Integrating Ethics into Behavior Change and Choice Architecture
Clinicians and policymakers are now turning increasingly to the science of behavior change (SOBC), which includes the core disciplines of behavioral psychology and behavioral economics, for tools to change individual and group health-related decisions and behaviors. The SOBC (often employed by “libertarian paternalists,” “choice architects,” or “nudge proponents”) exploits increasingly well understood features of the psychology of decision making in order to change people’s decisions and behaviors. As such, it raises serious ethical concerns about manipulation and the resulting impact on autonomy, as well as ethical concerns about who is defining “better” decisions and behaviors. While much attention is being paid to the efficacy of various SOBC techniques, little or no attention is being paid to their ethical desirability in light of these questions. My work offers conceptual clarity about the relation between forms of influence and autonomy, and ethical insight as to when the use of SOBC techniques is acceptable or desirable. By articulating and defending normative guidelines for policymakers and clinicians, I hope to promote the responsible development and deployment of SOBC in clinical practice and health policy. This work is supported by a Greenwall Faculty Scholars Award in Bioethics (2011-2014) , a Pfizer Fellowship in Bioethics (2011-2013), and a Greenwall Foundation Making A Difference in Real World Bioethics Dilemmas grant (2014-2016). See CV for related publications and works in progress.
Development and User Testing of a Decision Aid for Ventricular Assist Device (VAD) Placement
I am leading a research team that is creating a patient-centered decision aid that presents outcomes, risks, experiences, and uncertainties about ventricular assist device placement in a clear, comprehensive, scientifically-valid, and unbiased manner to help heart failure patients make informed and value-based decisions. The research team is very multi-disciplinary with co-investigators from ethics (Courtenay Bruce, J.D. from BCM), decision science (Robert Volk, Ph.D. from MD Anderson), qualitative and quantitative methods (Sheryl McCurdy, Ph.D. from UT School of Public Health and Charles Minard, Ph.D. from BCM), cardiology and cardiovascular surgery (Jerry Estep, M.D., Matthias Loebe, M.D., Ph.D., and Brian Bruckner, M.D. all from Houston Methodist), and three patient representatives. This work is funded by the Patient Centered Outcomes Research Institute (2014-2017), $1,332,504. See CV for related publications and works in progress.
Descriptive Studies of Judgment and Decision Making
I have recently led two empirical studies on judgment and decision making in medicine, and am taking part in two others. One that I recently led was a quantitative study of physicians’ recommendations in response to five hypothetical clinical scenarios to examine the presence of certain “cognitive biases” (loss aversion, anchoring, frequency, and availability) in their judgments. The other was a qualitative study of communication and decision-making for fetal surgery–looking at how doctors present risks, how directive they are, how patients respond, and how cognitive biases and heuristics enter into the picture. The field of fetal surgery is a new, rapidly advancing field with complex decisions and ethical issues. The two studies that I am taking part in are a study of how physicians deliver and patients respond to whole genome sequencing results in the clinical setting, and a study of how physicians make decisions about and engage in informed consent for tracheostomy placement for neurologically devastated children. See CV for related publications and works in progress.
Family and Clinician Perceptions Regarding Patients with Disorders of Consciousness
In collaboration with Sunil Korhari MD, director of the Disorders of Consciousness Program at TIRR Memorial Hermann, we seek to understand (through qualitative interviews) the views of family members and clinicians of/for patients with disorders of consciousness (persistent vegetative state, minimally conscious states) regarding consciousness and its moral significance. Do they match how philosophers and neuroscientists think about consciousness?
Blumenthal-Barby JS, Opel DJ. Nudge or Grudge? Choice Architecture and Parental Decision Making. Hastings Center Report, 2018 March-April (forthcoming).
Blumenthal-Barby JS, Ubel PA. Truth Be Told: Not All Nudging Is Bullshit. Journal of Medical Ethics, 2018 Feb 14 [Epub ahead of print].
Fedson SE, MacKenzie KK, Delgado ED, Abraham MN, Estep JD, Blumenthal-Barby JS, Bruce CR. ASAIO Journal, 2017 Oct 23 [Epub ahead of print].
Wilhelms LA, Blumenthal-Barby JS, Kostick KM, Estep JD, Bruce CR. Patients’ Perspectives on Transplantation While Undergoing Left Ventricular Assist Device Support. ASAIO Journal, 63(6), 2017:740-744.
Jamal L, Robinson JO, Christensen KD, Blumenthal-Barby JS, Slashinski MJ, Perry DL, Vassy JL, Wycliff J, Green RC, McGuire AL. When Bins Blur: Patient Perspectives on Categories of Results from Clinical Whole Genome Sequencing. AJOB Empirical Bioethics, 8(2), 2017:82-88.
Loewenstein, G., Hagmann, D., Schwartz, J., Ericson, K., Kessler, J. B., Bhargava, S., Blumenthal-Barby, J., D’Aunno, T., Handel, B., Kolstad, J., Nussbaum, D., Shaffer, V., Skinner, J., Ubel, P., Zikmund-Fisher, B. J. (2017). A Behavioral Blueprint for Improving Health Care Policy. Behavioral Science & Policy, 5(1), 2017:53-66.
Kaplan JA, Kandodo J, Sclafani J, Raine S, Blumenthal-Barby JS, Norris A, Norris-Turner A, Chemey E, Beckham JM, Khan Z, Chunda R. An Investigation of the Relationship Between Autonomy, Childbirth Practices, and Obstetric Fistula Among Women in Lilongwe District, Malawi. BMC International Health and Human Rights 17(7), 2017:1-10.
Won T, Chacko M, Blumenthal-Barby JS. Paid Protection?: Ethics of Incentivized Long-Acting Reversible Contraception in Adolescents with Alcohol and Other Drug Use, Journal of Medical Ethics 43(3), 2017:182-187.
Blumenthal-Barby JS. “That’s the Doctor’s Job”: Overcoming Patient Reluctance to Become Involved, Patient Education and Counseling 100(1), 2017:14-17.
Liao K, Blumenthal-Barby JS, Sikora AG. Factors Influencing Head and Neck Surgical Oncologists’ Transition from Curative to Palliative Treatment Goals, Otolaryngology–Head and Neck Surgery 156(1), 2017:46-51.
de la Garza S, Phuoc V, Throneberry S, Blumenthal-Barby JS, McCullough L, Coverdale J. Teaching Medical Ethics in Graduate and Undergraduate Medical Education: A Systematic Review of Effectiveness, Academic Psychiatry 41(4), 2017:520-525.
Blumenthal-Barby JS, Loftis L, Cummings CL, Meadow W, Lemmon M, Ubel PA, McCullough L, Rao E, Lantos JD. Should Neonatologists Give Opinions Withdrawing Life-sustaining Treatment? Pediatrics 138(6), 2016:1-7.
Blumenthal-Barby JS, Ubel PA. Gunmen and Ice Cream Cones: Harm to Autonomy and Harm to Persons, American Journal of Bioethics 16(11), 2016:13-14.
Blumenthal-Barby JS. Biases and Heuristics in Decision-Making and Their Impact on Autonomy, American Journal of Bioethics 16(5), 2016:5-15.
Arora NS, David JK, Kirby C, McGuire AL, Green RC, Blumenthal-Barby JS, Ubel PA, MedSeq Project, Personalized Medicine 14(5), 2016:423-431.
Kostick K, Minard C, Wilhelms L, Delgado E, Abraham M, Bruce C, Estep J, Loebe M, Volk R, Blumenthal-Barby JS. Development and Validation of a Patient-Centered Knowledge Scale for LVAD Placement, Journal of Heart and Lung Transplantation 35(6), 2016: 768-777.
Blumenthal-Barby JS, Shipchandler Z, Kaplan J. An Ethical Framework for Public Health Nudges: A Case Study of Incentives as Nudges for Vaccination in Rural India. Nudging Health: Health Law and Behavioral Economics, Johns Hopkins University Press (2016): 112-123.
Blumenthal-Barby JS. What Sort of Collective Afterlife Matters and How, Philosophia: Philosophical Quarterly of Israel 44(1), 2016:87-100.
Blumenthal-Barby JS, Lazaridis C. A Woman in Her 30’s Whose Family Becomes Distrustful After an Initial Prognosis Proves Inaccurate. CHEST 149(4), 2016:115-117.
Lugo P, Robinson J, Diamond P, Jamal L, Danysh H, Blumenthal-Barby JS, Lehmann L, Vassy J, Christensen K, Green R, McGuire A. Patients’ Perceived Utility of Whole-Genome Sequencing for their Healthcare: Findings from the MedSeq Project, Personalized Medicine 13(1), 2016:13-20.
Bramstedt KA, Colaco CMG, De Silva E, Rehfield PL, Blumenthal-Barby JS. Exploring the Perceptions of Australian and US Medical Students and their Teachers about Clinical Professional Attire (LAPEL Study). The Journal of the American Osteopathic Association 116(4), 2016:244-254.
Blumenthal-Barby JS. Dilemmas for the Rarity Thesis in Virtue Ethics and Virtue Epistemology, Philosophia: Philosophical Quarterly of Israel 44(2), 2016:395-406.
Blumenthal-Barby JS, Krieger H, Wei A, Kim D, Olutoye O, Cass DL. Communication About Maternal-Fetal Surgery for Myelomeningocele and Congenital Diaphragmatic Hernia: Preliminary Findings with Implications for Informed Consent and Shared Decision Making, Journal of Perinatal Medicine 44(6), 2016:645-643.
Christensen KD, Vassy JL, Jamal L, Lehmann LS, Slashinski MJ, Perry DL, Robinson JO, Blumenthal-Barby JS, Feuerman LZ, Murray MF, Green RC, McGuire AL. Are Physicians Prepared for Whole Genome Sequencing? A Qualitative Analysis, Clinical Genetics 89(2), 2016: 228-234.
Blumenthal-Barby JS, Naik A. In Defense of Nudge-Autonomy Compatibility. American Journal of Bioethics 15(10), 2015:45-47.
Lazaridis, C, Blumenthal-Barby JS. Organ Donation Beyond Brain Death: Donors as Ends and Maximal Utility. American Journal of Bioethics 15(8), 2015:17-19.
Bui, Krieger H, Blumenthal-Barby JS. Framing Effects on Physicians’ Judgment and Decision Making, Psychological Reports 117(2), 2015: 508-522.
Kostick K, Blumenthal-Barby JS. A Failing Heart and the Downside of Life-Prolonging Technology, Health Affairs 34(8), 2015: 1418-1422.
Bruce CR, Blumenthal-Barby JS, Meyers D. Benefits and Challenges of Early Introduction of Left Ventricular Assist Device Placement: A Patient-Centered Perspective, Journal of the American College of Cardiology 66(16), 2015: 1762-1765.
Allen N, McCullough L, Blumenthal-Barby JS. Placing and Evaluating Unproven Interventions Within a Clinical Ethical Taxonomy of Treatments for Ebola Virus Disease. American Journal of Bioethics 15(4), 2015:50-53.
Bruce CR, Liang C, Blumenthal-Barby JS, Zimmerman J, Downey A, Pham L, Theriot L, Delgado E, White D. Barriers and Facilitators to Initiating and Completing Time-Limited Trials in Critical Care Medicine. Critical Care Medicine 43(12), 2015: 2535-2543.
Bruce CR, Kostick KM, Delgado ED, Wilhelms LA, Volk RJ, Smith ML, McCurdy SA, Loebe M, Estep JD, Blumenthal-Barby JS. Reasons Why Eligible Candidates Decline Left Ventricular Assist Device Placement, Journal of Cardiac Failure 21(10), 2015: 835-839.
Kostick KM, Blumenthal-Barby JS, Wilhelms LA, Delgado ED, Bruce CR. Content Analysis of Social Media Related to Left Ventricular Assist Devices, Circulation: Cardiovascular Quality and Outcomes 8(5), 2015: 517-523.
Volk R, Kinsman G, Le Y, Swank P, Blumenthal-Barby JS, McFall S, Byrd T, Mullen P, Cantor S. Designing Normative Messages About Active Surveillance for Men With Localized Prostate Cancer, Journal of Health Communication 20(9), 2015: 1014-1020.
Blumenthal-Barby JS, Denise L, Volk R. Towards Ethically Responsible Choice Architecture in Prostate Cancer Treatment Decision Making. CA: A Cancer Journal for Clinicians 65(4), 2015: 257-260.
Blumenthal-Barby JS, Kostick KM, Delgado ED, Volk RJ, Kaplan HM, Wilhelms L, McCurdy S, Estep JL, Loebe M, Bruce CR. Assessment of Patients’ and Caregivers’ Informational and Decisional Needs for Left Ventricular Assist Device Placement: Implications for Informed Consent, Journal of Heart and Lung Transplantation 34(9), 2015:1182-1189.
Blumenthal-Barby JS, McGuire A, Green R, Ubel P. How Behavioral Economics Can Help Avoid “The Last Mile Problem” in Whole Genome Sequencing. Genome Medicine 2015 Jan 22;7(1): 3.
Blumenthal-Barby JS, Robinson E, Cantor SB, Russell HV, Naik A,Volk RJ. The Neglected Topic: Presentation of Cost Information in Patient Decision Aids, Medical Decision Making 35(4), 2015: 412-418.
Lazaridis C, Blumenthal-Barby JS. Biology, Metaphysics and Brain Death Criteria. Journal of Critical Care 30(2), 2015: 417-418.
Blumenthal-Barby JS, Krieger H. Cognitive Biases and Heuristics in Medical Decision-Making: A Critical Review, Medical Decision Making 35(4), 2015: 539-557.
Blumenthal-Barby JS. A Framework for Assessing the Moral Status of Manipulation, in Manipulation, Eds. Christian Coons and Michael Weber, Oxford University Press, (August 2014): 121-134.
Blumenthal-Barby JS, McGuire AL, Ubel PA. Why Information Alone Is Not Enough: Behavioral Economics and the Future of Genomic Medicine. Annals of Internal Medicine 161(8), 2014.
Blumenthal-Barby JS. Psychiatry’s New Manual (DSM-5): Ethical and Conceptual Dimensions, Journal of Medical Ethics, 40(8), 2014: 531-536.
Bruce CR, Fetter JE, Blumenthal-Barby JS. Cascade Effects in Critical Care Medicine: A Call for Practice Changes. American Journal of Respiratory and Critical Care Medicine 188(12), 2013: 1384-1385. Listen here: http://static.thoracic.org/podcast/AJRCCM-interviews/rccm-201309-1606ED.mp3
Blumenthal-Barby JS. “Choosing Wisely” to Reduce “Low Value Care”: A Conceptual and Ethical Analysis, Journal of Medicine and Philosophy, 3, 2013: 559-580.
Blumenthal-Barby JS, McCullough L, Krieger H, Coverdale J. A Typology and Ethical Analysis of Methods of Influence in Psychiatric Decision Making. Harvard Review of Psychiatry 21(5), 2013: 275-279.
Abhyankar P, Volk R, Blumenthal-Barby JS, Bravo P, Buchholz A, Ozanne E, Vidal DC, Col N, Stalmeier P. Balancing the Presentation of Information and Options In Patient Decision Aids: An Updated Review, BMC Medical Informatics and Decision Making 13(Suppl. 2), 2013: S6.
McGuire AL, Joffe S, Koenig BA, Biesecker BB, McCullough LM, Blumenthal-Barby JS, Caufield T, Terry SF, Green RC. Ethics and Genomic Incidental Findings. Science 340(6136), 2013: 1047-1048.
Blumenthal-Barby JS. On Nudging and Informed Consent: Four Key Undefended Premises. American Journal of Bioethics 13(6), 2013: 31-33.
Blumenthal-Barby JS, Cantor S, Naik A, Russell H, Volk R. Decision Aids: When Nudging Patients to Make a Particular Choice is More Ethical Than Balanced, Nondirective Content. Health Affairs 32(2), 2013: 303-310.
Blumenthal-Barby JS. Choice Architecture: A Mechanism for Improving Decisions While Preserving Liberty? in Paternalism: Theory and Practice, Eds. Christian Coons and Michael Weber, Cambridge University Press (March 2013): 178-196.
Blumenthal-Barby JS. Between Reason and Coercion: Ethically Permissible Influence in Health Care and Health Policy Contexts. Kennedy Institute of Ethics Journal 22(4), 2012: 345-366.
Braverman J, Blumenthal-Barby JS. Assessment of the Sunk Cost Effect in Clinical Decision Making. Social Science & Medicine 75(1), 2012:186-192.
Blumenthal-Barby JS, Burroughs H. Seeking Better Healthcare Outcomes: the Ethics of Using the “Nudge.” American Journal of Bioethics 12(2), 2012:1-10.
Frumovitz M, Kriseman M, Sun C, Blumenthal-Barby JS, Bodurka D, and Soliman P. Unverifiable Academic Accomplishments and Publications on Applications for Gynecologic Oncology Fellowships. Obstetrics and Gynecology 119(3), 2012: 504-508.
Blumenthal-Barby JS. On the Concept and Measure of Voluntariness: Insights from Behavioral Economics and Cognitive Science. American Journal of Bioethics 11(8), 2011: 25-26.
Cardon, A, Blumenthal-Barby JS. Should Repugnance Give Us Pause? On the Neuroscience of Daily Moral Reasoning. American Journal of Bioethics Neuroscience 2(2), 2011: 47-48.
Blumenthal-Barby (Swindell) JS. On the Utility and Distinctness of the Concept of Behavioral Equipoise. American Journal of Bioethics 11(2), 2011: 9-10.
Swindell JS, McGuire AL, Halpern SD. Shaping Patients’ Decisions. CHEST 139(2), 2011: 424-429.
Swindell JS, McGuire AL, Halpern SD. Beneficent Persuasion: Techniques and Ethical Guidelines to Improve Patients’ Decisions. Annals of Family Medicine 8(3), 2010: 260-264.
Swindell JS, McCullough LM, Crisp-Han H, Coverdale JC. Responsibly Managing Refusal of Medical or Surgical Diagnostic Work-Up by Psychiatric Inpatients. Psychiatric Services 61(9), 2010: 868-870.
Swindell JS. Ambivalence. Philosophical Explorations: An International Journal of Philosophy of Mind and Action 13(1), 2010: 23-34.
McGuire AL, Majumder MA, Halpern SD, Swindell JS, Yaeger LV, Gibbs RA, Wheeler TM. Taking DNA from the Dead. Nature Reviews Genetics 11(5), 2010: 318.
Swindell JS. Review of Harry G. Frankfurt, Taking Ourselves Seriously and Getting It Right (Stanford, CA: Stanford University Press, 2006). Journal of Value Inquiry 44(1), 2010: 117-121.
Swindell JS. Video Tool in Dementia: Ethical Concerns. British Medical Journal 339, 2009:b2720.
Swindell JS. Behavioural Science Sheds Light on Patient Perceptions of Impact of Disease and Quality of Life, Creates Ethical Challenges. International Journal of Clinical Practice 6(12), 2009: 1673-1674.
Swindell JS, Kass JS. Clinical and Ethical Response to the Case of “A 60-Year-Old Woman With Mild Memory Impairment”. JAMA September 30, 2008 (electronic letters published).
Swindell JS. Facial Allograft Transplantation, Personal Identity, and Subjectivity. Journal of Medical Ethics 33(8), 2007: 449-453.
Swindell JS. Review of Tim O’Keefe, Epicurus on Freedom (Cambridge University Press, 2005). Journal of Value Inquiry 41(1), 2007: 107-112.