Hastings Cent Rep
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In January 2016, Medicare began reimbursing clinicians for time spent engaging in advance care planning with their patients or patients' surrogates. Such planning involves discussions of the care an individual would want to receive should he or she one day lose the capacity to make health care decisions or have conversations with a surrogate about, for example, end-of-life wishes. ⋯ Although it seems that political barriers to reimbursement for such planning have largely faded, the Medicare policy's impact on provider billing practices appears to be limited, suggesting other barriers to clinician engagement in advance care planning. Additionally, the effects of this policy on patient behavior and the clinician-patient relationship are not yet known.
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The U. S. Food and Drug Administration's drug advisory committees provide expert assessments of the safety and efficacy of new therapies considered for approval. ⋯ The committees convene at the request of the FDA when the risks and harms of novel products are not immediately clear, and their final decisions carry significant weight, as most therapies that receive advisory committee approval are subsequently approved by the FDA. In recent years, across a series of diverse publications, the financial conflicts of interest of each category of participants in the meetings have been investigated. Here, we summarize these findings and their ethical implications, focusing on the FDA Oncologic Drugs Advisory Committee, and we suggest ways to move toward more transparent and impartial advisory committee meetings.
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Consider any choice that affects some social policy. A decision that considers evidence will, at its heart, contain some kind of explicit or implicit "because" statement: "We are doing X because the evidence says Y." But can evidence ever truly speak for itself, in the sense of being reducible to objective utterances that are either correct or in need of correction? Before answering, consider what you'd prefer. Would you rather receive evidence that was free of any value judgments imposed by human actors, that was laden with value judgments that you agree with, or laden with value judgments that you disagree with? The central assertion of this essay is that, throughout policy analysis but especially in assessments of the costs and benefits of regulating versus encouraging new technologies (cost-benefit analysis, or CBA), the first possibility above is a mirage, and the second and third are self-contradictory. ⋯ The alternative judgments highlight the width of the spectrum of reasonable conclusions an analyst could reach merely by substituting other judgments for the ones currently embedded. Bringing hidden value judgments to light is doubly valuable. First, it allows discussion to ensue on a level playing field; instead of conclusory statements about what the evidence says, transparency permits statements taking the form of "when channeled through these value judgments, the evidence says this." Perhaps more importantly, transparency about value judgments permits participants in the discussions to offer interpretations of evidence contingent on there being different value judgments chosen at one or more points in the analysis, interpretations that may suggest that alternative course(s) of action are preferable to the one being championed.
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In the struggle over the durability of the Affordable Care Act, defenders of the ACA stand guard at many fronts. A major contribution of the ACA to nondiscrimination law, however, appears increasingly vulnerable. The ACA established significant new nondiscrimination protections for patients under section 1557 and its implementing regulations. ⋯ To evaluate these protections, we must consider not only their impacts on discriminatory behavior but also their behavioral and attitudinal impacts on patients and communities. This is because supportive or stigmatizing rules can exert an expressive effect: laws communicate information about prevailing social norms, they give some norms greater authority by virtue of the state's support, and they can shape community values. Through these expressive impacts, nondiscrimination laws may affect not only discriminatory behavior in health activities but also the attitudes, beliefs, and decisions of people who are legally protected.
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In 2012, Loyola University Chicago's Stritch School of Medicine became the first medical school in the United States to actively recruit and accept undocumented immigrants who received protections granted under the Deferred Action for Childhood Arrivals program that was established by presidential memorandum. By 2016, sixty-one medical schools were considering applications from DACA recipients for admission, and more than 110 students applied. ⋯ These students contribute both diversity and talent to our medical community; they could also have a significant impact on the care of underserved and immigrant populations. The recent decision by the Trump administration to rescind DACA therefore comes with serious pragmatic and ethical ramifications, impeding our medical community's efforts to develop a diverse and representative workforce committed to improving access to quality care for all patients.