Research Program at the Mayo Clinic in Rochester, Minn. She received her Ph.D. from the University of California, Berkeley and San Francisco joint program in Medical Anthropology. She is an active participant in policy, having served on the ethics committee that advises the director of the CDC and the Department of Health and Human Services “Secretary’s Advisory Committee on Genetic Testing.” She recently served on a state-wide “Health Data Governance Task Force” which advised UC’s president.

Click here for the video recording of the 2018 Bishop Lecture.

Supporting information for: 2018 CBSSM Research Colloquium and Bishop Lecture (Barbara Koenig, PhD)

Parent Perceptions of Antenatal Consultation for Extreme Prematurity
Presenter: Stephanie Kukora, MD
 

Co-authors: Naomi Laventhal, MD, MA; Haresh Kirpilani, MD; Ursula Guillen, MD
 

Antenatal consultation (AC) for extreme prematurity is routine in neonatology practice, but questions remain about how best to meet the needs of expectant parents. Decision-aids have demonstrated improvement in communication of statistical outcomes, but whether they are uniformly helpful in AC, and whether provision of outcome data is essential to shared decision-making in the AC encounter remains uncertain.

To characterize the experience of parents threatened with extreme prematurity between 22 and 25 weeks gestation who received AC, identify aspects that parents perceived as favorable or unfavorable, and identify areas for improvement.

We analyzed free text responses of expectant parents enrolled in a multi-center randomized trial evaluating the use of a validated decision-aid (DA) compared to standard counseling. Qualitative thematic analysis of responses identified items valued for decision-making about delivery room resuscitation.

 201 parents were enrolled; 126 provided substantive free-text comments. 45 (36%) parents described their counseling experience positively.  31 (25%) reported a negative experience, and 23 (18%) offered suggestions for improvement.  Desire for a tailored approach was a major theme reported by many parents, with subthemes of too much or too little information, facts vs values-based counseling, and diverse learning styles.  Another major theme was shared decision-making. Subthemes included:  good or poor understanding of the decision/options; trust; parent engagement, feeling supported in decision-making.  Need for clinician sensitivity also emerged as a major theme, with subthemes of hope, thoughtful timing of AC, and identification and support of parents’ stress and emotions. 31 parents receiving AC with the DA (n=102) commented that visual depiction of the statistical information helpful.

Many parents expressed that factual information about outcomes was influential to their decisions, but some parents dislike this approach.  In addition to tailoring how and what information is communicated during AC, clinicians should be sensitive to parents’ individual needs in this context.

 

Hospice Care Quality in U.S. Nursing Homes Reported by Patients and Caregivers in Yelp Reviews

Presenter: Chithra Perumalswami, MD, MSc
 

Co-authors: Jayme Laurencelle, MD; Shawna O’Reilly, MD; Jennifer Griggs, MD, MPH; Raina Merchant, MD, MSHP
 

Background: The need to assess the quality of hospice care provided in nursing homes is a national priority. Patients and caregivers often utilize online forums such as Yelp to informally report on the experience of their healthcare episodes. These narratives are a unique data source and may provide valuable insights into the quality of care provided in U.S. nursing homes at the end of life.

Objective: To explore the content of Yelp reviews of nursing homes providing care at the end of life, specifically utilizing quality measures for palliative and hospice care determined by the National Quality Forum (NQF).

Methods: We performed a qualitative content analysis of 3421 Yelp reviews.  The reviews were double coded and the final coding scheme incorporated concepts from all of the NQF domains. Larger themes were determined by consensus.

Results: Four themes were identified: 1) staff interpersonal expertise (empathic characteristics and effective communication), 2) staff technical competence (expertise in skills, staff attention, and efficiency of response), 3) systems issues (physical facility characteristics and cleanliness), and 4) patient wellbeing (physical and emotional wellbeing, family trust and confidence in care).

Conclusion: Yelp reviews of nursing homes providing hospice identify concepts that are mostly congruent with the current NQF domains. Medicare uses the NQF domains and preferred practices in the Hospice Quality Reporting Program (HQRP) to measure and report on quality. Utilizing Yelp reviews may help to identify additional quality measures, including a more nuanced view of aspects of quality of care in nursing homes at the end of life. Future research should focus on how to make such unprompted narratives more accessible and on how to incorporate additionally identified concepts regarding quality into the HQRP.


Impact of MCI on Patient and Care Partner Preferences and Physician Decision Making for Cardiovascular Treatment

Presenters: Bailey Reale, MPH; Emilie Blair
 

Co-authors: Darin Zahuranec, MD, MS; Kenneth Langa, PhD;  Jane Forman, ScD, MHS; Bruno Giordani, PhD; Brenda Plassman, PhD; Kathleen Welsh-Bohmer, PhD; Colleen Kollman, MBA; Deborah Levine, MD, MPH
 

Background: The leading cause of death for the 5.4 million older adults with mild cognitive impairment (MCI) in the US is cardiovascular disease (CVD). Despite this, patients with pre-existing MCI may receive fewer treatments for CVD events such compared to cognitively normal patients. We conducted interviews of patients, care partners, and physicians to understand how MCI influences decision making for CVD treatments.

Methods: Qualitative study based on in-depth, semi-structured, in-person interviews with patient-care partner dyads (n=23) and physicians (n=18) using a standard guide. We used qualitative content analysis to identify unifying and recurrent themes. We gathered reflections on data suggesting neurologists recommend fewer treatments for stroke to older adults with MCI and elicited how MCI influences patient-care partner preferences for 5 common CVD treatments. We also sought to understand how a patient’s having MCI influenced physicians’ decisions to recommend these 5 CVD treatments.

Results: Most MCI patients, cognitively normal patients, and their care partners wanted all 5 stroke treatments (Table 1). Participants reported several factors affecting their decision-making for treatment (Table 1). Some participants thought that physicians might recommend fewer stroke treatments to patients with pre-existing MCI because physicians have biases about MCI patients (Table 1).

Most physicians described MCI as influencing their recommendations for CVD treatments in at least one of five ways (Table 2). Physicians reported recommending CVD treatments less to MCI patients due to their assumptions about the MCI patients and MCI itself (Table 2).

Conclusions: MCI patients have similar preferences for treatments for CVD events as do cognitively normal patients, yet physicians often recommend these treatments less often to MCI patients. We need to better understand how physician recommendations contribute to potential underuse of effective CVD treatments in MCI patients in order to improve the quality of CVD care for this large and growing population.


It’s all about Context: A Mixed-Methods Study of Institutional Review Board’s Local Context Assessment
Presenter: Adrianne Haggins, MD


Co-authors: Deneil Harney; Sacha Montas, MD, JD; Joy Black, BSN, MS; Neil Dickert, MD, PhD; Timothy Guetterman, PhD; Michael Fetters, MD; Robert Silbergleit, MD


Background: Local context assessment ostensibly allows review boards to closely consider the potential impact to study populations, the institution, and local laws and regulations.  Given the trend toward utilization of central review boards for multicenter trials, a better understanding of single institution review board assessment processes are needed.

 Objective: To explore how local context assessments in multicenter trials are made by single institution review boards.

Methods: We used a mixed methods approach to explore attitudes and perceptions of key stakeholders.  We elicited stakeholder perspectives by observing, and audiotaping IRB deliberations of trials conducted under exception from informed consent (EFIC). In-depth semi-structured interviews (n=26) and an online survey (n=80, response rate=13%) were conducted of IRB stakeholders (IRB members, central review board members, regulatory officials, etc.). Two authors independently reviewed the observations and interview transcripts to identify meaningful statements, which were grouped into codes and broader themes.  Descriptive statistics were performed on the survey results.

Results: Deliberations related to local context highlighted the importance of taking into consideration: scientific rigor, community consultation and public disclosure process, as well as local laws/regulations, weighing relative benefit vs. risk, medical standards/practices, concerns of local groups, prior experiences with investigators and within the institution.  Themes from interviews underscored the important role investigators, and IRB community members are expected to play in knowing the local population and community. Top reasons for considering local context included: knowing about community concerns, showing respect for local public, and the influence of local laws/ordinances on clinical care.

Conclusion: Local context assessment provides a mechanism to ensure research and investigators are perceptive to the concerns and impact on the broader community. A wide variety of factors are considered. To further inform central review processes, future research is needed to differentiate which factors are essential for a high-quality local context assessment.   


Does Enhancing Individual Choice and Control Promote Freedom? Challenges in Contemporary Bioethics

Bishop Lecture Keynote Presenter: Barbara Koenig, PhD
 

Over the past three decades, the discipline of bioethics has advocated for enhanced patient choice and control over a range of medical decisions, from care near the end of life to participation in clinical research. Using two current policy challenges in California—1) the advent of legally sanctioned medical aid in dying and, 2) efforts to share UC Health “big data” from the electronic health record in research with private sector partners—Professor Koenig will explore how current bioethics practices may unintentionally and ironically impede our shared goals of promoting human freedom.

 

Bioethics Grand Rounds

Wed, September 28, 2016, 12:00pm
Location: 
UH Ford Amphitheater & Lobby

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.

Bioethics Grand Rounds: Paul Lichter, MD

Wed, November 30, 2016, 12:00pm
Location: 
UH Ford Amphitheater & Lobby

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.

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