Dr. Kelly-Blake a co-author of new article in ‘Health Services Research and Managerial Epidemiology’

Karen Kelly-Blake photoCenter Assistant Professor Dr. Karen Kelly-Blake is co-author of an article published in Health Services Research and Managerial Epidemiology, “Sex Differences in Statin Prescribing in Diabetic and Heart Disease Patients in FQHCs: A Comparison of the ATPIII and 2013 ACC/AHA Cholesterol Guidelines.”

The team of Michigan State University College of Human Medicine researchers, Nazia Naz S. Khan, Karen Kelly-Blake, Zhehui Luo, and Adesuwa Olomu, found statin underprescribing for both men and women with atherosclerotic cardiovascular disease and diabetes mellitus in Federally Qualified Health Centers.

The full text is available online with open access via Sage Journals.

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Dr. Cabrera co-authors ‘AJOB Neuroscience’ commentary on deep brain stimulation for depression

Laura Cabrera photo“Interpreting Patients’ Beliefs About Deep Brain Stimulation for Treatment-Resistant Depression: The Need for Caution and for Context” is an open peer commentary available in the latest AJOB Neuroscience issue. Michigan State University co-authors Dr. Laura Cabrera, Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Translational Science & Molecular Medicine, and Dr. Robyn Bluhm, Associate Professor in the Department of Philosophy and Lyman Briggs College, are currently working on an NIH BRAIN Initiative funded project on a related topic.

Dr. Cabrera and Dr. Bluhm focus on two points raised by the Lawrence et al. paper. First, they discussed a couple methodological decisions made by the authors which may have had an important influence on the results presented in the article. The second point relates to the work of Dr. Cabrera and Dr. Bluhm, examining differences in the bioethics literature’s discussion of deep brain stimulation and public comments on newspaper and magazine studies covering the intervention; this part of the open peer commentary shows how their findings can help to deepen the analysis by Lawrence et al.

The full text is available online via Taylor & Francis Online (MSU Library or other institutional access may be required to view this article).

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Bioethics for Breakfast: Addressing Maternal Mortality in the Childbearing Year

Bioethics for Breakfast Seminars in Medicine, Law and SocietyEvery woman who dies during or after pregnancy has a story to tell, a story that can teach us how to prevent other maternal deaths.

Renée Canady, PhD, MPA, and Cheryl Larry-Osman, RN, MS, CNM, presented at the February 21st Bioethics for Breakfast event, offering perspectives and insight on the topic “Just Caring for All Michigan Mothers: Addressing Maternal Mortality in the Childbearing Year.” Drawing from the 2018 Michigan Maternal Mortality Surveillance report, the speakers reminded the audience that “every woman who dies during or after pregnancy has a story to tell, a story that can teach us how to prevent other maternal deaths.” The presenters introduced the session with compelling personal experiences, illustrating the scope and scale of the problem. Using an ethics yardstick Dr. Canady then invited the 33-member audience to respond to graphic depictions of the U.S. maternal mortality death rate – the highest rate within the developed world. Those numbers give evidence of a profound social injustice and a need to modify resource allocation accordingly.

Yet as in much of the U.S., evidence suggests that Michigan has not met the mark. As the speakers noted, race matters – a lot. From 2011-2015 Black women in Michigan were found to be three times more likely than white women to die of a pregnancy-related cause; upon review nearly half (44%) were considered preventable. Black mothers in Michigan were twice as likely to die from a pregnancy-associated cause; upon review, 39% were deemed preventable. Social and medical advances have disproportionately failed to address pregnancy needs for Black mothers. Sociodemographic variables do not fully explain the observed gap – the disparities are rooted in multilevel (system, practitioner, patient) inequalities including place, communication, and discrimination. A health equity approach recognizes that one must comprehensively address institutional racism, class oppression, and exploitative gender discrimination.

As a just and caring society we have an obligation to ensure safe and healthy pregnancy and birth experiences for all mothers. Ms. Larry-Osman noted that a virtue ethics approach leans on the character of health professionals to engage compassion, reason and discipline in the interest of maternal well-being. In concert, a communitarian ethics approach emphasizes shared values, ideals and goals to identify barriers to care as well as interventions and solutions. As reported by attendee Lynette Biery, Maternal Child Health Director at the Michigan Department of Health and Human Services, maternal mortality reviews such as the Michigan Maternal Mortality Surveillance Program provide data necessary to address changes that would improve women’s health before, during and after pregnancy. Michigan has seen some improvement after the 2016 implementation of hemorrhage and hypertension “safety bundles” and the MI-AIM (Alliance for Innovation on Maternal Health) is now working on opioid bundles as well. But given the scale of the problem, are such efforts enough?

Approximately 50% of Michigan women rely on Medicaid for prenatal care and give birth in a Medicaid supported hospital, but that program is targeted for cuts under the current federal administration. What is the state/physician obligation to address this? Should the state ensure the availability of labor support “doulas” as part of standard maternity care as is being done in other states? Mortality reviews help, but are they sufficient to raise awareness and address the multilevel problems? What structural strategies might best pave the way for continuity of care and community care? How can solutions avoid racist calls for “personal responsibility for heath”? What are the effects of pervasive racism and how might the state best address them? Many in audience lingered past the session’s end to continue discussing these questions. Our thanks to health law firm Hall, Render, Killian, Heath & Lyman for generously supporting these important conversations.

Renée Canady
Renée Canady, PhD, MPA, is Chief Executive Officer of the Michigan Public Health Institute. She is a nationally recognized thought leader in health disparities and inequities, cultural competence, and social justice. She additionally is Assistant Professor in MSU’s Division of Public Health within the College of Human Medicine. In her scholarly work, she emphasizes the social context of mental and physical health, and the pregnancy experiences of African-American women.

Cheryl Larry-Osman
Cheryl Larry-Osman, RN, MS, CNM, is a Perinatal Clinical Nurse Specialist at Henry Ford Hospital (Detroit). She additionally is trained as a Healthcare Equity Ambassador for the hospital and serves as a cultural competency and healthcare equity expert within that system. She has over 18 years of experience in obstetrics and is a passionate advocate for the optimal and equitable care of women and children.

About Bioethics for Breakfast:
In 2010, Hall, Render, Killian, Heath & Lyman invited the Center for Ethics to partner on a bioethics seminar series. The Center for Ethics and Hall Render invite guests from the health professions, religious and community organizations, political circles, and the academy to engage in lively discussions of topics spanning the worlds of bioethics, health law, business, and policy. For each event, the Center selects from a wide range of controversial issues and provides two presenters either from our own faculty or invited guests, who offer distinctive, and sometimes clashing, perspectives. Those brief presentations are followed by a moderated open discussion.
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What social and ethical challenges are presented by female cosmetic genital surgery?

bbag-blog-image-logoFemale Cosmetic Genital Surgery: Social and Ethical Considerations

Event Flyer

In recent years, there has been an upsurge in plastic surgery for women who wish to alter the look and feel of their genitalia. The women who undergo these procedures claim they are empowering, but critics worry such surgeries pathologize normal genital appearance. Several surgeons are also using social media to document these surgeries, granting them greater visibility and legitimacy. This talk will discuss the latest innovations in female cosmetic genital surgery, the history behind the medical community’s involvement in defining women’s sexuality, and the ethical and social challenges these surgeries present.

March 13 calendar iconJoin us for Dr. Stahl’s lecture on Wednesday, March 13, 2019 from noon until 1 pm in person or online.

Dr. Devan Stahl is an Assistant Professor of Clinical Ethics in the Center for Ethics and Humanities in the Life Sciences at Michigan State University. She received her Ph.D. in Health Care Ethics from St. Louis University. Dr. Stahl teaches medical students and residents in the College of Human Medicine and performs ethics consultation services at hospitals in Lansing, Michigan. Her research interests include medicine and the visual arts, theological bioethics, and disability studies. Dr. Stahl’s recent book, Imaging and Imagining Illness: Becoming Whole in a Broken Body, examines the power of medical images and their impact on patients and the wider culture.

In person: This lecture will take place in C102 Patenge Room in East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? All webinars are recorded! Visit our archive of recorded lecturesTo receive reminders before each webinar, please subscribe to our mailing list.

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What happens when people express hope for a miracle in the context of medicine?

No Easy Answers in Bioethics logoNo Easy Answers in Bioethics Episode 12

How do patients, their families, or their caregivers express hope for a miracle in the clinical setting? How can medical professionals respond to these desires for a miracle to occur?

Guests Dr. Devan Stahl, Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and Department of Pediatrics and Human Development at Michigan State University, and Dr. Trevor Bibler, Assistant Professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine, have written on this topic, with articles published in the American Journal of Bioethics and the Journal of Pain and Symptom Management. In this episode they discuss the framework for categorizing the various ways in which people hope for a miracle, while also drawing from experiences they have had as clinical ethicists. They also discuss the importance of not making assumptions when miracle language is used, emphasizing the need for all religious beliefs to be respected by medical professionals.

Ways to Listen

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: “While We Walk (2004)” by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License. Full episode transcript available.

About: No Easy Answers in Bioethics is a podcast series from the Center for Ethics and Humanities in the Life Sciences in the Michigan State University College of Human Medicine. Each month Center for Ethics faculty and their collaborators discuss their ongoing work and research across many areas of bioethics—clinical ethics, evidence-based medicine, health policy, medical education, neuroethics, shared decision-making, and more. Episodes are hosted by H-Net: Humanities and Social Sciences Online.

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Medicare For All: This Is Going to Hurt

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Leonard M. Fleck, PhD

Let me start with a clear unequivocal commitment in response to the January Washington Post editorial regarding Medicare for All. From the perspective of what a just and caring society ought to be, “Medicare for All” should be embraced, especially when compared to the costly, fragmented, unjust, inefficient health care financing system we currently have in the United States. For openers, if we abolished private health insurance, we would immediately achieve administrative savings of about $300 billion. We would have the same administrative efficiency as Canada. We would also have a more egalitarian approach for financing and accessing needed health care. What we would NOT have is effective health care cost control. Developing that ability would be ethically, politically, and economically painful.

If we literally mean Medicare for all, recall that substantial co-payments are part of Medicare, which is why a majority of Medicare recipients purchase a private supplementary plan to cover that financial risk. That necessary additive supplement represents a significant compromise of the egalitarian ideal that Medicare is supposed to represent. That represents financial and ethical pain.

The most painful parts of Medicare for All would be three things: (1) the transition itself from employer-funded health care; (2) the scope of the benefit package; and (3) effective cost control. Currently, the federal government covers about $1.5 trillion in health care costs (mostly Medicare, Medicaid and the Veterans Affairs system) out of total health spending in the U.S. in 2017 of $3.5 trillion. Virtually all of that spending would become part of the federal budget. To fund that, the federal government would have to recapture through taxes all that employers (and employees) currently contribute to the cost of their health plan. This would be neither easy nor equitable because of the huge variation from one employer to another, both in scope of coverage and allocation of costs.

Individual holding Medicare For All sign

An individual is photographed holding a sign up above their head that reads “Love it! Improve it! Medicare For All!” Image source: Glyn Lowe PhotoWorks/Flickr Creative Commons

Second, what should be the scope of the benefit package? Should it be whatever Medicare covers now, which is reasonably comprehensive? However, many employers offer more comprehensive benefit packages. That would mean employees had to accept a diminished benefit package. Alternatively, the federal government could upgrade Medicare to that optimal level. That would add substantially to that $3.5 trillion in current health spending, and the taxes needed to finance that upgrade. This is political and economic pain. We could permit private insurance upgrades, as in the UK, or forbid such upgrades, as in Canada. Either way, political and ethical pain is the result.

Third, the most painful problem would be controlling health care costs, as the former Princeton economist Uwe Reinhardt has noted with his notion of Great Equations, Cost Control = Income Control or Care Control. Every dollar in health care costs represents someone’s income, and that particular someone does not want to sacrifice their own income for a vague greater good, or someone else’s care. This is the problem of health care rationing.

Political conservatives have denounced health care rationing and contended that “human life is priceless,” (to the benefit of pharmaceutical companies). Liberals have argued that we should not be “throwing granny off a cliff” (when Paul Ryan pushed for privatizing Medicare). In either case, rationing is in fact pervasive in the U.S. health care system. We mostly ration by ability to pay, sometimes in the form of employer-restricted very thin health care coverage or coverage with very high deductibles. We collectively avert our eyes from this private pain.

As I have written extensively, this is essentially invisible health care rationing (Fleck, 71-99). It is widely dispersed among hundreds of thousands of employers. An employer might refuse to cover an extraordinarily expensive (but effective) life-prolonging drug for an employee who dies prematurely because of that denial. The obituary will not list rationing as the cause of death, and the Washington Post will not cover this unjust death.

If Medicare covers everyone, however, then decisions by Medicare not to fund these extraordinarily expensive targeted cancer therapies for patients with metastatic cancer become front-page headlines in the Washington Post and the lead story on Fox News. Pharmaceutical companies become the frontline troops in attacking the bureaucrats for having hearts of stone and consciences of jelly: “Human life is priceless (and pharmaceutical profits too).” In fairness, hospitals, physicians, home health agencies, long-term care facilities and so on will all resist health care cost control. They are all doing good work. Why, they will ask rhetorically, would a just and caring society seek to constrain such good work?

Healthy taxpayers want health care costs controlled; taxpayers with metastatic cancer want access to anything and everything medicine offers that might prolong their life, no matter the cost (because they paid all those taxes) (Eddy). This is irrational (but real). One refrain (seen as politically safe) is to get rid of waste and inefficiency in the health care system. Nothing obviously irrational or unethical about that, except that one person’s waste and inefficiency is another person’s life-prolonging care.

Consider this challenge as part of Medicare for All: CAR T-cell immunotherapy for several refractory leukemias has front-end costs of $475,000, plus several hundred thousand dollars more if a patient experiences a severe form of cytokine release syndrome as a side effect. Roughly, 30% of those patients will fail to survive a year. If we have biomarkers and other medical criteria that can predict with 95% confidence which patients will be in that 30%, would a future possible version of yourself in that 30% group accept a rationing protocol that would deny yourself CAR T-cell therapy because for you it was “wasteful and inefficient”? In theory, 60,000 Americans each year would be candidates for this therapy; potential savings from that protocol would be $15 billion. Alternatively, call a friend with end-stage heart disease and ask if he would be willing to give up his $500,000 artificial heart so you can get CAR T-cell therapy.

If we aspire to be a just and caring society with limited resources (money) to meet unlimited health care needs, then we must have these painful public conversations. Moreover, these conversations must be rational and respectful. Current invisible rationing practices are nothing more than opioids for our consciences.

Fleck smallLeonard M. Fleck, PhD, is Acting Director and Professor in the Center for Ethics and Humanities in the Life Sciences and Professor in the Department of Philosophy at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, March 7, 2019. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

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New article from Dr. Cabrera’s research team in ‘Social Science & Medicine’

Laura Cabrera photoCenter Assistant Professor Dr. Laura Cabrera is co-author of an article in the January issue of Social Science & Medicine. The article, “Online comments about psychiatric neurosurgery and psychopharmacological interventions: Public perceptions and concerns,” was written by Dr. Cabrera, Marisa Brandt, Rachel McKenzie, and Robyn Bluhm.

The study was supported by a Science and Society at State (S3) internal Michigan State University grant, “Psychiatric Interventions: Values and Public Attitudes.”

Abstract: The field of biological psychiatry is controversial, with both academics and members of the public questioning the validity and the responsible use of psychiatric technological interventions. The field of neuroethics provides insight into these controversies by examining key themes that characterize specific topics, attitudes, and reasoning tools that people use to evaluate interventions in the brain and mind. This study offers new empirical neuroethical insights into how the public responds to the use and development of psychiatric technological interventions by comparing how the public evaluates pharmacological and neurosurgical psychiatric interventions, in the context of online comments on news media articles about these topics. We analyzed 1142 comments from 108 articles dealing with psychopharmacological and psychiatric neurosurgery interventions on websites of major circulation USA newspapers and magazines published between 2005 and 2015. Personal anecdote, medical professional issues, medicalization, social issues, disadvantages, scientific issues and cautionary realism were among the main themes raised by commenters. The insights derived from the comments can contribute to improving communication between professionals and the public as well as to incorporating the public’s views in policy decisions about psychiatric interventions.

The full text is available online via Science Direct (MSU Library or other institutional access may be required to view this article).

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