Wednesday, February 6, 2013

Analysis: Under diplomatic fire, Israel faces settlement showdown

JERUSALEM (Reuters) - Israel risks sleepwalking into a crisis with its allies over relentless settlement-building in the occupied West Bank and East Jerusalem unless it realizes that the international anger is genuine and adjusts its course.

The next few months may prove crucial if Israel is to avoid diplomatic disaster, with a new government forming around Prime Minister Benjamin Netanyahu and U.S. President Barack Obama set to make his first official visit to the Holy Land in the spring.

Obama will not just be coming for a photo opportunity. He is expected to try to revive a push for peace in hopes of finding an Israeli coalition receptive to deepening Western concerns about the prospects of creating a viable Palestinian state.

"The two-state solution is not dead, but it is in mortal danger," said Daniel Seidemann, an Israeli lawyer and an expert on settlement expansion.

"We are hanging onto it by our finger nails. This is the last opportunity to save it for the foreseeable future. The prospects are not great, but this is the last best hope."

Should these hopes wither, Israel can expect repercussions.

These might range from tighter international regulations on the export of Israeli goods made in the occupied territories to tacit foreign backing for the Palestinians should they pursue Israel in the International Criminal Court over the settlements.

Obama himself, with no re-election to worry about, could review security and defense cooperation that Israeli officials say reached new heights during his first term, with annual U.S. military aid from Washington put at some $3 billion.

"Israel is walking blindly towards isolation and censure in the eyes of the world," said one of the most senior Western envoys in Jerusalem, who declined to be named given the enormous sensitivities surrounding the issue.

"What I don't understand is if Mr. Netanyahu doesn't realize what is happening, or if he doesn't give a damn."

BLOOMING SETTLEMENTS

In the past two months Israel has received sometimes fierce criticism from the United Nations, European Union and United States over its announcement of plans to build more than 11,000 new houses on land Palestinians want for a future state.

Last week, Israel boycotted the U.N. Human Rights Council in Geneva as it was planning a routine review of the Jewish state. Days later, U.N. investigators issued a strongly worded report that said the settlements could constitute a war crime.

Israeli leaders have largely shrugged off the opprobrium. They assert a right to build on territory seized in a 1967 war and accused the Geneva council, which includes non-democratic states like Cuba and Saudi Arabia, of bias and hypocrisy.

However, past and present Israeli diplomats are nervous about the mounting friction as Israel faces a multitude of challenges piling up along its troubled borders, with Islamists taking power in Egypt and on the rise in Syria's civil war.

"I am worried and so are many other Israelis," said Itamar Rabinovich, a former Israeli ambassador to the United States.

"Our legitimacy is being eroded and the more isolated and delegitimized Israel is, the more difficult it will be to get public opinion on our side regarding Iran," he added, referring to suspicions the Islamic Republic is seeking nuclear weapons.

Israelis started moving to the West Bank soon after the 1967 conflict, and the numbers soared in the wake of the 1993 Oslo Accords that granted limited self-rule to the Palestinian Authority - but placed no limits on Jewish settlement growth.

In 1993 there were an estimated 111,600 settlers in the territory. There are now more than 325,000, with a further 200,000 living in East Jerusalem, which was annexed by Israel after 1967 in a move not recognized internationally and is claimed by the Palestinians as their capital city.

"A Palestinian state has never been further away than it is today," Dani Dayan, outgoing head of the main settler council, was quoted as saying in the Jerusalem Post on Tuesday.

"The settlements today are blossoming ... There is almost no settlement without construction," added Dayan, who endorsed Netanyahu ahead of the January 22 election, which was won by the prime minister, albeit with a sharp fall in support.

Critics have long railed against the settlements, but successive Israeli governments have pushed back with vigor.

They were confident they had the support of mainstream America - Washington has long been Israel's most steadfast ally - and dismissed EU complaints as largely irrelevant.

Internal Palestinian political divisions, coupled with regular bouts of violence, have also enabled Israel to argue that they do not have any genuine partners for peace.

Diplomats insist the mood abroad is hardening. They say that if the settlements get any bigger there will be no more room for a contiguous Palestinian state, dashing the chance of an accord. They also maintain that Palestinian President Mahmoud Abbas is the most moderate leader that the Israelis can hope for.

Noting this change of tone, the Institute for National Security Studies, a respected Israeli think-tank, said this week that for the first time, the country faced the possibility of "concrete punishment measures" tied to its settlement expansion.

STUCK WITH LABELLING

Israel's solitude was seen most starkly in November when a mere eight countries, including the United States and four micro Pacific nations, voted with the Jewish state in a failed bid to prevent the Palestinians from gaining de-facto statehood recognition at the United Nations.

EU diplomats in Jerusalem forecast that such isolation would become a way of life for Israel, but dismissed any suggestion that Europe might impose economic sanctions on the Jewish state.

"The most we would expect is a move towards labeling of all settler products as coming from occupied territories," said one diplomat, who declined to be named. "Sanctions are a no-no."

Even a labeling change is likely to elicit fury in Israel. When South Africa proposed a similar move last May, the Israeli foreign ministry said the decision was "tainted" with racism.

Many ordinary Israelis see deep-rooted anti-Semitism at play in the criticism that is raining down on their nation, with the politically divided Palestinians only rarely admonished in the court of world opinion for their own missteps.

"The issue of delegitimisation goes beyond a simple United Nations report. We are aware of the situation as Jewish people and worried by it," said Zalman Shoval, another former Israeli ambassador to the United States who is close to Netanyahu.

However, he predicted that Obama and the prime minister would be able to find some way to resuscitate the peace process, which collapsed in 2010 after the Palestinians refused to take further part unless settlement building ceased.

"Knowing what Mr. Netanyahu's plans are in trying to move the conundrum forward ... I think cooperation between the two leaders will be very successful," Shoval said, without elaborating.

Before he meets Obama, Netanyahu must first assemble a new coalition - a particularly tricky task given the unexpected success of the new centrist party Yesh Atid (There is a Future).

Although many of the thorniest issues are entwined with domestic affairs, Yesh Atid has said that re-starting peace negotiations should be Netanyahu's main foreign policy goal.

That sits uneasily with many of Netanyahu's party faithful who reject the two-state solution. It will also be hard to square with another natural coalition partner - the pro-settler Jewish Home, which wants to annex much of the West Bank.

The top selling Israeli daily Yedioth Ahronoth said on Wednesday the surprise announcement on Tuesday that Obama was planning an imminent visit would thrust peace considerations to the top of the agenda in the ongoing coalition talks.

"Barack Obama is urging Benjamin Netanyahu to find solutions, and there is no room here for deceptions. The State of Israel is likely to find itself in another few weeks poised before one of its most important moments of truth," it wrote.

(Editing by Mark Heinrich)

Source: http://news.yahoo.com/analysis-under-diplomatic-fire-israel-faces-settlement-showdown-171700004.html

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Kim Jong Un's Cell Mystery Solved

SEOUL, South Korea -Yet another North Korean mystery has been solved. That smart phone spotted next to the regime's leader Kim Jong Un is a Taiwanese phone, made by HTC.

The high-tech phone stirred interest when spotted in a photo released by North Korea's Central News Agency partly because so few people in the low-tech country could afford one and because Kim has ordered people hiding cell phones to be shot.

But there was also speculation whether Kim owned a Samsung or Apple phone. Samsung is a South Korean company while Apple is from Kim's arch enemy America.

A South Korean government official said the phone was apparently a HTC brand, made in Taiwan. HTC declined to confirm, but said in a statement that it appreciates the "support of all users."

North Korean leader Kim Jong-Un presides over a national defense meeting with his top officials, Jan. 27, 2013. (Yonhap News/Newscom)

The next question is does that smartphone work as an internet data-transmitting device? If so, that means Kim could be surfing the net, googling his name, and could even read this article.

There has been evidence of using smartphones in North Korea in the past. StatCounter.com which tracks search engines, browsers, and operating systems around the globe confirmed in 2011 that some North Koreans used Apple's iPhone and Nokia's smartphones. In 2010, Foursquare had confirmed a check-in from North Korea as well.

Whether this was simply a test run of the 3G network by the state or for private use is not known. The 3G mobile phone service started in 2008 provided by Koryolink which is a joint venture between North Korea and Orascom Telecom, an Egyptian company.

Most recent data shows 1.5 million people subscribe to the service, mostly Pyongyang's elites that comprise 5 percent of the population. These privileged owners are carefully screened and strictly controlled with regards to their allegiance to the communist party and loyalty to the leader.

But witnesses who have been in North Korea recently say most people who own phones own Chinese cell phones - folder types and sliding types - not smartphones. Currently, North Koreans could text messages but have no access to the internet from their mobile devices.

Non-Pyongyang residents comprising the lower rank in North Korea's social system use smuggled mobile phones from China using Chinese networks with roaming coverage. Many defectors to South Korea communicate with their families back in the North by delivering these illegal mobile phones through brokers.

If caught hiding the phones, authorities used to arrest and send illegal phone users to political camps for reformation. But starting this year Kim Jong Un has given strict orders to have villains be shot to death.

For average North Koreans, the mobile phones are way above what they could afford anyway. Cell phones cost almost 25 times what an average person earns in a month.

Also Read

Source: http://news.yahoo.com/kim-jong-uns-cell-mystery-solved-162446833--abc-news-topstories.html

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EPA: Decline in carbon pollution from power plants

WASHINGTON (AP) ? The Environmental Protection Agency says heat-trapping gases from U.S. power plants fell 4.6 percent in 2011 from the previous year as plants burned less coal, the biggest source of greenhouse gas pollution.

The report, released Tuesday, said power plants remain the largest stationary source of carbon dioxide and other greenhouse gases that trigger global warming. Power plants were responsible for 2,221 million metric tons of carbon dioxide in 2011.

The reduction from 2010 reflects a relative decline in the use of coal, the dominant U.S. energy source, and an increase in natural gas and renewable sources that produce lower amounts of greenhouse gases.

Power plants produced roughly one-third of total U.S. emissions, followed by petroleum and natural gas systems, with refineries the third-largest pollution source.

Source: http://news.yahoo.com/epa-decline-carbon-pollution-power-plants-195913558--finance.html

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Tuesday, February 5, 2013

Iran arrests official implicated in prison deaths

TEHRAN, Iran (AP) ? A senior Iranian government official and former Tehran prosecutor general has been arrested, two years after a parliamentary probe found him responsible for deaths by torture of at least three jailed anti-government protesters, state media reported.

Saeed Mortazavi ? a close ally of President Mahmoud Ahmadinejad ? was taken to Tehran's Evin prison late Monday night, according to the reports, which gave no details or explanation for the arrest.

Mortazavi has been at the center of a growing confrontation between Ahmadinejad and the president's conservative rivals in parliament ahead of the June presidential election.

Ahmadinejad cannot run a third time because of term limits and many of his allies have either been arrested or pushed to the political margins because of the president's attempt to extend his powers.

Mortazavi's detention came a day after Ahmadinejad displayed in parliament a barely audible video showing Fazel Larijani, brother of parliament speaker Ali Larijani, meeting with Mortazavi and allegedly seeking a bribe in return for ensuring his brother's support for the president. Ali Larijani denied any links to the video.

Ahmadinejad strongly denounced Mortazavi's arrest, accusing the judiciary of being run as a "family institution" ? a reference to the Larijanis. Ayatollah Sadeq Larijani, another brother of Ali Larijani, is Iran's judiciary chief.

"The judiciary should be the judiciary of the nation and not one special family's private organization," said Ahmadinejad in remarks posted on the president's website.

"This is very ugly. It's not appropriate for the people of the Islamic Republic and the judiciary," Ahmadinejad said ahead of his departure to Egypt where he is to attend a summit of the Organization of Islamic Cooperation. "I'll definitely pursue this matter seriously when I return."

Mortazavi was Tehran city prosecutor in 2009, during massive protests in the wake of Ahmadinejad's disputed re-election. At the time, he was responsible for Kahrizak prison in the Iranian capital, where at least three anti-government protesters were tortured to death. He now heads the country's social security fund.

Iran's reformists have openly criticized Mortazavi during his years in the judiciary. He was even dubbed "butcher of the press" for the closures of more than 120 newspapers and the imprisonment of dozens of journalists and political activists over the past 13 years.

The semiofficial Mehr news agency said Mortazavi was detained at midnight Monday while Fars, another semiofficial news agency, said he was detained as he was leaving work and taken to Evin prison, just north of Tehran.

Fars also said the arrest was related to Mortazavi's role in the 2009 prison deaths of the protesters. The following year, a parliamentary probe into the case found Mortazavi responsible for what had happened at Kahrizak. He was suspended as Tehran prosecutor general and the case remained open for a judicial investigation, though no further action was taken against Mortazavi.

The judiciary said earlier this year that the prison deaths would again be investigated in March.

The three prisoners, detained in mass street protests against Ahmadinejad, died in Kahrizak a month after their arrest. The case significantly embarrassed the authorities and drew some of the fiercest criticism against Iran's government and its treatment of those arrested in the turmoil following the election.

On Sunday, Iranian lawmakers impeached the country's labor minister and another Ahmadinejad ally, Abdolreza Sheikholeslami, for appointing Mortazavi as head of the social security fund.

Source: http://news.yahoo.com/iran-arrests-official-implicated-prison-deaths-054230578.html

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Super Bowl falls short of ratings record

NEW YORK (AP) ? With a partial power outage, an overly excited quarterback and a game that suddenly turned from snoozer to sizzler, CBS had its hands full at the Super Bowl. The game fell short of setting a viewership record, but it stands as the third most-watched program in U.S. television history.

The Nielsen Co. said an estimated 108.4 million people watched the Baltimore Ravens' 34-31 victory over the San Francisco 49ers. The most-watched events in U.S. TV history were last year's game, seen by 111.3 million, and the 2010 game, with 111 million viewers.

CBS had hoped to make it the fourth year in a row that football's ultimate game broke the record for most-watched event in American television history. But pro football ratings in general have been down slightly this year.

When the Ravens' Jacoby Jones returned the opening kickoff of the second half for a touchdown and gave his team a 28-6 lead, CBS' dream of a ratings record surely became even more distant. And then half the lights went out. CBS' ratings immediately dipped by two full ratings points in the overnight measurement of big cities.

When the lights returned, so did the 49ers. They quickly jumped back in the game and CBS' audience, no doubt fueled by social media chatter, came back, too. CBS was blessed with the dream of every network that telecasts the Super Bowl: a game that isn't decided until the final play.

CBS had a moment of dead air when the field darkened, since power was lost in the control booth where Jim Nantz and Phil Simms worked. After a commercial break, sideline anchor Steve Tasker appeared to say there had been a power outage. CBS then filled time with its football pregame team, showing highlights and speculating on how the delay would affect the teams.

At the precise moment the lights went out, CBS' Armen Keteyian was in the NFL's control booth, conducting an interview with Frank Supovitz, senior vice president of the NFL in charge of events.

"In the NFL control room, there was no panic, but there was an undeniable amount of uncertainty about the cause," Keteyian said Monday on "CBS This Morning." Keteyian was filming for a "60 Minutes Sports" report scheduled to be aired Wednesday on Showtime. CBS News did not participate in live coverage of the power outage.

The power outage was an immediate hot topic for quips and questions online. There were an estimated 47.7 million social media posts during the game, according to the company Trendrr TV, which tracks activity on Twitter, Facebook and other social networks. That compares with 17 million during last year's game and 3 million in 2010, Trendrr said.

Baltimore had the highest rating of any individual city, Nielsen said. San Francisco was not among the top 10 cities in ratings.

CBS showcased its freshman drama, "Elementary," to an estimated audience of 20.8 million people after the game. That was markedly down from the 37.6 million who watched "The Voice" on NBC after the 2011 game or the 26.8 million who saw "Glee" on Fox in 2010. CBS noted that the drama did not begin until 11:11 p.m. on the East Coast because of the Superdome power outage.

CBS drew criticism from the Parents Television Council for not editing out a profanity said by Ravens quarterback Joe Flacco shortly after the game. Flacco was caught by microphones describing his team's victory as "f------ awesome."

"No one should be surprised that a jubilant quarterback might use profane language while celebrating a career-defining win, but that is precisely the reason why CBS should have taken some precautions," said Tim Winter, president of the lobbying group, asking for the Federal Communications Commission to rebuke CBS.

The network had no immediate comment Monday on the complaint.

CBS has said it was airing the pregame, postgame and halftime portions of the show on tape delay to guard against the use of bad language or wardrobe malfunctions. The postgame delay does not begin until the first block of commercials after the game, which hadn't happened before Flacco's expletive.

CBS' Craig Ferguson was quick to poke fun at the power outage on his comedy show, which aired after "Elementary." He was shown plugging actress Lucy Liu's cellphone charger into a power outlet at the Superdome, despite instructions not to use it.

"It's one outlet," Ferguson said. "What could possibly go wrong?"

The picture switched to the lights going out in half the dome.

Source: http://news.yahoo.com/super-bowl-falls-short-ratings-record-203244420--spt.html

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Alabama hostage standoff ends with child safe, gunman dead

MIDLAND CITY, Alabama (Reuters) - U.S. authorities stormed an underground bunker in rural Alabama on Monday, rescuing a 5-year-old boy held hostage for nearly a week and leaving his kidnapper dead.

After a standoff of more than six days, FBI agents entered the bunker when they feared the child was in "imminent danger" at the hands of his abductor, who had killed a school bus driver, said Steve Richardson, special agent in charge in Mobile, Alabama.

The kidnapper, identified as 65-year-old Jimmy Lee Dykes, had previously allowed authorities to deliver medication, coloring books and toys to the kindergarten student, who is due to celebrate his birthday on Wednesday.

But negotiations deteriorated in the 24 hours before agents entered the bunker, Richardson told a news conference.

"Mr. Dykes was observed holding a gun," the FBI agent said.

Law enforcement officials would not confirm on Monday how Dykes died.

The standoff gripped a rural corner of southeast Alabama with dread, shuttering local schools and prompting prayers and vigils for the boy identified only as Ethan.

By all accounts, Dykes had taken him from the bus at random, reinforcing concerns that have been raised about U.S. school safety and gun violence since the December shooting deaths of 20 children and six adults at a Connecticut elementary school.

"It just shows you how close it can come," one of Dykes' neighbors, 42-year-old Angie Adams, said of the violence, adding she now plans one day to home school her 2-year-old daughter.

"We waited 10 years to have her and we would be devastated" if something happened, Adams said.

The drama near Midland City began when Dykes, a retired trucker who served in the Navy during the Vietnam War era, boarded a school bus ferrying more than 20 children home last Tuesday and demanded that the driver let a student off the bus, according to authorities.

PHYSICALLY UNHARMED

When driver Charles Albert Poland, 66, refused, Dykes shot him four times with a 9 mm handgun, local sheriff's department officials said.

"To Mr. Poland's family, we would like to express our condolences," Dale County Sheriff Wally Olson said. "Also our appreciation to a hero who through his brave actions saved many lives."

Dykes fled with the child to a homemade bunker equipped with a television and electric heaters on the man's property off a dirt road. Authorities would not confirm news reports that said negotiators had remained in contact with Dykes by talking through a PVC pipe connected to the underground shelter.

The child was being treated at a local hospital but appeared physically unharmed, Richardson said. He is said to suffer from Asperger's Syndrome and attention deficit-hyperactivity disorder.

"He's laughing, joking, playing, eating," Richardson said. "He's very brave. He's very lucky."

A local law enforcement source said a stun or flash grenade was detonated as part of the operation to free the boy, but further details were not immediately released.

Late on Monday, bomb technicians were clearing the crime scene and looking for explosives, said FBI Special Agent Jason Pack. Authorities said the investigation could take days to complete.

Law enforcement officials offered few insights about Dykes and their negotiations with him before the rescue.

Dale County Sheriff Wally Olson said the gunman had a "very complex" story to tell.

"Based on our discussion with Mr. Dykes, he feels like he has a story that's important to him, although it's very complex," Olson said, without elaborating.

According to neighbors, the reclusive Dykes moved into the Midland City area about two years ago and was often seen patrolling the property where he lived in a trailer with a gun and flashlight at night.

He had been due to appear for a trial before a judge last Wednesday after his recent arrest on a menacing charge involving one of his neighbors.

Another neighbor, who said he grew up with Dykes and also served in the Navy around the same time, suspected the court case might have sparked his unraveling.

"When he kidnapped those kids, he was afraid of losing his property, his rights, his freedom and going to jail," said Mel Adams, who owns a used car lot.

But, Adams added, "We had no idea on Earth he would turn into a monster like this."

(Additional reporting by Tom Brown; Writing by Colleen Jenkins; Editing by Cynthia Johnston, Cynthia Osterman and Xavier Briand)

Source: http://news.yahoo.com/alabama-hostage-standoff-ends-child-safe-gunman-dead-012955611.html

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A 'nudge' can be the ethical choice

A 'nudge' can be the ethical choice [ Back to EurekAlert! ] Public release date: 4-Feb-2013
[ | E-mail | Share Share ]

Contact: Gracie Gutierrez
ggutierr@bcm.edu
713-798-4710
Baylor College of Medicine

HOUSTON -- (Feb. 6, 2013) As patients and physicians share decision-making in choices among treatment options, decision aids such as videos, websites, pamphlets or books are coming to play an important role. However, in some cases, it may be ethical for the decision aids to provide a "nudge" toward a particular option, said researchers from Baylor College of Medicine, the Michael E. DeBakey Veterans Affairs Medical Center and the University of Texas MD Anderson Cancer Center in a report that appears in the journal Health Affairs.

In general, decision aids are meant to be even-handed, presenting information in a non-judgmental way, said Dr. Jennifer Blumenthal-Barby, assistant professor in the Center for Medical Ethics and Health Policy at BCM. However, as she began to consider different situations in which they might be used, she realized that this might not always be helpful to patients.

"There are situations in which I think it is okay for a decision aid to favor one option more," she said. In the paper, she and her colleagues described three scenarios in which such "nudges" might be the ethical choice:

  • In early stage prostate cancer, active surveillance of early stage prostate cancer is a clinically viable option of which patients are often aware and are often not offered.
  • Screening for colorectal cancer, which is low risk and high benefit.
  • Treatment for deep vein thrombosis, which involves a choice between two alternatives that could be affected by the patient's habits, concerns or preferences.

In using decision aids, the patient and physician are supposed to sit down together and watch a video, look at a website or go over written material that is designed to spell out the risks and benefits of each treatment for a particular disease.

"Decision aids came into being because of the concern that clinicians aren't telling patients all the options," said Blumenthal-Barby. "Decision aids standardize things so patients get a fair view of all the options, their risks and benefits."

In some cases, however, an even-handed presentation may not give patients a fair understanding of the options. In those cases, it might be ethical to alter the playing field by placing a certain option first or help patients understand how one option might be compatible with their lives while another might not.

In the case of early prostate cancer, the data support active surveillance as a viable treatment option for a subset of patients, but many physicians do not discuss it as an option or do not go into it in depth. In that case, she said, designing the decision aid to make patients think about it more might be the best choice.

In the second case, the guidelines recommend that people ages 50 to 75 years be screened by one of four methods. In this case, said Blumenthal-Barby and her colleagues, the aid might highlight the four methods colonoscopy, flexible sigmoidoscopy, computed tomography colonography or fecal tests and not include a fifth option no screening at all.

In this way, the decision aid is even-handed in its presentation of screening options but unbalanced in the decision of screening versus not screening.

Patients who have suffered deep vein thrombosis (a blood clot deep in the body) require extended treatment to prevent future blood clots. For most patients, taking an anticoagulant called warfarin by mouth or injections of low-molecular weight heparin (another anticoagulant) under the skin is equally effective.

However, the oral warfarin treatment requires that patients exclude some foods such as leafy green vegetables or alcohol from their diets and have their blood levels of the drug checked frequently. While the daily or twice daily injections of heparin may be distasteful to people who dislike needles, they do not require the dietary changes or the frequent testing of the other treatment.

In this case, said Blumenthal-Barby, the decision aid should include a "values clarification" exercise that enables the patient to consider what is most important to him or her and then the option that is most in line with that should be encouraged t.

###

Others who took part in this report include Dr. Heidi Voelker Russell, associate professor of pediatrics at BCM, Dr. Aanand D. Naik, of the Houston VA Health Services Research and Development Center of Excellence at the Michael E. DeBakey VA Medical Center and assistant professor of medicine health services research at BCM, Dr. Scott B. Cantor, professor of biostatistics, and Dr. Robert J. Volk, professor of general internal medicine, both at The University of Texas MD Anderson Cancer Center.

Funding for this work came from the Greenwall Foundation, the Pfizer Foundation and the Michael E. DeBakey Veterans Affairs Medical Center.

This paper and others on the "New Era of Patient Engagement" will be discussed at a briefing in Washington, D.C., at 8 a.m. on Feb. 6, 2013. Blumenthal-Barby will be one of the presenters.


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A 'nudge' can be the ethical choice [ Back to EurekAlert! ] Public release date: 4-Feb-2013
[ | E-mail | Share Share ]

Contact: Gracie Gutierrez
ggutierr@bcm.edu
713-798-4710
Baylor College of Medicine

HOUSTON -- (Feb. 6, 2013) As patients and physicians share decision-making in choices among treatment options, decision aids such as videos, websites, pamphlets or books are coming to play an important role. However, in some cases, it may be ethical for the decision aids to provide a "nudge" toward a particular option, said researchers from Baylor College of Medicine, the Michael E. DeBakey Veterans Affairs Medical Center and the University of Texas MD Anderson Cancer Center in a report that appears in the journal Health Affairs.

In general, decision aids are meant to be even-handed, presenting information in a non-judgmental way, said Dr. Jennifer Blumenthal-Barby, assistant professor in the Center for Medical Ethics and Health Policy at BCM. However, as she began to consider different situations in which they might be used, she realized that this might not always be helpful to patients.

"There are situations in which I think it is okay for a decision aid to favor one option more," she said. In the paper, she and her colleagues described three scenarios in which such "nudges" might be the ethical choice:

  • In early stage prostate cancer, active surveillance of early stage prostate cancer is a clinically viable option of which patients are often aware and are often not offered.
  • Screening for colorectal cancer, which is low risk and high benefit.
  • Treatment for deep vein thrombosis, which involves a choice between two alternatives that could be affected by the patient's habits, concerns or preferences.

In using decision aids, the patient and physician are supposed to sit down together and watch a video, look at a website or go over written material that is designed to spell out the risks and benefits of each treatment for a particular disease.

"Decision aids came into being because of the concern that clinicians aren't telling patients all the options," said Blumenthal-Barby. "Decision aids standardize things so patients get a fair view of all the options, their risks and benefits."

In some cases, however, an even-handed presentation may not give patients a fair understanding of the options. In those cases, it might be ethical to alter the playing field by placing a certain option first or help patients understand how one option might be compatible with their lives while another might not.

In the case of early prostate cancer, the data support active surveillance as a viable treatment option for a subset of patients, but many physicians do not discuss it as an option or do not go into it in depth. In that case, she said, designing the decision aid to make patients think about it more might be the best choice.

In the second case, the guidelines recommend that people ages 50 to 75 years be screened by one of four methods. In this case, said Blumenthal-Barby and her colleagues, the aid might highlight the four methods colonoscopy, flexible sigmoidoscopy, computed tomography colonography or fecal tests and not include a fifth option no screening at all.

In this way, the decision aid is even-handed in its presentation of screening options but unbalanced in the decision of screening versus not screening.

Patients who have suffered deep vein thrombosis (a blood clot deep in the body) require extended treatment to prevent future blood clots. For most patients, taking an anticoagulant called warfarin by mouth or injections of low-molecular weight heparin (another anticoagulant) under the skin is equally effective.

However, the oral warfarin treatment requires that patients exclude some foods such as leafy green vegetables or alcohol from their diets and have their blood levels of the drug checked frequently. While the daily or twice daily injections of heparin may be distasteful to people who dislike needles, they do not require the dietary changes or the frequent testing of the other treatment.

In this case, said Blumenthal-Barby, the decision aid should include a "values clarification" exercise that enables the patient to consider what is most important to him or her and then the option that is most in line with that should be encouraged t.

###

Others who took part in this report include Dr. Heidi Voelker Russell, associate professor of pediatrics at BCM, Dr. Aanand D. Naik, of the Houston VA Health Services Research and Development Center of Excellence at the Michael E. DeBakey VA Medical Center and assistant professor of medicine health services research at BCM, Dr. Scott B. Cantor, professor of biostatistics, and Dr. Robert J. Volk, professor of general internal medicine, both at The University of Texas MD Anderson Cancer Center.

Funding for this work came from the Greenwall Foundation, the Pfizer Foundation and the Michael E. DeBakey Veterans Affairs Medical Center.

This paper and others on the "New Era of Patient Engagement" will be discussed at a briefing in Washington, D.C., at 8 a.m. on Feb. 6, 2013. Blumenthal-Barby will be one of the presenters.


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Source: http://www.eurekalert.org/pub_releases/2013-02/bcom-ac020113.php

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