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Wendy Uhlmann, Scott Roberts, and Ray De Vries will serve as panelists on Monday, September 11th for FINDING COMMON GROUND: A Conversation on Genetics and Religion at the Ann Arbor Downtown Library.

More information can be found here.

Research Topics: 

Joel Howell, MD, PhD

Faculty

Joel D. Howell is a Professor at the University of Michigan in the departments of Internal Medicine (Medical School), Health Management and Policy (School of Public Health), and History (College of Literature, Science, and the Arts), as well as the Victor C. Vaughan Professor of the History of Medicine. He received his M.D. at the University of Chicago, and stayed at that institution for his internship and residency in internal medicine. At the University of Pennsylvania, he was a Robert Wood Johnson Clinical Scholar, and received his Ph.D. in the History and Sociology of Science.

Research Interests: 
Last Name: 
Howell

Supporting information for: 2017 CBSSM Research Colloquium and Bishop Lecture (Norman Daniels, PhD)


"Setting priorities for Medicaid: The views of minority and underserved communities"
Presenter: Susan Goold, MD, MHSA, MA


Co-authors: Lisa Szymecko, JD, PhD; H. Myra Kim, ScD; Cengiz Salman, MA; A. Mark Fendrick, MD; Edith Kieffer, MPH, PhD; Marion Danis, MD, Zachary Rowe, BBA


Setting priorities for state Medicaid programs challenges policy makers. Engaging beneficiaries affected by tradeoffs could make allocations more just and more sensitive to their needs. 

Academic-community partnerships adapted the simulation exercise CHAT (CHoosing All Together) to engage community members in deliberations about Medicaid spending priorities.  After an informational video about Medicaid, individuals and deliberating groups choose from a menu of spending options constrained by limited resources. We randomly assigned participants from low-income communities throughout Michigan to participate in CHAT with (n=209) or without group deliberations (n=181) in English, Spanish or Arabic. Data collection included pre- and post-CHAT individual priorities and group priorities.

Low-income participants ranged from 18 to 81 years old (Mean 48.3); 61.6% were women. Over half (56.7%) self-identified as white, 30.8% African-American, 17.3% Hispanic, 9.2% Native American, and 12.1% Arab, Arab-American or Chaldean. Most (65.9%) had a chronic condition and 30.3% reported poor or fair health.

Before CHAT, most participants prioritized eligibility consistent with Medicaid expansion. They also prioritized coverage for a broad range of services. Most accepted daily copays for elective hospitalization (71.6% deliberators, 67.9% controls) and restricted access to specialists (60.2% deliberators, 57.4% controls). Deliberators were more likely than controls to increase, after deliberations, what they allocated to mental health care (between arm difference in allocation=0.22, p=.03) and eligibility (between arm difference in allocation=0.18, p=.04). Deliberating groups also prioritized eligibility; only 3 of 22 chose pre-expansion eligibility criteria, and 9 of 22 chose to expand eligibility further.

Members of underserved communities in Michigan put a high priority on Medicaid expansion and broad coverage. When given the opportunity to deliberate about priorities,  participants increased the priority given to expanded eligibility and coverage for mental health services.


"How Acceptable Is Paternalism? A Survey-Based Study of Clinician and Non-clinician Opinions on Decision Making After Life Threatening Stroke"
Presenter: Kunal Bailoor, MD Candidate


Co-authors: Chithra Perumalswami, MD, MSc; Andrew Shuman, MD; Raymond De Vries, PhD; Darin Zahuranec, MD, MS


Complex medical scenarios may benefit from a more paternalistic model of decision making. Yet, clinicians are taught to value patient autonomy, especially at the end-of-life. Little empirical data exist exploring opinions on paternalism.

Methods: A vignette-based survey exploring surrogate decision making after hemorrhagic stroke was administered to clinicians (faculty, residents, and nurses) at an academic health center, and non-clinicians recruited through a university research volunteer website. The cases involved an urgent decision about brain surgery, and a non-urgent decision about continuation of life support one week after stroke. Respondents rated the acceptability of paternalistic decision making, including clinicians not offering or making an explicit recommendation against the treatment, on a 4 point Likert scale.

Results: Of 924 eligible individuals, 818 (649 non-clinicians, 169 clinicians) completed the survey (completion rate 89%).  A minority of respondents (15.3%) found it acceptable not to offer surgery. Most believed it was acceptable to make an explicit recommendation that would likely result in death (73% for avoiding surgery, 69% for stopping the ventilator). Clinicians were more likely than non-clinicians to consider not offering surgery acceptable (30% vs 11%, p<0.0001). Clinicians were more likely to consider recommendations against surgery acceptable (82% vs 71%, p=0.003) and to consider recommendations to discontinue the ventilator acceptable (77% vs 67%, p=0.02). There were no differences between the nurse and physician acceptability ratings (p=0.92).

Conclusions: Clinicians and the lay public differ on the acceptability of paternalistic decision making. Understanding these differences are vital to improving communication between clinicians, patients, and families.


"Ethical Challenges Faced by Providers in Pediatric Death: A Qualitative Thematic Analysis"
Presenter: Stephanie Kukora, MD


Co-authors: Janice Firn, PhD, MSW; Patricia Keefer, MD; Naomi Laventhal, MD, MA
 

Background: Care providers of critically ill patients encounter ethically complex and morally distressing situations in practice. Though ethics committees guide ethical decision-making when conflicts arise in challenging cases, they rarely address routine needs of individual providers. Without ethics education, providers may lack skills necessary to resolve these conflicts or insight to recognize these dilemmas.

Objective: We sought to identify whether providers remark on ethical dilemmas/moral distress without being specifically prompted, when asked to comment on a recent in-hospital pediatric death. We also sought to characterize the nature of dilemmas or distress if found.

Methods: Providers involved in a deceased child’s care in the 24 hours prior to death were electronically surveyed. Questions included demographic information and free-text response. Free-text responses were thematically analyzed in Dedoose.

Results: There were 307 (35%) free-text responses in 879 completed surveys (33% total response rate), regarding the deaths of 138 patients (81% of in-hospital pediatric deaths) from November 2014 to May 2016. Multidisciplinary care team members from diverse hospital units were represented. 52 respondents described ethical challenges and/or moral distress. Disagreement/regret was a major theme, with subthemes of futility, suffering, and “wrong” medical choice made. Failure of shared decision-making was also a major theme, with subthemes of autonomy and best interest, false hope, denial, and misunderstanding/disagreement between the family and medical team. Some providers revealed personal ethical struggles pertaining to their role, including medication provision for pain at the end of life, struggling to be “truthful” while not divulging information inappropriate for their role, and determining when providing comfort care is ethically permissible.

Discussion/Conclusion: Providers experience ethical conflicts with pediatric end-of-life care but may be unwilling or unable to share them candidly. Education assisting staff in identifying and resolving these dilemmas may be helpful. Further support for providers to debrief safely, without criticism or repercussions, may be warranted.


"Capacity for Preferences:  An overlooked criterion for resolving ethical dilemmas with incapacitated patients"
Presenters: Jason Adam Wasserman, PhD; Mark Navin, PhD
 

Clinical bioethics traditionally recognizes a hierarchy of procedural standards for determining a patient’s best plan of care. In broad terms, priority is given first to autonomous patients themselves and then to surrogates who utilize substituted judgments to choose as they believe the patient would have chosen. In the absence of good information about what the patient would have wanted, clinical ethicists typically retreat to the “best interest” standard, which represents a relatively objective assessment designed to maximize benefits and/or minimize harms.  In this paper, we argue that “capacity for preferences” is a conceptually distinct and morally salient procedural standard for determining a patient’s best plan of care.  We build our argument on the grounds that 1) that many patients who lack decisional capacity can nevertheless reliably express preferences (an empirical claim); 2) these preferences are distinct from best interest and not reducible to best interest considerations; 3) that capacity for preferences, at a minimum, has moral valence for situations in which best interest is undetermined (and we argue this happens more frequently than commonly recognized); and, finally, 4) that capacity for preferences in incapacitated patients lacking reliable or valid surrogates might even subvert a best interest course of action in some cases.  Some precedent for our analysis can be found in the concept of pediatric assent. However, the idea that patient preferences matter morally has broad application for adult patients, including for those with advanced dementia and other mental illnesses that preclude capacity for decision-making.

Angela Fagerlin, PhD

Alumni

Dr. Fagerlin served as Co-Director of CBSSM from 2010-2015. She is currently Chair of the Department of Population Health Sciences at University of Utah School of Medicine and Research Scientist, Salt Lake City VA Center for Informatics Decision Enhancement and Surveillance (IDEAS)

Last Name: 
Fagerlin
Research Projects: 

Policy and Public Outreach

The Bishop Lectureship in Bioethics

Together with the Bishop endowment, CBSSM sponsors the Bishop Lecture in Bioethics.  The Bishop Lecture in Bioethics was made possible by a generous gift from the estate of Ronald and Nancy Bishop, both graduates of the University of Michigan Medical School (Class of ‘44). The Bishop lecture typically serves as the keynote address for the CBSSM Research Colloquium. The Bishop Lecture selection committee is headed by Susan Goold, MD, MHSA, MA. Click here for more details.

CBSSM Research Colloquium

The Center for Bioethics and Social Sciences in Medicine (CBSSM) Research Colloquium features presentations focusing on bioethics and social sciences in medicine across multiple disciplines. Click here for more details.

CBSSM Seminar Series

Building upon the very successful “joint seminars” of past years sponsored by the Bioethics Program and the Center for Behavioral and Decision Sciences in Medicine (CBDSM), CBSSM hosts seminars on a bimonthly basis throughout the academic year, inviting investigators to present both developing and finished research topics. Click here for more details.

Sponsored Events

In addition to the Bishop Lecture in Bioethics, CBSSM has sponsored and co-sponsored a number of other events.

Bioethics Grand Rounds

With support from the UMHS Office of Clinical Affairs and C.S. Mott Children’s Hospital and Von Voigtlander Women’s Hospital, CBSSM’s Program in Clinical Ethics sponsors the monthly Bioethics Grand Rounds, focusing on ethical issues arising in health care and medicine. This educational session is open to UMHS faculty and staff.

Film Screening & Moderated Discussion

CBSSM also sponsors film screenings and moderated panel discussions. In 2017, CBSSM sponsored a free film screening of "Concussion." The moderated panel included Ellen Arruda, PhD, Mechanical Engineering; Karen Kelly-Blake, PhD, Bioethics, MSU; & Matthew Lorincz, MD, PhD, Neurology. The moderator was Raymond De Vries, PhD.

In 2015, CBSSM co-sponsored a free film screening of "Still Alice." The panel included Nancy Barbas, MD and J. Scott Roberts, PHD and the moderator was Raymond De Vries, PhD. The event was co-sponsored by the Michigan Alzheimer's Disease Center.

Current Event Panels

In 2014, CBSSM co-sponsored the panel "Incidental Findings in Clinical Exome and Genome Sequencing: The Drama and the Data" featuring Robert C. Green, MD, MPH, Associate Professor of Medicine, Division of Genetics at Brigham and Women’s Hospital and Harvard Medical School, as the keynote speaker. The panel included Jeffrey W. Innis, MD, PhD, Morton S. and Henrietta K. Sellner Professor in Human Genetics and Director, Division of Pediatric Genetics, and Wendy R. Uhlmann, MS, CGC, Clinical Associate Professor, Department of Internal Medicine and Department of Human Genetics. The panel was moderated by Sharon L.R. Kardia, PhD, Director, Public Health Genetics Program and the Life Sciences and Society Program, School of Public Health, University of Michigan. This event was also co-sponsored by the Department of Human Genetics, Genetic Counseling Program and Life Sciences and Society, Department of Epidemiology.

In 2013, CBSSM sponsored the panel "What does the Supreme Court ruling on gene patents mean for public health?" The panel featured panelists, Rebecca Eisenberg, JD, Robert and Barbara Luciano Professor of Law; Sofia Merajver, MD, PhD, Professor, Department of Internal Medicine; and Shobita Parthasarathy, PhD, Associate Professor of Public Policy, Gerald R. Ford School of Public Policy. The panel was moderated by Edward Goldman, JD, Associate Professor, UM Department of ObGyn Women's Hospital and Adjunct Assistant Professor, Department of Health Management and Policy.

Decision Consortium

Each year, CBSSM sponsors one Decision Consortium speaker with a focus on health-related decision making. Decision Consortium, hosted by the Department of Psychology, is a University-wide distributed center for scholarship on decision making. Each session involves a vigorous discussion of new ideas and research on problems that have significant decision making elements. CBSSM-sponsored speakers included Kevin Volpp, MD, PhD, UPenn (2015), Karen Sepucha, PhD, Harvard (2013), and Ellen Peters, PhD, OSU (2012). In 2016, CBSSM will sponsor Lisa Schwartz, MD, MS and Steven Woloshin, MD, MS from the Dartmouth Institute.

The Waggoner Lecture

In November of 2010, CBSSM co-sponsored the 15th annual Waggoner Lecture, an annual event in honor of the late Dr. Raymond Waggoner, former chair of the Department of Psychiatry.  The lecture was presented by Bernard Lo, MD,  Director of the Program in Medical Ethics at the University of California-San  Francisco, and was entitled, “Stem cells: Intractable ethical dilemmas or  emerging agreement.”

In November 2011, CBSSM co-sponsored the Waggoner Lecture breakfast.  The lecture was presented by Laura Roberts, MD, chair of the Department of  Psychiatry and Behavioral Sciences at Stanford University School of Medicine, and was entitled, “Becoming a Physician: Stresses and Strengths of Physicians- in-Training.”

Deadly Medicine: Creating the Master Race

In 2012, in conjunction with Taubman Health Sciences Library and the UM Center for the History of Medicine,  CBSSM co-sponsored the  United States Holocaust Memorial Museum’s traveling exhibition, “Deadly Medicine: Creating the Master Race.” The exhibition illustrates how Nazi leadership enlisted people in professions traditionally charged with healing and the public good, to legitimize persecution, murder and, ultimately, genocide.

MICHR Research Education Symposium

In 2013, CBSSM co-sponsored the Michigan Institute for Clinical & Health Research (MICHR) Research Education Symposium, "Life at the Interface of Genomics and Clinical Care." The symposium included a series of talks on topics with implications for translational and clinical research. The keynote speaker was Dr. Ellen Wright Clayton, JD, MD, Rosalind E. Franklin Professor of Genetics and Health Policy; Craig-Weaver Professor of Pediatrics; Professor of Law; and Director, Center for Biomedical Ethics and Society, at Vanderbilt University. Dr. Wright Clayton’s topic was “Addressing Biomedical Ethics.” 

 

Naomi Laventhal, MD, MA

Faculty

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).

Last Name: 
Laventhal

Sarah Hawley, PhD, MPH

Faculty

Dr. Sarah T. Hawley is a Professor in the Division of General Medicine at the University of Michigan and a Research Investigator at the Ann Arbor VA Center of Excellence in Health Services Research & Development. She holds a PhD in health services research from the University of North Carolina and an MPH from Yale University Department of Public Health. Her primary research is in decision making related to cancer prevention and control, particularly among racial/ethnic minority and underserved populations.

Last Name: 
Hawley
Press Coverage: 

Reshma Jagsi will be a Keynote Speaker at “Strategies to Empower Women to Achieve Academic Success," which will be held June 7th (8:30 a.m. – 11 a.m., A. Alfred Taubman Biomedical Science Research Building). The event is sponsored by the A. Alfred Taubman Medical Research Institute.

Click here for more details.

Research Topics: 
Thu, February 26, 2015

Joel Howell is co-author in a paper published in Perspectives in Biology and Medicine, “The heartfelt music of Ludwig van Beethoven.”  The paper analyzes several of Beethoven's compositions for clues of a heart condition some have speculated he had.

“His music may have been both figuratively and physically heartfelt,” says co-author Joel Howell, M.D., Ph.D, a professor of Internal Medicine at the University of Michigan Medical School and member of the U-M Institute for Healthcare Policy and Innovation. “When your heart beats irregularly from heart disease, it does so in some predictable patterns. We think we hear some of those same patterns in his music.”

Goldberger ZD, Whiting SM, Howell JD. The heartfelt music of Ludwig van Beethoven. Perspect Biol Med. 2014 Spring;57(2):285-94. doi: 10.1353/pbm.2014.0013.

Research Topics: 
Mon, April 24, 2017

Reshma Jagsi was recently quoted in the Reuters Health News article, "How consent requirements may shape teen mental health research."

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