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The Privileged Choices (Jan-08)

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.

Scenario 1

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?

  • Yes
  • No

Scenario 2

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?

  • Yes 
  • No

Scenario 3

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?

  • Yes 
  • No

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.

CBSSM Seminar: Michele Gornick, PhD

Thu, January 15, 2015, 3:00pm to 4:00pm
Location: 
NCRC 16-266C

Michele Gornick, PhD

VA HSRD Fellow & CBSSM Research Investigator

Title: The public’s preferences for the return of secondary findings identified through genome sequencing: Information and deliberation make a difference

Summary: Genomic sequencing is becoming a part of clinical practice. Existing studies are limited and conclude that people would like unrestricted access to all of their genetic information. However, we do not know the extent to which respondents in these studies took into account the complex scientific and ethical issues that attend genome sequencing. In order to address this gap, we organized a deliberative democracy (DD) session to educate members of the public on genome sequencing, to engage them in dialogue about the benefits and risks of the clinical implementation of this technology, and to elicit their informed perspectives about policies governing the return of secondary findings.

BROCHER RESIDENCIES 2016 -- CALL FOR PROPOSALS

The Brocher Foundation offers visiting researchers the opportunity to come at the Brocher Centre in a peaceful park on the shores of Lake Geneva, to write a book, articles, an essay or a PhD thesis. The visiting positions are an occasion to meet other researchers from different disciplines and countries as well as experts from numerous International Organizations & Non Governmental Organizations based in Geneva, such as WHO, WTO, WIPO, UNHCR, ILO, WMA, ICRC, and others. The Brocher Foundation residencies last between 1 and 4 months.

They give researchers (PhD students to Professors) the opportunity to work at the Brocher Centre on projects on the ethical, legal and social implications for humankind of recent medical research and new technologies. Researchers can also apply with one or two other researchers to work on a collaborative project.

CHECK CONDITIONS AND APPLY ON WWW.BROCHER.CH/CALLS

CBSSM Seminar: Jodyn Platt, MPH, PhD

Thu, October 08, 2015, 3:00pm to 4:00pm
Location: 
NCRC, Building 16, Room 266C

Jodyn Platt, MPH, PhD


Research Investigator
Department of Learning Health Sciences

Terms and Conditions for Trust in Learning Health Systems

The next generation of health information technology, organized as “learning health systems,” promises efficient, engineered solutions to the well-known and enduring maladies of the existing U.S. health infrastructure: escalating costs, poor health outcomes, ineffective use of technology, sluggish research pipelines, dangerous medical error rates, and failure to implement known clinical best practices. Learning health systems would capitalize on "big data" enterprises to accelerate the production and application of knowledge in health care. However, the sharing of health information required, both within and across institutions, greatly exceeds the public’s understanding.  These initiatives are riding a precarious edge as the gap between public expectations and the realities of institutional data sharing widens at an unprecedented rate.  This presentation considers the causes and consequences of trust and mistrust of health information systems, their data sharing practices, and their policy implications. 
 

 

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

PIHCD: Kevin Kerber and Will Meurer

Thu, November 19, 2015, 2:00pm
Location: 
B004E NCRC Building 16

Dr. Kevin Kerber and Dr. Will Meurer will be presenting an implementation trial on the topic of diagnosis and treatment of benign positional vertigo in the emergency department. At this meeting, they will be discussing and seeking input regarding plans for the in-person provider training presentation. Part of the intervention is a website to educate and motivate providers. Please review the website prior to the meeting.

To access the educational website please go to www.dizztinct.com and sign up with your uniqname@med.umich.edu  email address and create a password.  After signing up, you'll receive an email with a link to click, in order to activate your account.

If you do not have a med.umich.edu email address, you can still get access by contacting Patty Johnson at johnspat@med.umich.edu

A number of CBSSM faculty spoke at the recent Michigan State Medical Society Conference on Neonatal and Pediatric Ethics on November 13-14 in Ann Arbor

  • Welcome and Opening & Closing Remarks:  Lauren B. Smith, MD, Chair, MSMS Committee on Bioethics
  • “What’s New at the Margin of Viability?”  Naomi Laventhal, MD, MA, FAAP, Assistant Professor, Pediatrics; Brandon Neonatal Intensive Care, C. S. Mott Children’s Hospital
  • “Elective Operations in Children” Christian J. Vercler, MD, MA, Clinical Assistant Professor, Plastic Surgery; Co-Chair, Pediatric & Adult Ethics Committees; and Co-Director, Clinical Ethics Program, CBSSM
  • “Harms of Newborn Screening: Fact or Fiction?” Beth A. Tarini, MD, Assistant Professor, Department of Pediatrics and Communicable Diseases

Visit this link for more information on the conference.

Give me colostomy or give me death! (Aug-06)

Click to decide between death and living with a colostomy. Which would you choose? Are you sure?

Given the choice, would you choose immediate death,or living with a colostomy (where part of your bowel is removed and you have bowel movements into a plastic pouch attached to your belly)?

  •  Immediate Death
  •  Colostomy

Think about what it would be like if you were diagnosed with colon cancer. You are given the option of choosing between two surgical treatments.The first is a surgery that could result in serious complications and the second has no chance of complications but has a higher mortality rate.

Possible outcome Surgery 1
(complicated)
Surgery 2 
(uncomplicated)
Cure without complication 80% 80%
Cure with colostomy 1%  
Cure with chronic diarrhea 1%  
Cure with intermittent bowel obstruction 1%  
Cure with wound infection 1%  
No cure (death) 16% 20%

If you had the type of colon cancer described above, which surgery do you think you would choose?

  • Surgery 1
  • Surgery 2

How do your answers compare?

In fact, past research has shown that 51% people choose the surgery with a higher death rate, even though most of them initially preferred each of the four surgical complications, including colostomy, over immediate death.

Are you saying what you really mean?

CBDSM investigators Brian Zikmund-Fisher, Angela Fagerlin, Peter Ubel, teamed up with Jennifer Amsterlaw, to see if they could reduce the number of people choosing the surgery with the higher rate of death and therefore reducing the discrepancy. A large body of past research has shown that people are notoriously averse to uncertainty. The investigators had a hunch that uncertainty could account for some of the discrepancy. Surgery 1 has a greater number of ambiguous outcomes, perhaps causing people to be averse to it. In an effort to minimize this uncertainty, the investigators laid out a series of scenarios outlining different circumstances and presentations of the two surgeries. For example the research presented some of the participants with a reframing of the surgery information, such as:

Possible outcome Surgery 1
(complicated)
Surgery 2 
(uncomplicated)
Cured without complication 80% 80%
Cured, but with one of the following complications: colostomy, chronic diarrhea, intermittent bowl obstruction, or wound infection 4%  
No cure (death) 16% 20%

The investigators believed by grouping all of the complications together that people would be more apt to chose the surgery with the lower mortality rate, because seeing a single group of undesirable outcomes, versus a list, may decrease some of the ambiguity from previous research.

Although none of the manipulations significantly reduced the percentage of participants selecting Surgery 2, the versions that yielded the lowest preference for this surgery all grouped the risk of the four possible complications into a single category, as in the example shown above.

Why these findings are important

Over the past several decades there has been a push to give patients more information so they can make decisions that are consistent with their personal preferences. On the other hand there is a growing psychological literature revealing people's tendency to make choices that are in fact inconsistent with their own preferences; this is a dilemma. Because the present research suggests that the discrepancy between value and surgery choice is extremely resilient, much research still needs to be done in order to understand what underlies the discrepancy, with the goal of eliminating it.

The research reported in this decision of the month is currently in press. Please come back to this page in the near future for a link to the article.

Read the article:

Can avoidance of complications lead to biased healthcare decisions?
Amsterlaw J, Zikmund-Fisher BJ, Fagerlin A, Ubel PA. Judgment and Decision Making 2006;1(1):64-75.

 

 

 

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"

 

CBSSM investigators Holly Witteman, Andrea Fuhrel-Forbis, Angela Fagerlin, and Brian Zikmund-Fisher, along with CBSSM alumni Peter Ubel and Andrea Angott will give a plenary talk at the Society for Medical Decision Making's 32nd Annual Meeting in Toronto on Monday, October 25.  The talk is titled, "Colostomy is Better than Death, but a 4% Chance of Death Might Be Better Than a 4% Chance of Colostomy: Why People Make Choices Seemingly At Odds With Their Stated Preferences." 

Abstract:

Purpose: When asked for their preference between death and colostomy, most people say that they prefer colostomy. However, when given the choice of two hypothetical treatments that differ only in that one has four percent chance of colostomy while the other has four percent additional chance of death, approximately 25% of people who say that they prefer colostomy actually opt for the additional chance of death. This study examined whether probability-sensitive preference weighting may help to explain why people make these types of treatment choices that are inconsistent with their stated preferences.

Method: 1656 participants in a demographically diverse online survey were randomly assigned to indicate their preference by answering either, “If you had to choose, would you rather die, or would you rather have a colostomy?†or, “If you had to choose, would you rather have a 4% chance of dying, or would you rather have a 4% chance of having a colostomy?†They were then asked to imagine that they had been diagnosed with colon cancer and were faced with a choice between two treatments, one with an uncomplicated cure rate of 80% and a 20% death rate, and another with an uncomplicated cure rate of 80%, a 16% death rate, and a 4% rate of colostomy.

Result: Consistent with our prior research, most people whose preferences were elicited with the first question stated that they preferred colostomy (80% of participants) to death (20%), but many then made a choice inconsistent with that preference (59% chose the treatment with higher chance of colostomy; 41% chose the treatment with higher chance of death). Compared to the first group, participants whose preferences were elicited with the 4% question preferred death (31%) over colostomy (69%) more often (Chi-squared = 24.31, p<.001) and their treatment choices were more concordant with their stated preferences (64% chose the treatment with higher chance of colostomy; 36% chose the treatment with higher chance of death, Chi-squared for concordance = 36.92, p<.001).

Conclusion: Our experiment suggests that probability-sensitive preference weighting may help explain why people’s medical treatment choices are sometimes at odds with their stated preferences. These findings also suggest that preference elicitation methods may not necessarily assume independence of probability levels and preference weights.


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