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Evening Ethics Discussions 2019

 

“Is It Ethical for Physicians to Strategically Lie to Third-Party Payers On Behalf of Their Patients?” with Saundra Buys, MD, and Susan Sample, PhD, MFA

Deception, or the intentional falsification of information, is not typically considered an acceptable moral norm in American society. Yet when a patient’s survival depends upon an unaffordable, expensive procedure or prescription, the ethical issues become complicated. Physicians are trained to put their patients’ interests first—to advocate for them. Insurance policies are guided by a different ethic: to restrain burgeoning healthcare costs and to manage the use of limited resources. When, if ever, are physicians justified to withhold information or provide inaccurate information to insurance companies in order for patients to receive what their doctors consider to be medically necessary care? Under what conditions does the rule of patient priority take precedence over rules of truthfulness and disclosure, both of which are considered foundational in health care? Should third-party payers be regarded as not having the right to certain information, particularly if insurance coverage policies seem unjust? Are there workable solutions that might help relieve these ethical tensions between physicians and the third-party payer financial gatekeepers? Please join us for what is sure to be an interesting discussion. The background reading for this session can be found at:

https://www.nytimes.com/2018/06/21/well/the-strategic-lies-of-oncologists.html 

“Informed consent: enduring challenges and opportunities” With Jeffrey Botkin MD, MPH, 2019 David Green Memorial Speaker

The 70th anniversary of the Nuremberg Code was celebrated in 2017. The code is a set of principles intended to guide the conduct of research in the aftermath of the Nazi experiments during WWII, with the first principle reading, “The voluntary consent of the human subject is essential.” The year 2019 will be the 40th anniversary of the Belmont Report, drafted in the aftermath of the Tuskegee syphilis experiments to provide a foundation for ethics and regulations governing human subjects research. Yet, despite decades of experience, ethical analysis, and regulatory oversight, informed consent for research is commonly described as broken. In this discussion, we will discuss the current limitations of the consent form and process and the challenges to achieving informed decision-making in clinical research and clinical care. Several strategies to improve the form and process will be discussed. For background reading before this discussion, please contact linda.carrlee@hsc.utah.edu

“Ethical and practical challenges with shared decision making in serious illness” with 2019 Cowan Memorial Lecturer, Douglas B. White, MD, MAS

This session will focus on the ethical and practical complexities of shared decision making between clinicians and surrogate decision makers of patients with advanced illness. For example, although there is broad support that surrogates should be involved in making preference sensitive medical decisions near the end of life, there remains controversy about how best to accomplish this. Moreover, there are legitimate questions about what It means to truly “share” in decision making with patients, and whether there are limits to shared decision making for incapacitated patients near the end of life. Background article for this session is Shared Decision Making in ICUs: An American College of Critical Car Medicine and American Thoracic Society Policy Statement. Kon AA, Davidson JE, Morrison W, Danis M, White DB; American College of Critical Care Medicine; American Thoracic Society. (Crit Care Med. 2016 Jan;44(1):188-201.) (Contact linda.carrlee@hsc.utah.edu for a copy of this article.)

Our 2019 Cowan Memorial Lecturer is Douglas B. White, MD, MAS. Dr. White is University of Pittsburgh Medical Center (UPMC) Chair for Ethics in Critical Care Medicine, Professor, Departments of Medicine and Critical Care Medicine, University of Pittsburgh School of Medicine, and Director, Program on Ethics and Decision Making in Critical Illness, CRISMA Center, Department of Critical Care Medicine.

 "Exploring Frida Kahlo's Artistic Expression of Her Body to Reclaim the Art of Medicine" with Dani Golomb, 3rd year medical student and Susan Sample, PhD, MFA

Dani Golomb, a third-year medical student at the University of Utah, presented a unique poster in February 2018 at the Mount Sinai Third Annual Medical Student Conference, “Becoming a Physician:  Ethical Challenges in Medical Education.”  Golomb drew upon Marxist theory to understand how medicine has become a commodity that negatively impacts patient care.  As she writes:

There is a transformative magic that does its work under the veil of capitalism.  As Karl Marx wrote, workers imbue the objects of their labor (the commodities) with their own humanity.  As a result, the commodities become animated, and the workers, objectified.  Under the guise of modern health care and medical education, a similar phenomenon occurs.  The insistence on evidence-based medicine and outcome-driven treatment goals causes patients to become objects while their diseases become life-like.  The art of medicine is lost.

Medical students are the next generation of doctors, so it is essential that we explore, analyze, and deconstruct the “objectivity” that engulfs our health-care and education systems. We must take meticulous care to reclaim the art and profound responsibility of medicine.  For both guidance and inspiration, I look to the oeuvre of Frida Kahlo.  The Mexican artist was no stranger to illness or pain—scoliosis, polio, and most significantly, a near-fatal bus accident.  What launched “her artistic voice as a painter of personal traumas and self-realization,” however, was a devastating and complicated abortion she had while living in Detroit in 1932. She struggled with injuries the rest of her life, attempting to integrate her suffering with the help of both her doctors and her art. 

Golomb will present artwork by Kahlo and her husband, Diego Rivera, the well-known muralist, to begin our discussion.  What do we learn from their paintings as to how medical trainees as well as health-care providers can return dignity to our patients and work with them toward healing their suffering?  How does their art challenge us to be accepting of a patient’s humanity, individuality, and intrinsic uncertainty?

For Background readings, Please contact linda.carrlee@hsc.utah.edu

Ethical Issues Surrounding Medical Marijuana

Last December, the Utah State Legislature enacted a replacement bill for Prop 2.  The Utah Medical Cannabis Act presents many complex issues for health care systems.  These include whether to offer medical cannabis, which providers should become qualified medical professionals for medical cannabis, how to certify patients, and whether to make available to patients information about whether medical cannabis is offered.  Because a number of institutions must be in place before the Act is fully operational, health care systems will also face ethical issues in managing the transitional period.  For example, the Act requires establishment of a Compassionate Use Board to consider approvals for medical cannabis of patients who do not have a listed qualifying condition or who are under 21 but who seek approval for their use of medical cannabis.  

 As background preparation for this session, the University of Utah's statement can be found at  https://healthcare.utah.edu/medical-marijuana/ You might also want to look at this, reporting on Intermountain, https://www.deseret.com/2019/2/14/20665864/intermountain-healthcare-gives-its-utah-doctors-ok-to-recommend-medical-marijuana. In addition, for a fact sheet from the Utah Department of Health on the Medical Cannabis Act that may be helpful contact linda.carrlee@hsc.utah.edu

Being White in Healthcare – Exploring Biases, Privilege, and Outcomes with Amy Cowan, MD and Susan Sample, PhD, MFA

This discussion is intended to recognize how pervasive systemic racism is in our society, shaping our lives. We will explore what we do that supports racism and how we can interrupt it.  In medicine, white is the default, considered the "norm"; often being white is never mentioned. Our discussion will flip the script, exploring what it means to see white.  Participants will view photographs from Myra Greene’s work, My White Friends, as an entry point for discussion. Can surroundings, spaces and environments like the hospital, be white? And why does talking about being white make us uncomfortable?  Focusing on the healthcare setting, data on under-represented students in medical school and residency, and current pay discrepancy among women and people of color,  we will discuss how our biases play a role and what happens to our patients in all of this. 

Suggested Background Readings:

Going Blind: Coming out of the dark about vision loss--A film screening and Q&A with Film Director, Joseph Lovett

This Evening Ethics is presented in collaboration with the Center for Disability & Access, Disability Studies Program, Moran Eye Center, National Center for Veterans Studies, and the Spencer S. Eccles Health Sciences Library (EHSL).

Going Blind is a unique documentary film by Peabody Award-winning producer/director Joseph Lovett that increases public awareness of sight loss and low vision issues profoundly affecting the lives of more and more people around the world.  It tells the stories of everyday people and how they live successfully in today’s world with vision loss.  Each has a fascinating story about dealing with the vision loss caused by sight-robbing diseases, infections, and accidents.  The film looks at each aspect of vision loss, detecting, treating, and coping, from the point of view of the patient.

In a review of the film, the British Journal of Ophthalmology describes the film as “an uplifting documentary…that instills inspiration to lead a productive life” and the Washington Post stated, “Going Blind encourages and inspires people to take action to preserve, prolong, and maximize the precious gift of sight…”

About Joseph Lovett:  Joseph Lovett is an award-winning filmmaker, whose films have informed, engaged and inspired people into action. Joe’s film, Going Blind, and its Outreach Campaign, Going Blind and Going Forward, have ignited a global movement of individuals, grassroots organizations and medical professionals sponsoring screenings to raise awareness and to improve access to vision enhancement services.

Misfits between the law and people with opioid use disorders with Leslie Francis, JD, PhD and Teneille Brown, JD

 

PARCKA and Evening Ethics will discuss some of the ways in which current federal and state law do not mesh well with the treatment needs of people with opioid use disorder. Professor Teneille Brown will explain how drug court functions, the advantages of drug court for people who are charged with non-violent offenses and who suffer from addiction, and discuss stigmas and anti-discrimination law in opioid use disorder.  Professor Leslie Francis will discuss problems with employment discrimination and housing discrimination law because current drug use is not considered a disability and people may lose housing subsidies if they or their relatives plead no contest to charges involving drugs. 

The Evening Ethics session has two background readings: (1) ILLEGAL SUBSTANCE ABUSE AND PROTECTION FROM DISCRIMINATION IN HOUSING AND EMPLOYMENT: REVERSING THE EXCLUSION OF ILLEGAL SUBSTANCE ABUSE AS A DISABILITY (Leslie Francis, Utah Law Review, 2019) and (2) Social Stigma Toward Persons With Prescription Opioid Use Disorder: Associations With Public Support for Punitive and Public Health–Oriented Policies (A. Kennedy-Hendricks, et.al., Psychiatric Services 68:5, May 2017)

This Evening Ethics is presented in collaboration with the Division of Epidemiology's Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA) The noon-1PM, October 15th  PARCKA Parley session will have a policy emphasis; the October 22nd,  5:30pm-7:00pm Evening Ethics session will have an ethics emphasis. Each session will stand alone, but build on each other, so that you can attend one or both.

"Patients, Parents, and Professionals: Ethical Issues in the Treatment of Trans Adolescents" with 2019-20 David Green Speaker, Armand H. Matheny Antommaria, MD, PhD, FAAP

 Armand H. Matheny Antommaria, MD, PhD, FAAP, Director, Ethics Center, Lee Ault Carter Chair of Pediatric Ethics, Cincinnatti Children Hospital, Attending Physician, Division of Hospital Medicine, Associate Professor, University of Cincinnatti Department of Pediatrics, will be our 23rd Annual David Green Lecturer.

Medical treatment of trans adolescents is controversial. Proponents of hormonal and surgical treatment emphasize the high rates of depression and suicide in this population. Opponents contend that evidence supporting the current standard of care is lacking and highlight individuals who regret their treatment. Our discussion will focus on ethical issues such as the following: What are the potential benefits, risks, and alternatives to treatment with puberty blockers and gender affirming hormonal and surgical treatment? What does reversibility mean in this context and what role should it play in the ethical analysis? May health care professionals refuse to treat trans patients and what constitutes medical neglect in this domain?

For background readings before this discussion, please contact linda.carrlee@hsc.utah.edu
                                                                  ********

For those interested, Dr. Antommaria will be presenting the David Green Lectureship, “Establishing Goals of Care and Ethically Limiting Treatment” at Pediatric Grand Rounds the next morning, Thursday, December 5th, 2019, 8 am, Primary Children’s Hospital, 3rd floor Auditorium.
 

Polygenic Risk Scores for Embryo Selection: Making a Healthier Human, or a False Promise? with Erica B. Johnstone, MD & Erin Rothwell, PhD

Polygenic risk scores have been developed from genome-wide association studies, and incorporate data on numerous genetic polymorphisms to predict the chances that an individual will develop a given disease.  The original goal of this tool was to enable early intervention for individuals at high risk of disease, in the hopes of preventing illness or mitigating its consequences.  This technology can now be applied to human embryos.  Will this technology offer parents the opportunity to prevent disease in their children, in the vein of preimplantation genetic diagnosis for Mendelian disorders such as spinal muscular atrophy? Or are children placed at risk by premature adoption of an intervention with uncertain outcomes? When and how should polygenic risk scores for embryo selection be offered? How should this innovation be evaluated before making it clinically available?

Background Reading:

https://www.biorxiv.org/content/biorxiv/early/2019/05/05/626846.full.pdf

"Caring--How can we work together to address drug shortages and drug costs?" with Erin Fox, PharmD, BCPS, FASHP and Jim Ruble, PharmD, JD

Drug shortages and high drug prices can both affect patient access to criti-cally needed medications. Medications cannot be effective, if patients can’t obtain needed treatments. In some cases, shortages and high prices lead to rationing, as well as tension in patient-provider relationships. Our discussion will focus on some of the ongoing actions to improve drug shortages and high prices. We will also provide some information about how patients can lower their drug costs, and communication tips for dialogue between clinicians and their patients.

Recommended background readings for this discussion:

For an overview on shortages: https://www.mayoclinicproceedings.org/article/S0025-6196(13)01043-4/abstract

For the most current stats on shortages: https://www.ashp.org/Drug-Shortages/Shortage-Resources/Drug-Shortages-Statistics

For an overview on drug pricing: https://hbr.org/2017/04/how-pharma-companies-game-the-system-to-keep-drugs-expensive

Healthcare: Stories of Rebellion (UtahPresents Collaboration)

Following last season’s powerful performance, our healthcare-themed storytelling event returns this year with the first of two new topics. Healthcare: Stories of Rebellion will highlight how we navigate illness, treatment, and the “way it’s always been done.” With some storytellers selected from the audience, the evening will include prepared and impromptu true stories about making different choices, pushing back, going against the grain, and finding our own way. This is a UtahPresents event that is co-sponsored with the Program in Medical Ethics and Humanities and the University of Utah Health’s Resiliency Center.

"STUMPED: An extraordinary journey through tragedy, comedy and restoration"--film viewing and Q & A with Will Lautzenheizer

Will Lautzenheizer, after losing his arms and legs to a deadly infection, became the third patient to undergo a double-arm transplantation at the Brigham and Women’s Hospital in Boston. The documentary, STUMPED, chronicles how Will copes with the loss of his filmmaking career by pursuing stand-up comedy, how he navigates personal relationships, and how he transforms, physically and spiritually, with newly transplanted arms. STUMPED was filmed over four years. Natalia Washington, PhD and Angela Smith, PhD will facilitate discussion of the many ethical issues faced in this journey of pioneering medicine .

Will Lautzenheizer will skype in to join us for this discussion and to answer questions. Please join us and add your questions and thoughts to a long list of possible ethics topics, including informed consent in VCA transplants, cultural representations of disability, ableism, disability misconceptions that may affect decision making, resource allocation for cutting edge technological devices, the use of anti-rejection medications for non-life threatening situations, the role of insurance decisions in healthcare, federal funding for after emergent care, the role of comedy in healing, and the burden of care on families and other caregivers.

This Evening Ethics is a collaboration with University of Utah’s Burn Center and the Eccles Health Sciences Library.

DISCLOSURE:

This program is approved for 1-½ hours of CME credit.

 

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