Look at him zip around in that wheelchair. He is so independent and inspirational. But I wonder how he goes to the bathroom, if he’s really as happy as he seems, does he have sex, how does that work, is he in pain, does he work? What are the health problems he has to deal with, what are medical expenses? There are many dimensions to a happy and healthy life, and everyone would agree that life is complicated. But when multiplied by a spinal cord injury (SCI), the complexity of life can be off the charts—what we used to take for granted becomes a monumental challenge. This talk will explore life with SCI from a first-person perspective.
Join us for Mark Van Linden’s lecture on Wednesday, October 16, 2019 from noon until 1 pm in person or online.
Mark Van Linden grew up in Lansing, MI and had a very stable and nurturing childhood. Raised by his Dad, Mark attended a private high school, played basketball in college, graduated with a BS in manufacturing, and started out in his career as a manufacturing engineer in the automotive industry. His career was going very well; seemingly right on schedule he met a girl, got married, started a family, and the American Dream was well on its way to reality. Then in 2009, it was discovered that he had an aortic aneurysm, and the required surgery would replace his entire aorta from the arch to the femoral artery. During that surgery, at age 39 with two kids ages 2 and 4, he became paralyzed from the waist down. Everything he knew was now turned upside-down, and a new life was about to begin.
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.
“We overworked, underpaid, and we underprivileged They love us, they love us (Why?) Because we feed the village”
– Killer Mike of Run the Jewels
“Lie, Cheat, Steal,” Run the Jewels 2 (2014)
In the United States, persons of color suffer disproportionately from a host of health care disparities related to racism, discrimination, lack of access, and undertreatment. When considering this disproportionate suffering, it is relevant to note the impact of the current physician shortage. That shortage is especially acute for underrepresented in medicine (URiM) physicians. Moreover, it is equally salient to recognize that URiM physicians provide care for underserved populations at levels disproportionate to their professional representation. There is a powerful narrative that a diverse and representative medical workforce, one reflecting general population characteristics, can effectively address access issues, increase satisfaction, and ultimately improve health outcomes. It seems reasonable to surmise that shared concordant characteristics (e.g. race/ethnicity, language, gender, geographic location, etc.) between patients and physicians might lead to improved communication and satisfaction in the clinical setting. Alsan et al. found that black patients paired with black physicians were more likely to agree to preventive screening, leading the authors to conclude that the racial/ethnic concordance between patient and physician was a significant factor for the observed increase in screening adherence. Kelly-Blake et al. found that the most mentioned rationales for increasing patient-physician concordance were patient-physician relationship and service commitment to care for the underserved.
A 2001 IOM (now the National Academy of Medicine) report warned that “we must be vigilant against the potentially pernicious effects of creating the expectation that minority physicians are being trained solely to provide health care services to minority patients or to research minority health issues.” It is now 2019 – nearly 20 years on – and so it seems a good time to revisit that prudent caution. Have we heeded the IOM’s prescient warning? I invite you to join me for a brief thought experiment. Suppose we made the profession of medicine responsible for caring for our most vulnerable—the sickest sick and poorest poor? Imagine that all patient panels included a significant number of homeless, poor, mentally ill, and uninsured. Imagine an equal, fair, and just distribution of medical care service to the underserved. The described distribution would lighten the service expectation on URiM physicians. We know that URiM physicians bear a disproportionate burden of providing care for the most vulnerable patients in the most challenging resource poor environments. It’s not unreasonable to imagine how such a burden might substantially constrain their ability to meet quality care metrics for reimbursement. Moreover, as we move from volume to value for reimbursement, for those URiM physicians who carry comparably higher educational loan debt and work to a greater degree than their white counterparts in resource poor communities with the sickest sick, the challenge of achieving measurable improvements in quality care would seem untenable.
The individual altruistic motivations of URiMs to “give back,” “make a difference,” and “help the community” are powerful. And indeed, those motivations are likely influenced by “community” expectations that people will return “home” to practice. Certainly, URiMs have valuable insider experiential knowledge about navigating the challenging, socially-layered U.S. landscape. Those perspectives would undoubtedly bring an enhanced sociocultural perspective to the clinical encounter. Community expectations align with similar sentiments. Individuals coming from underserved communities who desire to become a physician are often supported, encouraged and, yes, expected to come back to serve in the community. The community understandably holds out hope that someone from the neighborhood will come back and do good work for the community. While understandable, is such a community expectation fair?
Image description: an individual with angel wings wearing blue surgical scrubs, a face mask covering their mouth, a cap, and glasses is standing with their arms crossed in front of a neutral background. They have a stethoscope around their neck. Image source: Sathish Kumar Periyasamy from Pixabay.
Desire to serve and to give back are laudable and admirable virtues, but is the “narrative of service” subtext disproportionately and perhaps unfairly limiting URiM potential professional opportunities? In our desire to have URiMs serve the underserved as physicians, are we paradoxically denying them opportunities to serve the profession of medicine as Chairs of Departments, Deans of Medical Schools, Chief Executive Officers of Hospitals, or Heads of NIH? Are we saying, “welcome to the house of medicine, but we need you to work in the basement kitchen”? If URiM have become the workhorses of medicine, who then is provided the opportunity to become the stallions and thoroughbreds? White medical student and physician counterparts do not receive the same targeted messaging about service commitment.
Research has shown that higher numbers of primary care physicians lead to better health and decreased mortality. Despite the call and the need for more primary care physicians, medical students are not choosing primary care specialties. Mona Signer, CEO of The Match, suggests that income is a factor because choosing a non-primary care specialty means a higher paycheck. The highest paying specialties remain overwhelmingly white and male. Who then is allowed the unfettered freedom to make the non-primary care specialty choice? Who gets to have access to opportunities untied to community and societal expectations? The burden of serving exhausts URiM talent and expertise. So, who reaps the benefits? If the argument is that: 1) society benefits from more primary care physicians in underserved areas, especially critical in rural areas, 2) medical schools benefit by meeting more stringent LCME accreditation requirements for student diversity, and 3) patients benefit by having physicians in their community that look like and sound like them, then undertaking strategies to ensure a broadly representative medical workforce is indeed a national priority. But, if the argument is that URiM value is to “serve the underserved” then the IOM warning has indeed been ignored. Racial congruity alone is insufficient to address the disparities gap in U.S. health care, and like-to-like patient-physician matching may dangerously and perversely heighten discrimination against URiM physicians.
URiM should not be selectively steered, based solely on assumptions of their background, to pursue a particular medical career pathway. The healthcare workforce should reflect the nation’s population and equally, it is still fair and just to question why we are channeling URiMs to do work not expected of the entire medical workforce. How might we ensure equity of healthcare work practice? Ensuring such equity is a moral obligation and the rightthing to do. Professional fairness and responsibility within medicine mandate that the medical workforce equitably and fairly assume shared responsibility for meeting the healthcare needs of the underserved. Continuing an expectation of burdening the already overburdened is not just health care.
Karen Kelly-Blake, PhD, is an Associate Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine in the Michigan State University College of Human Medicine.
Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, August 1, 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.
Center 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.
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.
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.
Leonard 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.
Medicine has long been one of the most self-regulating of all professions. In the 1970s, the new field of bioethics was designed to challenge this prevailing system. As Senator Ted Kennedy explained at the founding of Georgetown’s Kennedy Institute of Ethics, “Human life is too precious and the decisions regarding it too important to leave to any one group of specialists.” Still, even fifty years later, medicine remains largely self-regulating. And patients have suffered. In this presentation, Professor Pope will discuss recent initiatives to constrain the scope of physician discretion and how these initiatives improve patient safety and protect patient rights. He will place particular emphasis on the growing transition from traditional informed consent to shared decision-making with patient decision aids.
Join us for Dr. Pope’s lecture on Wednesday, October 10, 2018 from noon until 1 pm in person or online.
Thaddeus Mason Pope, JD, PhD, is Director of the Health Law Institute and Professor of Law and at Mitchell Hamline School of Law in Saint Paul, Minnesota. He is also: (1) Adjunct Professor with the Australian Centre for Health Law Research at Queensland University of Technology; (2) Adjunct Associate Professor with the Alden March Bioethics Institute at Albany Medical College; and (3) Visiting Professor of Medical Jurisprudence at St. Georges University. Professor Pope has over 140 publications in: leading medical journals, law reviews, bar journals, nursing journals, bioethics journals, and book chapters. He coauthors the definitive treatise The Right to Die: The Law of End-of-Life Decisionmaking. And he runs the Medical Futility Blog (with over three million page views).
In person: This lecture will take place in E4 Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.
Borderline personality disorder (BPD) is a serious mental illness that effects 2-3% of the population, is highly stigmatized, and is often comorbid with other mental disorders. Although no pharmaceutical interventions exist, long-term psychotherapy has been shown to alleviate the symptoms of BPD. Nonetheless, behavioral health care professionals often hesitate to discuss BPD with their patients even when it is clear they have this disorder. Why do psychiatrists, in particular, fall silent? In this talk, Dr. Sisti will sketch the history of BPD and describe ethical arguments for and against of therapeutic nondisclosure. Dr. Sisti will summarize empirical data regarding psychiatrist nondisclosure of BPD, including recent research conducted by his team at Penn. Dr. Sisti will argue that diagnostic nondisclosure, while well-intentioned, can have long-term negative consequences for patients, caregivers, and the health system more generally. As a form of therapeutic privilege, nondisclosure of BPD is ethically inappropriate.
Join us for Dr. Sisti’s lecture on Wednesday, September 19, 2018 from noon until 1 pm in person or online.
Dominic Sisti, PhD is director of the Scattergood Program for the Applied Ethics of Behavioral Health Care and assistant professor in the Department of Medical Ethics & Health Policy at the University of Pennsylvania. He holds secondary appointments in the Department of Psychiatry, where he directs the ethics curriculum in the residency program, and in the Department of Philosophy. Dominic’s research examines the ethics of mental health care services and policies, including long-term psychiatric care for individuals with serious mental illness and ethical challenges in correctional mental health care. He also studies how mental disorders are defined, categorized, and diagnosed with a focus on personality disorders. Dr. Sisti’s writings have appeared in peer-reviewed journals such as JAMA, JAMA Psychiatry, Psychiatric Services, and the Journal of Medical Ethics. His work has been featured in popular media outlets such as the New York Times, NPR, Slate, and The Atlantic. Dr. Sisti received his PhD in Philosophy at Michigan State University, working under the supervision of Professor Tom Tomlinson. A native of Philadelphia, Dominic received his Master’s degree in bioethics from the University of Pennsylvania and his bachelor’s degree from Villanova University.
In person: This lecture will take place in C102 East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.
Center Professor Dr. Leonard Fleck has a new article published in the April 2018 issue of Cambridge Quarterly of Healthcare Ethics. The article, “Controlling Healthcare Costs: Just Cost Effectiveness or “Just” Cost Effectiveness?,” appears in a special section on justice, healthcare, and wellness.
Abstract: Meeting healthcare needs is a matter of social justice. Healthcare needs are virtually limitless; however, resources, such as money, for meeting those needs, are limited. How then should we (just and caring citizens and policymakers in such a society) decide which needs must be met as a matter of justice with those limited resources? One reasonable response would be that we should use cost effectiveness as our primary criterion for making those choices. This article argues instead that cost-effectiveness considerations must be constrained by considerations of healthcare justice. The goal of this article will be to provide a preliminary account of how we might distinguish just from unjust or insufficiently just applications of cost-effectiveness analysis to some healthcare rationing problems; specifically, problems related to extraordinarily expensive targeted cancer therapies. Unconstrained compassionate appeals for resources for the medically least well-off cancer patients will be neither just nor cost effective.
The full text is available online through Cambridge University Press (MSU Library or other institutional access may be required to view this article).
Health care institutions are becoming increasingly deliberate about philanthropic fundraising given the need to sustain their missions in the face of decreases in governmental research funds and lowering reimbursement for clinical care. Donations from grateful patients constitute 20% of all philanthropic contributions to academic medical centers, totaling nearly $1 billion a year in recent years. Institutions frequently employ development professionals to facilitate philanthropy. The development literature describes various approaches for identifying patients capable of contributing, cultivating potential donors, and engaging physicians in the solicitation of grateful patients, emphasizing that patients themselves may also benefit from exercising altruism in this way. However, little evidence exists to guide the ethical practice of grateful patient fundraising, and concerns exist regarding privacy and confidentiality, patient vulnerability, and physicians’ conflicts of obligations in this context. Therefore, we will discuss how the process of philanthropic development should be structured in order to demonstrate respect for all persons involved, including patients who donate, those who might consider donation, those who do not wish to donate, and those who cannot afford to do so.
Join us for Dr. Jagsi’s lecture on Wednesday, April 11, 2018 from noon until 1 pm in person or online.
Reshma Jagsi, MD, DPhil, is Professor and Deputy Chair in the Department of Radiation Oncology and Director of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan. She graduated first in her class from Harvard College and then pursued her medical training at Harvard Medical School. She also served as a fellow in the Center for Ethics at Harvard University and completed her doctorate in Social Policy at Oxford University as a Marshall Scholar. Dr. Jagsi’s medical research focuses on improving the quality of care received by breast cancer patients, both by advancing the ways in which breast cancer is treated with radiation and by advancing the understanding of patient decision-making, cost, and access to appropriate care. Her social scientific research includes research into issues of bioethics arising from cancer care and research regarding faculty development and gender issues, including studies of women’s representation in the medical profession. Dr. Jagsi is the author of over 200 publications in peer-reviewed journals, including The New England Journal of Medicine and JAMA. Her research has been funded by the National Institutes of Health through multiple R01 awards, as well as by numerous philanthropic foundations, including the American Cancer Society, the Robert Wood Johnson Foundation, and the Doris Duke Foundation. She has been elected to the Board of Directors of the American Society of Clinical Oncology (ASCO), for which she formerly served as Ethics Committee Chair, and the Steering Committee of the Group on Women in Medicine and Science of the American Association of Medical Colleges (AAMC). In recognition of her research contributions, she was inducted into the American Society of Clinical Investigation.
In person: This lecture will take place in C102 East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.
References to the human experience of “pain” are common, but those references are often ambiguous and vague. Such ambiguity creates conceptual and practical challenges, especially in the work of clinical ethics consultation. Conceptual challenges arise, for example, from the distinction between pain and suffering. Practical challenges arise from tensions between objective and subjective components of pain, and clinical ethical challenges arise in cases like Charlie Gard’s. Here, on the one hand, the court argued that Charlie was in such extreme pain and suffering, he should be allowed to die. Alternatively, others stated that we could not truly know about the experience of his pain, and that treatment therefore should be made available. While pain is a relevant clinical problem, it is also a social construct shaped by culture, environment and gender. These distinctions however get lost in a simple “pain” reference. With several clinical ethics scenarios, Dr. Eijkholt will ask if references to pain help us with anything, or if we should perhaps abandon pain as a “useless concept.”
Join us for Dr. Eijkholt’s lecture on Wednesday, March 14, 2018 from noon until 1 pm in person or online.
Marleen Eijkholt, JD, PhD, is and Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Obstetrics, Gynecology and Reproductive Biology at the Michigan State University College of Human Medicine. Dr. Eijkholt focuses on a wide range of Ethical, Legal and Social Implications (ELSI) in health care ethics, including neurotechnology, reproductive medicine, clinical medicine and clinical research. Her work is eclectic like her background, including projects on pain, placebos, and reproductive rights, or deep brain stimulation, and experimental treatments like stem cells. She combines ethical, legal and philosophical theories in her research and scholarship. Additionally, she engages these in her professional life as an ethics consultant at Spectrum Health System. Dr. Eijkholt also contributes her expertise to the College of Human Medicine’s Shared Discovery Curriculum.
In person: This lecture will take place in C102 East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.
Since 2015, Michigan parents have had to attend education sessions at public health offices if they want their unvaccinated or under-vaccinated children to attend school or daycare. This policy seems to have succeeded: the state’s nonmedical exemption rate declined by 35% from 2014 to 2015. But what explains this apparent success? Are parents changing their minds as a result of mandatory vaccine education, or are they choosing to vaccinate rather than be inconvenienced by education sessions? Also, does vaccine education promote additional public health goals, i.e. other than short-term vaccination compliance? This presentation will attempt to answer these questions by drawing on immunization records, interviews with public health staff, and surveys of health department leaders, with the goal of informing arguments about the value of Michigan’s vaccine waiver education policy.
Join us for Dr. Navin’s lecture on Wednesday, February 14, 2018 from noon till 1 pm in person or online.
Mark Navin, PhD, is an Associate Professor of Philosophy at Oakland University. His recent work is primarily in bioethics and public health ethics. His book, Values and Vaccine Refusal, was published by Routledge in 2015.
In person: This lecture will take place in C102 East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.
Join us for Mark Van Linden’s lecture on Wednesday, October 16, 2019 from noon until 1 pm in person or online.
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Karen Kelly-Blake, PhD
Center Assistant Professor 
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Join us for Dr. Pope’s lecture on Wednesday, October 10, 2018 from noon until 1 pm in person or online.
Join us for Dr. Sisti’s lecture on Wednesday, September 19, 2018 from noon until 1 pm in person or online.
Center Professor 
Join us for Dr. Jagsi’s lecture on Wednesday, April 11, 2018 from noon until 1 pm in person or online.
Join us for Dr. Eijkholt’s lecture on Wednesday, March 14, 2018 from noon until 1 pm in person or online.
Join us for Dr. Navin’s lecture on Wednesday, February 14, 2018 from noon till 1 pm in person or online.
MSU Bioethics 