Tom Valley is an Assistant Professor in the Division of Pulmonary and Critical Care Medicine in the Department of Internal Medicine at the University of Michigan. He received his undergraduate degrees in history and chemistry from Emory University, and his medical degree from the University of Miami. He completed his internal medicine residency and chief residency at the University of Texas-Southwestern/Parkland Memorial Hospital.
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Please visit the events page of the CBSSM website to view the video of the February 1, 2012, talk and panel discussion, "Ethical Imperialism: The Case Against IRB Review of the Social Sciences," featuring Dr. Zachary Schrag of George Mason University; Dr. Cleo Caldwell of U-M's School of Public Health; Dr. Alford Young, Jr., of U-M's College of Literature, Science, & Arts; and Carl Schneider of U-M's Law School.
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.
Kathryn Moseley served as one of the judges at "The Big Ethical Question Slam 5" hosted by a2ethics.org. In addition, Naomi Laventhal, Michele Gornick, Christian Vercler, Lauren Smith, and Lauren Wancata served as judges at the "Michigan Highschool Ethics Bowl 2."
Thanks to all the CBSSM folks who contributed their time!
For more information about these events and other great ethics-related activites, go to a2ethics.org.
A short video about the Highschool Ethics Bowl can be found here.
When Death Comes Callin': Songs and Reflections About Death
Charlotte DeVries, Jeanne Mackey, Merilynne Rush, and friends offer a program of songs and brief readings reflecting various perspectives on death - humorous, sad, thoughtful, and quirky.
Lunch is provided on a first-come, first-served basis.
Vaccine refusal has an impact on public health; however, research has shown that it is very difficult to change attitudes towards vaccines. People are often hesitant about vaccines because they don’t trust that potential harms are documented and reported. The question is: how can we increase trust and vaccine utilization?
A 5% chance of death or a 10% chance of death: which would you choose?
Imagine that you have been diagnosed with a slow growing cancer. Right now, the cancer is not causing you to feel sick. For most people, the cancer will grow so slowly it will never cause them any trouble. For others, the cancer will grow to the point that it makes them sick. Untreated, five percent (5 out of 100) will die of the cancer. Your doctor tells you that you have two treatment options: watchful waiting or surgery. Watchful waiting means you will not do any treatment right away, but your doctor will follow your cancer closely and treat any symptoms that you have if it begins to spread. Although it would be too late to be cured, you would be comfortable and free of pain. There are no side effects to watchful waiting, but five percent (5 out of 100) of the people who choose this treatment will develop symptoms and die from their cancer within five years. On the other hand, the surgery would cure your cancer permanently. Following surgery you will feel more tired than usual and will experience stomach upset occasionally for the three months following your surgery. However, surgery has a ten percent (10 out of 100) risk of death during the surgery.
Imagine that both of these treatments are completely covered by your health insurance. Which would you choose?
- I would not take the surgery and accept the 5% chance of dying from this cancer.
- I would take the surgery and accept the 10% chance of dying from the surgery.
How do your answers compare?
In the real world, cancer patients sometimes choose treatments that may have devastating side effects over less invasive, yet equally or more effective, approaches. One explanation for this is that people may feel a strong need to "get the cancer out" of their bodies. Surgical removal of all potentially cancerous tissues may satisfy this desire so thoroughly that people end up ignoring important statistical information about adverse outcomes.
Making a choice not in their best interest
CBDSM investigators Angela Fagerlin, Brian Zikmund-Fisher, and Peter Ubel hypothesized that people perceive cancer diagnoses as a call to action, and more specifically, a call to get rid of the cancer through surgery, regardless of what statistical information might say to the contrary. Consequently, they predicted that when presented with hypothetical cancer diagnoses, many people would say they would pursue surgery even if such an action would decrease their chance of survival.
To explore the relative frequency of people's willingness to choose surgery when it wasn't in their best interest, the investigators designed a cancer scenario similar to the one you read on the previous page. Participants were presented either a surgery or a medication treatment that would either increase or decrease their chance of survival.
The investigators found that participants who were presented with the opportunity to rid themselves of their cancer through surgery were significantly more inclined to take action than those who were presented with the medication treatment. For example, when the treatment reduced their overall chance of survival, 65% chose the surgery, whereas only 38% chose the medication treatment. This suggests that people's treatment decisions may be based not on the effectiveness of the treatments, but rather on their beliefs about how cancer should be treated. Specifically, cancer diagnoses seem to conjure up a strong desire for active treatment. And people seem to have an intuitive belief that action should not just involve treatment, but surgical removal of the cancer.
Why these findings are important
The results of this study may resonate with many clinicians who have encountered cancer patients who seem to desire treatment for treatment's sake, or who have a preference for surgical intervention even before they learn about the pros and cons of their treatment alternatives. This study should serve to remind clinicians that patients' preference for action can be strong enough, at times, to be a bias. At a minimum, it is important for health care professionals to be aware of the potential for such biases, so they can decide whether to accept patients' preferences at face value, or try to convince patients that aggressively treating a tumor may not be in their best interests.
Read the article:
Cure me even if it kills me: Preferences for invasive cancer treatment.
Fagerlin A, Zikmund-Fisher BJ, Ubel PA. Medical Decision Making 2005;25(6):614-619.
How do your risk estimate and your actual level of risk impact your anxiety? Please answer the following question to the best of your ability:
What is the chance that the average woman will develop breast cancer in her lifetime?
The average lifetime chance of developing breast cancer is actually 13%.
How do your answers compare?
Making a risk estimate can change the feel of the actual risk
CBDSM investigators Angela Fagerlin, Brian Zikmund-Fisher, and Peter Ubel designed a study to test whether people react differently to risk information after they have been asked to estimate the risks. In this study, half the sample first estimated the average woman's risk of breast cancer (just as you did previously), while the other half made no such estimate. All subjects were then shown the actual risk information and indicated how the risk made them feel and gave their impression of the size of the risk. The graph below shows what they found:
As shown in the graph above, subjects who first made an estimated risk reported significantly more relief than those in the no estimate group. In contrast, subjects in the no estimate group showed significantly greater anxiety. Also, women in the estimate group tended to view the risk as low, whereas those in the no estimate group tended to view the risk as high.
So what's responsible for these findings? On average, those in the estimate group guessed that 46% of women will develop breast cancer at some point in their lives, which is a fairly large overestimate of the actual risk. It appears, then, that this overestimate makes the 13% figure feel relatively low, leading to a sense of relief when subjects find the risk isn't as bad as they had previously thought.
Why this finding is important
Clinical practice implications - The current research suggests that clinicians need to be very deliberate but very cautious in how they communicate risk information to their patients. These results argue that a physician should consider whether a person is likely to over-estimate their risk and whether they have an unreasonably high fear of cancer before having them make a risk estimation. For the average patient who would overestimate their risk, making a risk estimation may be harmful, leading them to be too relieved by the actual risk figure to take appropriate actions. On the other hand, if a patient has an unreasonably high fear of cancer, having them make such an estimate may actually be instrumental in decreasing their anxiety. Physicians may want to subtly inquire whether their patient is worried about her cancer risk or if she has any family history of cancer to address the latter type of patient.
Research implications - Many studies in cancer risk communication literature have asked participants at baseline about their perceived risk of developing specific cancers. Researchers then implement an intervention to "correct" baseline risk estimates. The current results suggest that measuring risk perceptions pre-intervention will influence people's subsequent reactions, making it difficult to discern whether it was the intervention that changed their attitudes or the pre-intervention risk estimate. Researchers testing out such interventions need to proceed with caution, and may need to add research arms of people who do not receive such pre-tests.
For more details: Fagerlin A, Zikmund-Fisher BJ, Ubel PA. How making a risk estimate can change the feel of that risk: shifting attitudes toward breast cancer risk in a general public survey. Patient Educ Couns. 2005 Jun;57(3):294-9.