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James Burke, MD

Faculty

Jim Burke, M.D. is a neurologist who completed residency and a stroke fellowship at the University of Michigan. His undergraduate degree is from the University of Notre Dame and his medical degree from the Loyola University Stritch School of Medicine. He is interested in understanding how physicians use the complex information acquired from modern diagnostic tests and improving decisions to order such tests.

Research Interests: 
Last Name: 
Burke

Bioethics Grand Rounds - Dr. Michael Jibson

Wed, August 26, 2015, 12:00pm
Location: 
Ford Auditorium

This month's grand rounds features: Michael Jibson, MD, Psychiatry Department speaking about "Psychiatry, Law, and Society: Ethical and Legal Issues in Mental Health"

Lunch provided!

Please join us for a lively discussion of medical ethics. The Bioethics Grand Rounds is co-sponsored by the Center for Bioethics and Social Sciences in Medicine, the UMHS Adult and Pediatric Medical Ethics Committee, and the Program of Society and Medicine. This educational session is open to all faculty and staff and members of the public. CME credit is available. 

To meet ACCME requirements for Faculty Planner disclosure and Presenter Disclosure to participants of CME activities at UM, please be advised that the following faculty planner(s)/co-planner(s) and presenter have no personal financial relationships relevant to the activity listed below:
Planners: 

  • Andrew Shuman, MD
  • Christian Vercler, MD

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.

Bioethics Grand Rounds: “Examining the Ethics of Victors Care”

Wed, February 28, 2018, 12:00pm
Location: 
Univerisity Hospital Ford Auditorium

Michigan Medicine has launched Victors Care, a concierge medical care model designed to deliver increased access, convenience and individually-tailored support within a primary care practice for patients who pay for membership. Like all concierge care programs, Victors Care raises ethical issues relating to justice, fairness, access, and consistency with the mission of Michigan Medicine. This Bioethics Grand Rounds will address the ethical issues of concierge care in a panel format with institutional leaders. The panel will address your questions directly. Questions will be solicited during the session, and can be submitted in advance via: https://umichumhs.qualtrics.com/jfe/form/SV_b4nJWM70ahHQtjD.

Panelists
Marschall S. Runge, M.D., Ph.D., EVPMA and Dean
Reshma Jagsi, M.D., D.Phil, Director, Center for Bioethics and Social Sciences in Medicine
David J. Brown, M.D., Associate Vice President and Associate Dean for Health Equity and Inclusion

Facilitators
Andrew Shuman, M.D., F.A.C.S & Christian J. Vercler, M.D, M.A, F.A.C.S – Service Chiefs, Clinical Ethics Service, Center for Bioethics and Social Sciences in Medicine

The University of Michigan School of Public Health has received federal funding to launch an integrated, interdisciplinary fellowship program that will provide training in the ethical, legal, and social implications (ELSI) of genomic science.

Led by Scott Roberts, professor of health behavior and health education at Michigan Public Health, the ELSI Research Training Program is funded by a T32 training grant from the National Institutes of Health’s National Human Genome Research Institute and will launch in fall 2018. Raymond De Vries, Wendy Uhlmann, Brian Zikmund-Fisher, Jodyn Platt, Kayte Spector-Bagdady are among the faculty who will serve as faculty mentors.

More information can be found here.

Research Topics: 

Bioethics Grand Rounds "Clinical Innovations Near the Boundary of Viability- The Artificial Placenta"

Wed, September 26, 2018, 12:00pm
Location: 
Univerisity Hospital Ford Auditorium

Ryan Antiel, MD, MSME, Department of General Surgery, Biomedical Ethics Program, Mayo Clinic

Extreme prematurity is the leading cause of infant death and morbidity.  The urgent need for a better way to support the extremely premature infant led to the development of an extrauterine system to better bridge the transition from fetal to postnatal life.  The goal of this “artificial womb” is to maintain prenatal physiology in the extremely premature neonate to support normal development and reduce the complications associated with prematurity.  In this presentation, we will discuss the development and applications of the artificial womb, as well as the limitations of this technology.  We will focus on three current ethical challenges: ectogenesis, the boundary of viability, and the difference between physiological and clinical success.  
 

Bioethics Grand Rounds -Alexander Langerman, MD

Wed, December 19, 2018, 12:00pm
Add to Calendar
Location: 
Univerisity Hospital Ford Auditorium

"Transparency in Surgery"

 

The operating room shifted over the last century from a historically open "theatre" to a sequestered space, and the proceedings of surgery became a mystery to those outside the surgical profession. The more recent and increasing societal interest in transparency suggests  professions such as surgery must develop new strategies to engender trust and inform the public and patients about what happens behind closed doors. Simultaneously, video and sensor technology has evolved to enable ubiquitous recording and analysis of surgical activities, creating a new source of data and the potential to reinstate a virtual surgical theatre. Such openness of a previously hidden space has implications for patients and surgical teams. This presentation will discuss the important ethical, technological, and regulatory considerations and challenges of a transition to greater transparency in surgery.

 

 

Supporting information for: 2011 CBSSM Research Colloquium

A bureaucratic framework of IRBs: Understanding how cultural forces influence the contemporary IRB bureaucracy

Presenting author: Apurba Chakrabarti, Undergraduate Student, University of Michigan

The Institutional Review Board (IRB) system is almost universally considered dysfunctional. Numerous commentators accuse IRBS of both over-regulation and inadequate protection.  Understanding IRBs within a bureaucratic framework provides a theoretical lens to analyze the genesis and persistence of failings in academic IRBs.  While some authors have used legal approaches, there has been little analysis of the influence of culture on the IRB bureaucracy.  Additionally, there is an absence of literature using the sociology of IRBs approach, where IRBs act as a model to understand bureaucracies in the general terms of organizational theory.  Accordingly, this paper will show that 1) IRBs are a Weberian bureaucracy, 2) a bureaucratic framework of IRBs explain why the contemporary IRB system has a procedural focus and censors research, and 3) IRBs can illustrate new dimensions about how culture influences bureaucracy, as posited in regulation, such as community sensitivity.  This failure is a result of culture-induced goal displacement.  The bureaucratic IRBs respond to the American distrust of government by avoiding real ethics debates and instead have a particularly high focus on more “objective” procedure and paperwork.  Furthermore, a combination of a culture of fear and an expectation of infallible regulatory bodies influences bureaucracies to censor ethically sound, but legally risky research in an effort to protect bureaucratic reputation and prevent legal liability. These examples illustrate how subtle cultural forces influence organizations, as postulated in neoinstitutional theory.  A bureaucratic framework helps address the influence of culture on the IRB bureaucracy, and informs ideas for reform that must not only consider legal and legislative issues, but cultural forces that molded the contemporary IRB system.

Apurba Chakrabarti is a fourth-year undergraduate at the University of Michigan studying cellular and molecular biology.  He is completing an honors thesis in retinal patterning in zebrafish at the Raymond lab in the Department of Molecular, Cellular, and Developmental Biology.  His interests also extend into the social forces influencing the practice of research, including the organization of science and the flaws in the contemporary IRB system.

 

Online sexual racism and the prevalence of HIV among black MSM

Presenting author: Nathaniel Coleman, Graduate Student, University of Michigan

The Sydney-based campaign, www.SexualRacismSux.com, is a unique worldwide campaign against online sexual racism (OSR) among men who have sex with men (MSM).  Sexual racism (SR) is a form of social segregation on the basis of race.  Like all forms of social segregation, SR has two faces: that of exclusion (= spatial segregation) and that of exploitation (= role segregation).  Exclusionary SR consists of the race-based denial of sexual approbation or activity.  For instance, some MSM declare in their online profiles that they are “not into” blacks, or that they will accept “no blacks” for sex.  Exploitative SR consists of the offer of sexual approbation or activity, but only on racially stigmatizing terms.  For instance, some MSM offer sex to blacks only if those blacks fulfill the “ethnosexual stereotypes” of the “Black Mandingo” and the “Savage black top.”  SR reduces a black MSM’s freedom to define himself sexually, for he is restricted to either (a) no sex at all, (b) sex only with others similarly excluded and exploited, or (c) sex only in which he “plays along with” ethnosexual stereotypes.  Option (a) denies a black MSM a basic human function.  Option (b) renders the sexual networks of black MSM relatively more tightly interconnected such that if HIV enters one part of the network, it is likely to spread more rapidly throughout.  Option (c) causes a black MSM who can’t or won’t perform ethnosexual stereotypes to experience low sexual self-confidence.  He is likely to consider himself to have inferior “bartering power” in the marketplace for sex with MSM.  This may cause him (a) to offer unprotected anal intercourse (UAI) as a unique selling proposition, or (b) to give in more readily to demands to engage in UAI.  This argument suggests that those who wish to halt the disproportionately high prevalence of HIV among black MSM should collaborate with www.SexualRacismSux.com.

Nathaniel Adam Tobias Coleman is a doctoral candidate in moral, social, and political philosophy at the University of Michigan.  He is a Fellow at the University of Michigan’s Center for Ethics in Public Life, a member of the Society for the Philosophy of Sex and Love, and a member of the Society for the Scientific Study of Sexuality.  Nathaniel is working under the supervision of Prof. Elizabeth Anderson.  His doctoral dissertation is entitled, The Duty to Miscegenate: From Sexual Racism to Cross-racial Companionship.  

 

Temptation and trespass in the pharmaceutical industry: Incentivizing ethical self-regulation

Presenting author: Henry Greenspan, PhD, University of Michigan

Certain structural features of the pharmaceutical industry are conducive to ethical trespass: the difficulty of developing successful new drugs; the limited time of patent exclusivity; the “blockbuster model” in which most companies rely on a very small number of drugs for a large percentage of annual sales; and the “evidence-free zone” (Gale) between product launch and before many potential adverse effects are shown. Within this business model, companies are induced to “make hay while the sun shines,” and many of the best known ethical problems follow: marketing violations like promotion for unapproved and unproven applications; failure to flag or investigate suspected problems; selective publication; tendentious research design; collusion with corruptible healthcare professionals; and, occasionally, outright data suppression and fraud.  In the meantime, studies show that most external sanctions - including criminal penalties, FDA surveillance, and product liability lawsuits - are relatively ineffective deterrents, and they always arise after the damage is done.  We have no choice, therefore, but to rely primarily on company self-regulation.  A company will always know more, and know sooner, about its products than any external regulator and draconian external sanctions only make it more likely for a company to externalize regulation on to “the cop,” which consistently results in ethical disaster (Braithwaite).  So the question becomes how to positively incentivize companies’ ethical self-regulation.  A number of potential avenues will be suggested, including “perks” like extended patent protection; ethical ratings of companies that have real-world consequences (in preferential contracts with pharmacy benefit managers, for example, along the model of “no sweat” apparel contracts); and the impact of a documented record of ethical excellence on employee productivity and consumer (including physician) loyalty.

Henry Greenspan, PhD, is a psychologist and playwright in UM's Residential College who has been writing and teaching about the Holocaust and other genocides for almost three decades. His most recent book is On Listening to Holocaust Survivors: Beyond Testimony, a second and expanded edition of the 1998 On Listening. This past January he co-led the "Hess Seminar for Professors of Holocaust Course" at the United States Holocaust Museum, the sixth such seminar the museum has offered. He was appointed Fulbright Visiting Research Chair at Concordia University in Montreal for Winter 2012. In between, he has been teaching about ethics, politics, and pharma for the past eight years and organized some of the Health Policy Forum programs on pharma-related topics. 

 

Obstetrician-gynecologists’ objections to and willingness to help patients obtain abortion in various clinical scenarios: A national survey

Presenting author: Lisa H. Harris, MD, PhD, University of Michigan

Co-authors: Farr Curlin, MD, University of Chicago; Ken Rasinski, PhD, University of Chicago; Alexandra Cooper, PhD, Duke University; Anne Drapkin Lyerly, MD, MA, University of North Carolina

Background: Despite debate about abortion ethics and conscientious objection, we know little about obstetrician-gynecologists’ views, or their manifestation in clinical practice.  Methods: We analyzed results of a national survey of 1800 U.S. obstetrician-gynecologists.  We presented respondents with seven scenarios in which a woman sought abortion.  For each, we asked if respondents morally object, and if they would help the patient obtain an abortion.  We analyzed demographic correlates of objection and assistance.  Results: Objection varied by scenario, from 82% in the case of sex selection to 16% in a patient with a potentially fatal cardiopulmonary condition.  Female ob-gyns were more likely to object to abortion in one or more scenarios (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.0 to 2.3). excluding sex selection, objection was less likely in female(OR 0.66, 95% CI 0.49-0.89) and Jewish ob-gyns (OR 0.3; CI 0.1-0.8), and more likely among those practicing in the South or Midwest (OR 1.8, CI 1.2-2.7; OR 2.0; CI 1.3-3.0), who had Catholic or Protestant-evangelical affiliation (OR 2.6, CI 1.6-4.1; OR 4.0, CI 2.4-10), or who indicated religion was fairly, very, or most important in their life (OR 1.7, CI 1.0-2.8; OR 3.4, CI 2.1-5.6; OR 14.9, CI 7-31.4).  With the exception of sex selection, more than 80% would help a patient obtain abortion in all scenarios.  Approximately two-thirds (57-70%) of objecting ob-gyns would help the patient obtain abortion, regardless of scenario.  Excluding sex selection, assistance despite objection was more likely among female ob-gyns (OR 2.1, CI 1.3-3.3), and less likely among those from the South or for whom religion was very important (OR 0.3, CI 0.2-0.6; OR 0.2, CI 0.1-0.6).  Conclusions: Most ob-gyns help patients obtain an abortion even if they have moral objection.  Willingness to help patients varies by clinical context and physician characteristics.

Lisa H. Harris, MD, PhD, is an Assistant Professor in the Department of Obstetrics and Gynecology at the University of Michigan.  She received her MD from Harvard University and completed her residency at the University of California, San Francisco, later obtaining a PhD in American Culture from the University of Michigan.  Dr. Harris has focused her clinical, research, teaching and advocacy career on reproductive justice, reflecting her overarching goal of working at the intersection of medicine, culture, and politics. She also serves on the faculty of the Department of Women’s Studies.

 

The misdiagnosis of the minority problem in cancer clinical trials: Is our focus on medical mistrust causing harm?

Presenting author:  Aisha T. Langford, MPH, University of Michigan

Co-authors: Scott Kim, MD, PhD, University of Michigan

Cancer is the second leading cause of death in the United States and costs the nation approximately $263.8 billion in patient care.  Less than 5% of adults with cancer participate in cancer clinical trials.  Of those who do participate, African Americans are underrepresented despite bearing the greatest cancer burden.  While there are many reasons for lower participation among African Americans, medical mistrust dominates the literature and is often used in reference to the U.S. Public Health Service Syphilis Study at Tuskegee.  Tuskegee did expose structural inequalities and racism in research; however, knowledge of Tuskegee has not been empirically associated with lower enrollment among African Americans, nor can it account for the full range of issues that contribute to medical mistrust.  A person’s experience with the healthcare system and medical providers over time is what increases or reduces trust.  The data suggest that minorities are just as willing to participate in health research when provided equal access.  The Minority-Based Community Oncology Programs and the SELECT trial are prime examples of this.  While mistrust is real, its role may be overstated and a distraction form more pressing issues such as: 1) Access/proximity of clinical trials to minority communities, 2) Patient-provider communication about research, 3) Provider bias in offering clinical trials, 4) Protocol design and eligibility criteria, 5) Better training and rewards for clinical trial faculty/staff, 6)Organizational transparency in research, 7) Community engagement outside of health system walls, and 8) Diversity and cultural competency among healthcare organizations.  Nicholson et al. demonstrated that disparities framed messages have a negative impact on African Americans’ intention to use the healthcare system.  Given this, we should be cautious about perpetuating mistrust assumptions, as they may be causing more harm than good.  Appropriate “solutions” to minority participation are dependent on a correct diagnosis of the underlying problem.

Aisha Langford, MPH, has been the Director of Community Outreach for the U-M Comprehensive Cancer Center since July 2007.  Prior to that time, she held positions in health communications, adult literacy, and public relations.  Ms. Langford holds a Masters Degree in Public Health, Department of Health Behavior & Health Education, from the University of Michigan.  She works with local African American churches and community organizations to implement Body and Soul, a National Institutes of Health/American Cancer Society collaboration to disseminate cancer control interventions.  Ms. Langford also works closely with Cancer Center faculty, staff, and UMHS units as appropriate to enhance health disparities research and participation by under-represented minorities in cancer clinical trials.  She serves on a variety of internal and external committees related to community outreach, minority health, and clinical trials.

 

Innovative therapies in the newborn intensive care unit: The ethics of off-label use of therapeutic hypothermia

Presenting author: Naomi Laventhal, MD, University of Michigan

Co-authors: John Barks, MD, University of Michigan; Scott Kim, MD, PhD, University of Michigan

Neonatologists, like other physicians, are under pressure to use therapies supported by scientific evidence.  In the newborn intensive care unit (NICU) this is an especially thorny issue because seemingly benign but untested treatments have resulted in serious injury, yet the drive to do something for patients at risk for poor outcomes is very strong.  We examine the case of therapeutic hypothermia (TH) for hypoxic-ischemic encephalopathy (HIE), a therapy with demonstrated efficacy for full-term infants in reducing death and disability, but unproven efficacy in pre-term infants.  Clinical trials for pre-term infants are planned; meanwhile guidelines advise against off-label use.  Anecdotal evidence suggests “off-label” TH use may be common.  Here we examine arguments for and against such practices.  Arguments favoring off-label TH use include the lack of alternatives for a disease with terrible outcomes, and the “biologic plausibility” that theses uses TH will be safe and effective. More generally, limiting physicians to therapies supported by randomized control trial (RCT) data would unreasonably constrain clinical practice, and “innovative” practices can be an important driver of progress.  But even if parents are fully informed of the uncertain benefits, this may not be a “nothing to lose” scenario.  Surviving infants treated with off-label TH may have a higher incidence of severe neurologic impairment; this redistribution of poor outcomes may be unacceptable to parents and neonatologists alike.  Premature infants treated with TH may also be more vulnerable to the serious potential adverse effects and have greater mortality. From a societal standpoint, off-label TH use may delay completion or compromise quality of RCTs, resulting in pre-term infants with HIE undergoing risky, ineffective treatment unnecessarily.  We believe that arguments against off-label use of TH are stronger than those favoring it, given the individual and societal risks.  Using this case study, we will discuss a general framework for dealing with “innovative” therapies in the NICU.

Dr. Naomi 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.  In the Holden Neonatal Intensive Care Unit at C.S. Mott Children’s Hospital, she cares for critically ill newborns, provides prenatal consultation for parents expecting to deliver premature infants, and teaches neonatal-perinatal medicine and bioethics to residents and medical students.  Her research is in neonatal clinical research ethics, and her current work focuses on attitudes of parents and health care providers regarding newborn infants as research subjects.

 

Resident attitudes and experience with palliative care in patients with advanced dementia

Presenting author: Erika R. Manu, MD, University of Michigan

Co-authors: Cathy Berkman, PhD, ACSW, Fordham University; Patricia Mullan, PhD, University of Michigan; Caroline Vitale, MD, University of Michigan

Purpose: To explore medical residents’ experience, attitudes and self-perceived confidence about end-of-life care in advanced dementia.  Methods: E-mail survey to all second, third and fourth-year residents in Internal Medicine, Medicine/Pediatrics, and Family Medicine at University of Michigan.  Queried residents’ experience, attitudes and self-perceived confidence approaching end-of-life discussions in patients with dementia, compared to heart failure and metastatic cancer.  Results: Surveys were e-mailed to 120 residents; 61 completed surveys were received after an initial e-mailing and one follow-up email reminder to non-responders, yielding a 51% response rate.  Sixty percent of respondents reported no formal training in estimating prognosis in patients with dementia.  Ninety-eight percent of respondents reported participating in family meetings addressing goals of care in the terminally ill.  Fifty-four percent of respondents agreed they felt confident eliciting patient/surrogate wishes regarding life-sustaining treatments in patients with advanced dementia, with 49% reporting this for patients with heart failure, and contrasting with 84% who agreed feeling confident eliciting wishes in patients with metastatic cancer.  Residents anticipate the need to elicit wishes of patients/surrogates of patients with advanced dementia (67%), heart failure (65%), and metastatic cancer (74%) in their future career. While only 37% feel confident assessing adequacy of caregiver support for their older patients, 82% anticipate they will be required to assess caregiver needs in their future career.  Conclusion: Medicine residents are actively involved discussing goals of care in terminally ill patients.  Despite this experience, they appear to have the lowest confidence in eliciting patient/surrogate wishes in dementia (vs. heart failure and metastatic cancer) and low confidence in assessing caregiver needs, yet believe these skills are important to attain.  These findings elucidate existing educational gaps in resident training and call attention to the need for enhanced education centering on optimal care of patients with advanced dementia.

Dr. Erika Manu is currently a fellow in Advanced Geriatrics at the VA Healthcare System and Clinical Lecturer in the Department of Internal Medicine, Division of Geriatric Medicine, at the University of Michigan.  She graduated from medical school in 1995 from the University of Medicine and Pharmacy, Timisoara, Romania.  She then completed an internship and residency in Physical Medicine and Rehabilitation in Romania before relocating to the United States in 2000.  In 2009, she graduated from the Internal Medicine residency program at St. Joseph Mercy Hospital in Pontiac, MI.  Her interests are focused on developing a career as a clinician educator with a focus on teaching and curriculum development that covers geriatric palliative care concepts in older adults with a strong commitment to the idea of enhancing medical resident knowledge and skills as they care for patients with dementia and other advanced chronic illnesses.

 

Considering virtue: Public health and clinical ethics

Presenting author: Karen M. Meagher, Graduate Student, Michigan State University

As bioethicists increasingly turn their attention to the profession of public health, many candidate frameworks have been proposed, often with an eye toward articulating the values and foundational concepts that distinguish this practice from curative clinical medicine.  First, I will argue that while these suggestions for a distinct ethics of public health are promising, they arise from problems with contemporary bioethics that must be taken into account.  Without such cognizance of the impetus for public health ethics, we risk developing a set of ethical resources meant exclusively for public health professionals, thereby neglecting implications for curative medical ethics and the practice of bioethics more broadly.  Secondly, I will present reasons for thinking some of the critiques of dominant contemporary bioethics can be met by a virtue ethics approach.  I present a virtue ethics response to criticisms that concern 1) increased rigor in bioethics discourse, 2) the ability of normative theory to accommodate context, and 3) explicit attention to the nature of ethical conflict. I conclude that a virtue ethics approach is a viable avenue for further inquiry, one that leads us away from developing ethics of public health in a vacuum and has the potential for overcoming certain pitfalls of contemporary bioethics discourse.

Karen M. Meagher is currently a PhD candidate in the Department of Philosophy at Michigan State University (MSU).  Her interests include public health ethics, philosophy of risk, and virtue ethics.  She previously taught at the University of Michigan-Flint in the Department of Public Health and Health Sciences.  She currently serves on the MSU and State Institutional Review Boards (IRBs) and is employed as a graduate assistant at MSU’s Center for Ethics and Humanities in the Life Sciences.

 

The right not to hear: The ethics of parental refusal of hearing rehabilitation

Presenting author: Andrew G. Shuman, MD, University of Michigan

Co-authors: Serena Byrd, BS, University of Michigan; Sharon Kileny, MD, University of Michigan; Paul R. Kileny, PhD, University of Michigan

Objective: To explore the ethics of parental refusal of auditory-oral hearing rehabilitation.  Study Design: Case study with medical ethical discussion and review.  Methods: Two young brothers present with severe-to-profound congenital sensorineural hearing loss.  The parents, both of whom have normal hearing and work as sign language interpreters, have decided to raise their children with American Sign Language as their only form of communication.  They have chosen not to pursue cochlear implantation nor support the use of hearing aids.  Discussion: This case raises significant questions concerning whether hearing rehabilitation should be mandated, and if there are circumstances in which parental preferences should be questioned or overridden with regard to this issue.  In addition, legal concerns may be raised regarding the possible need to file a report with child protective services. While similar cases involving the deaf community have historically favored parental rights to forego hearing rehabilitation with either cochlear implants or hearing aids, we explore whether conclusions should be different because the parents in this care are not hearing impaired.  Conclusions: The ethics of parental rights to refuse hearing augmentation are complex and strikingly context-dependent.  A comprehensive appreciation of the medical, practical and legal issues is crucial prior to intervening in such challenging situations.

Dr. Andrew Shuman is the chief resident surgeon in the Department of Otolaryngology, Head and Neck Surgery at the University of Michigan Hospitals.  Originally from New York, he is a 2002 graduate with high honors from the University of Michigan’s College of Literature, Science, and the Arts, and graduated with honors in 2006 from the University of Michigan Medical School.  He is pursuing sub-specialized fellowship training in head and neck surgical oncology.  Dr. Shuman has lectured and published in the areas of otolaryngology, emergency medicine, neurosurgery, and medical ethics.  His current research interests include clinical outcomes and ethical issues in head and neck cancer patients.

 

Pathology review of outside material: When does it help and when can it hurt?

Presenting author: Lauren B. Smith, MD, University of Michigan

Purpose: Pathology review is performed for patients when care is transferred to a tertiary care center after diagnostic tissue has been obtained.  While it has many benefits, this practice can lead to unforeseen difficulties in doctor-patient communication and patient well-being, especially if a diagnosis is overturned or modified years after treatment.  The aim of this analysis is to identify clinical situations in which pathology review can result in challenging discussions between patients and oncologists.  Methods: Representative case scenarios are presented in the subspecialty area of hematopathology.  Analysis of the clinical benefits and possible harm to patients, pathologists, and treating oncologists that may ensue from pathology review is performed.  Results: Pathology review may result in a valuable second opinion and expert sub-classification.  However, problematic situations may arise with pathology review, especially if the patient has already undergone definitive treatment and is referred to an academic institution in remission.  Difficulties can also arise when patients do not understand the limitations of diagnosing disease on small biopsies.  The patient may receive a different diagnosis or it may become apparent that the diagnosis could have been made more expeditiously.  These discrepancies must be communicated to the patient and may cause confusion and distress.  Conclusion: Pathology review can be beneficial or potentially harmful depending on the clinical situation.  Preliminary recommendations are provided for selecting cases for review.  Limiting pathology review to certain clinical situations and encouraging patients to get second opinions prior to initial treatment at local referral centers may be helpful in minimizing reassignment of diagnoses after definitive treatment.

Dr. Lauren Smith received her medical degree, pathology residence training, and hematopathology fellowship training at the University of Michigan.  She joined the University of Michigan faculty in 2007.  Dr. Smith is actively involved in the clinical hematopathology services including histopathology, flow cytometry and hemoglobin electrophoresis.  She has been a member of the adult ethics committee since 2005 and she serves on the adult ethics committee consultation service.  Her research interests include ethical issues in pathology.

Fri, July 26, 2013

Susan Goold is the senior author in a newly published study in JAMA, in which 2,500 U. S. physicians were asked about their views on 17 specific strategies to reduce health care spending, including proposed policies in the Patient Protection and Affordable Care Act. They were also surveyed on their perceived roles and responsibilities in addressing health care costs as care providers.

The vast majority of U.S. physicians (85 percent) agreed that trying to contain costs was a responsibility of every physician but most respondents prioritized patients’ best interests over cost concerns. Most surveyed physicians supported cost-containment initiatives aimed at improving the quality and efficiency of care, such as promoting chronic disease care coordination and limiting corporate influence on physician behavior. Substantial financing reforms, however, were much less popular among physicians. Examples include bundled payments, penalties for readmissions, eliminating fee-for-service reimbursement and other Medicare pay cuts. Physicians also believed that patients, pharmaceutical companies, and malpractice lawyers shared as much or more of the responsibility for containing escalating healthcare costs.

Jon C. Tilburt, M.D., M.P.H., of the Mayo Clinic, Rochester, Minn., was lead author of the study.

Tilburt JC, Wynia MK, Sheeler RD, Thorsteinsdottir B, James KM, Egginton JS, Liebow M, Hurst S, Danis M, Goold S (2013). Views of US Physicians About Controlling Health Care Costs. JAMA 310 (4): 380-388.

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