AI and the need for justification (to the patient)

Muralidharan, A., Savulescu, J. & Schaefer, G.O.

Ethics Inf Technol 26, 16 (2024).

https://doi.org/10.1007/s10676-024-09754-w

Abstract

This paper argues that one problem that besets black-box AI is that it lacks algorithmic justifiability. We argue that the norm of shared decision making in medical care presupposes that treatment decisions ought to be justifiable to the patient. Medical decisions are justifiable to the patient only if they are compatible with the patient’s values and preferences and the patient is able to see that this is so. Patient-directed justifiability is threatened by black-box AIs because the lack of rationale provided for the decision makes it difficult for patients to ascertain whether there is adequate fit between the decision and the patient’s values. This paper argues that achieving algorithmic transparency does not help patients bridge the gap between their medical decisions and values. We introduce a hypothetical model we call Justifiable AI to illustrate this argument. Justifiable AI aims at modelling normative and evaluative considerations in an explicit way so as to provide a stepping stone for patient and physician to jointly decide on a course of treatment. If our argument succeeds, we should prefer these justifiable models over alternatives if the former are available and aim to develop said models if not.

The article is here.

Here is my summary:

The article argues that a certain type of AI technology, known as "black box" AI, poses a problem in medicine because it lacks transparency.  This lack of transparency makes it difficult for doctors to explain the AI's recommendations to patients.  In order to make shared decisions about treatment, patients need to understand the reasoning behind those decisions, and how the AI factored in their individual values and preferences.

The article proposes an alternative type of AI, called "Justifiable AI" which would address this problem. Justifiable AI would be designed to make its reasoning process clear, allowing doctors to explain to patients why the AI is recommending a particular course of treatment. This would allow patients to see how the AI's recommendation aligns with their own values, and make informed decisions about their care.

Scientists are on the verge of a male birth-control pill. Will men take it?

Jill Filipovic

The Guardian

Originally posted 18 Dec 23

Here is an excerpt:

The overwhelming share of responsibility for preventing pregnancy has always fallen on women. Throughout human history, women have gone to great lengths to prevent pregnancies they didn’t want, and end those they couldn’t prevent. Safe and reliable contraceptive methods are, in the context of how long women have sought to interrupt conception, still incredibly new. Measured by the lifespan of anyone reading this article, though, they are well established, and have for many decades been a normal part of life for millions of women around the world.

To some degree, and if only for obvious biological reasons, it makes sense that pregnancy prevention has historically fallen on women. But it also, as they say, takes two to tango – and only one of the partners has been doing all the work. Luckily, things are changing: thanks to generations of women who have gained unprecedented freedoms and planned their families using highly effective contraception methods, and thanks to men who have shifted their own gender expectations and become more involved partners and fathers, women and men have moved closer to equality than ever.

Among politically progressive couples especially, it’s now standard to expect that a male partner will do his fair share of the household management and childrearing (whether he actually does is a separate question, but the expectation is there). What men generally cannot do, though, is carry pregnancies and birth babies.

The info is here.

Here are some themes worthy of discussion:

Shifting responsibility: The potential availability of a reliable male contraceptive marks a significant departure from the historical norm where the burden of pregnancy prevention was primarily borne by women. This shift raises thought-provoking questions that delve into various aspects of societal dynamics.

Gender equality: A crucial consideration is whether men will willingly share responsibility for contraception on an equal footing, or whether societal norms will continue to exert pressure on women to take the lead in this regard.

Reproductive autonomy: The advent of accessible male contraception prompts contemplation on whether it will empower women to exert greater control over their reproductive choices, shaping the landscape of family planning.

Informed consent: An important facet of this shift involves how men will be informed about potential side effects and risks associated with the male contraceptive, particularly in comparison to existing female contraceptives.

Accessibility and equity: Concerns emerge regarding equitable access to the male contraceptive, particularly for marginalized communities. Questions arise about whether affordable and culturally appropriate access will be universally available, regardless of socioeconomic status or geographic location.

Coercion: There is a potential concern that the availability of a male contraceptive might be exploited to coerce women into sexual activity without their full and informed consent.

Psychological and social impact: The introduction of a male contraceptive brings with it potential psychological and social consequences that may not be immediately apparent.

Changes in sexual behavior: The availability of a male contraceptive may influence sexual practices and attitudes towards sex, prompting a reevaluation of societal norms.

Impact on relationships: The shift in responsibility for contraception could potentially cause tension or conflict in existing relationships as couples navigate the evolving dynamics.

Masculinity and stigma: The use of a male contraceptive may challenge traditional notions of masculinity, possibly leading to social stigma that individuals using the contraceptive may face.

Many Americans receive too much health care. That may finally be changing

Elsa Pearson Sites

StatNews.com

Originally published 8 Nov 23

The opioid crisis rocked America, bringing addiction and overdose into the spotlight. But it also highlighted the overtreatment of pain: Medical and dental providers alike overprescribed opioids after procedures and for chronic conditions. Out of that overtreatment came an epidemic.

In American health care, overtreatment is common. Recently though, there has been a subtle shift in the opposite direction. It’s possible that “less is more” is catching on.

For many Americans, it can be challenging to even access care: Treatment is expensive, insurance is confusing, and there aren’t enough providers. But ironically, we often use too much care, too.

Now, some providers are asking what the line between necessary and unnecessary really is. The results are encouraging, suggesting that, in some cases, it may be possible to achieve the same health outcomes with less treatment — and fewer side effects, too.

This shift is particularly noticeable in cancer care.

The info is here.

Here is my take:

The article delves into the pervasive issue of overtreatment and overdiagnosis in the healthcare system. It highlights the unintended consequences of modern medical practices, where patients are often subjected to unnecessary tests, procedures, and treatments that may not necessarily improve their health outcomes. The article emphasizes how overtreatment can lead to adverse effects, both physically and financially, for patients, while overdiagnosis can result in the unnecessary burden of managing conditions that may never cause harm. The piece discusses the challenges in striking a balance between providing thorough medical care and avoiding unnecessary interventions, urging a shift toward a more patient-centered and evidence-based approach to reduce harm and improve the overall quality of healthcare.

The author suggests that addressing the issue of overtreatment and overdiagnosis requires a comprehensive reevaluation of medical practices, incorporating shared decision-making between healthcare providers and patients. The article underscores the importance of fostering a healthcare culture that prioritizes the avoidance of unnecessary interventions and aligns treatments with patients' preferences and values. By acknowledging and addressing the challenges associated with overmedicalization, the article advocates for a more thoughtful and personalized approach to healthcare delivery that considers the potential harm of unnecessary treatments and strives to enhance the overall well-being of patients.

Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter

Zulman DM, Haverfield MC, Shaw JG, et al.
JAMA. 2020;323(1):70–81.
doi:10.1001/jama.2019.19003

Key Points

Question  What are the most promising practices to foster physician presence and connection with patients?

Findings  This mixed-methods study identified 5 practices that may enhance physician presence and meaningful connection with patients in the clinical encounter: (1) prepare with intention; (2) listen intently and completely; (3) agree on what matters most; (4) connect with the patient’s story; and (5) explore emotional cues.

Meaning  For busy clinicians with multiple demands and distractions, 5 recommended practices have the potential to facilitate meaningful interactions with patients.

Abstract
Importance  Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction.

Objective  To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients.

Evidence Review  Preliminary practices were derived through a systematic literature review (fromJanuary 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n = 27 encounters); and qualitative interviews with physicians (n = 10), patients (n = 27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n = 30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (−4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their “top 5” practices from among those with median ratings of at least +2 for all 3 criteria. Finalrecommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes.

Findings  The systematic literature review (n = 73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient’s story (consider life circumstances that influence the patient’s health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient’s emotions).

Conclusions and Relevance  This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.

The research is here.

When a Patient Regrets Having Undergone a Carefully and Jointly Considered Treatment Plan, How Should Her Physician Respond?

L. V. Selby and others
AMA J Ethics. 2020;22(5):E352-357.
doi: 10.1001/amajethics.2020.352.

Abstract

Shared decision making is best utilized when a decision is preference sensitive. However, a consequence of choosing between one of several reasonable options is decisional regret: wishing a different decision had been made. In this vignette, a patient chooses mastectomy to avoid radiotherapy. However, postoperatively, she regrets the more disfiguring operation and wishes she had picked the other option: lumpectomy and radiation. Although the physician might view decisional regret as a failure of shared decision making, the physician should reflect on the process by which the decision was made. If the patient’s wishes and values were explored and the decision was made in keeping with those values, decisional regret should be viewed as a consequence of decision making, not necessarily as a failure of shared decision making.

(cut)

Commentary

This case vignette highlights decisional regret, which is one of the possible consequences of the patient decision-making process when there are multiple treatment options available. Although the process of shared decision making, which appears to have been carried out in this case, is utilized to help guide the patient and the physician to come to a mutually acceptable and optimal health care decision, it clearly does not always obviate the risk of a patient’s regretting that decision after treatment. Ironically, the patient might end up experiencing more regret after participating in a decision-making process in which more rather than fewer options are presented and in which the patient perceives the process as collaborative rather than paternalistic. For example, among men with prostate cancer, those with lower levels of decisional involvement had lower levels of decisional regret. We argue that decisional regret does not mean that shared decision making is not best practice, even though it can result in patients being reminded of their role in the decision and associated personal regret with that decision.

The info is here.

The New Age of Patient Autonomy: Implications for the Patient-Physician Relationship

Madison Kilbride and Steven Joffe
JAMA. Published online October 15, 2018.

Here is an excerpt:

The New Age of Patient Autonomy

The abandonment of strong medical paternalism led scholars to explore alternative models of the patient-physician relationship that emphasize patient choice. Shared decision making gained traction in the 1980s and remains the preferred model for health care interactions. Broadly, shared decision making involves the physician and patient working together to make medical decisions that accord with the patient’s values and preferences. Ideally, for many decisions, the physician and patient engage in an informational volley—the physician provides information about the range of options, and the patient expresses his or her values and preferences. In some cases, the physician may need to help the patient identify or clarify his or her values and goals of care in light of the available treatment options.

Although there is general consensus that patients should participate in and ultimately make their own medical decisions whenever possible, most versions of shared decision making take for granted that the physician has access to knowledge, understanding, and medical resources that the patient lacks. As such, the shift from medical paternalism to patient autonomy did not wholly transform the physician’s role in the therapeutic relationship.

In recent years, however, widespread access to the internet and social media has reduced physicians’ dominion over medical information and, increasingly, over patients’ access to medical products and services. It is no longer the case that patients simply visit their physicians, describe their symptoms, and wait for the differential diagnosis. Today, some patients arrive at the physician’s office having thoroughly researched their symptoms and identified possible diagnoses. Indeed, some patients who have lived with rare diseases may even know more about their conditions than some of the physicians with whom they consult.

The info is here.

Shared Decision-making for PTSD

Juliette Harik, PhD
PTSD Research Quarterly (2018) Volume 29 (1)

Here is an excerpt:

Although several different shared decision-making models exist (for a review see Lin & Fagerlin, 2014), one useful approach conceptualizes shared decision-making as consisting of three phases
(Elwyn et al., 2012): choice talk, option talk, and decision talk. Choice talk involves communicating
to patients that there is a decision to make and that they can be involved in this decision to the extent
that they are comfortable. Option talk consists of sharing accurate and comprehensive information
about treatment options. Ideally, this involves the use of a decision aid, which is an educational tool
such as a website, brochure, or video designed to help patients understand and compare various
options (for a review, see Stacey et al., 2017). The third and final step, decision talk, consists of an
exploration of the patient’s preferences and what matters most to him or her. The process of shared
decision-making is intended to help the patient develop informed preferences, and ultimately arrive
at the decision that is best for him or her. Importantly, patients with the same clinical condition may arrive at very different treatment decisions on the basis of unique values and preferences.

Shared decision-making has been evaluated most often among patients facing care decisions for chronic medical conditions, especially cancer. In medical patients, shared decision-making has been linked with greater confidence in the treatment decision, improved satisfaction with decision-making and with treatment, greater self-efficacy, and increased trust in the provider (Joosten et al., 2008; Shay & Lafata, 2015). In mental health, shared decision-making has been most often evaluated in the context of depression, yielding mixed results on both satisfaction and treatment outcomes (Duncan, Best, & Hagen, 2010). Fewer studies have evaluated the effectiveness of shared decision-making for other mental health conditions such as PTSD.

The information is here.