questions

Study Discussion Questions

1. Whose perspective do you agree with—Sandy's or Grace's? Why?
2. Do you think there are important differences between the cases of Henrietta Lacks, Jean, and the Havasupai? Explain your answer.
3. Are there cases of advances in medical knowledge that do not, at least potentially, threaten to violate the privacy of individual patients?
4. Does a patient have the right to use the genetic information that belongs to her direct-lineage family members? Extended family or relatives? Other patients with a similar condition?
5. What moral, ethical, and legal protocols can be considered in guiding clinicians in this case?
6. What moral, ethical, and legal protocols can be considered in guiding researchers in this case?

imothy B. Patrick, Peter J. Tonellato, and Mark A. Hoffman

Two health sciences graduate students, Sandy and Grace, are discussing the value of clinical uses of genetic and genomic patient information.

Sandy: It's always the same story—the supposed trade-off between the benefits to society and the sacrificed rights of the individual! Just remember the case of Henrietta Lacks. HELA cells—cancer cells taken from Henrietta before she died—have been invaluable to medical science; they led to the polio vaccine and other medical “miracles.” But Henrietta was never told what was going to be done with her cells; she never gave her permission. Nor did her close relatives and family know or give their permission. It's a clear case of science overstepping its bounds to the detriment of the individual.

Grace: Sandy, you know that scientific research's benefit to society really means the medical care benefit to the individual. Don't you remember the recent case that took place here in our own hospital—the case of Jean, a 17-year-old who was visiting the home of a friend when she fell down, struck her head, and suffered serious injuries? She was raced to the emergency room, where she required emergency surgery, and neither her parents nor her relatives could be reached before the procedure. The mother of Jean's friend provided the hospital with Jean's name and home address, which allowed the ER personnel to associate Jean with her parents in the system. Using the hospital's healthcare information system, the surgeon entered an order for the protocol that she was planning to use to treat Jean. Among the details included in the protocol was the use of halothane, a type of anesthesia. Jean had never been the subject of genetic testing, but her father had had a genetic test that found a mutation in the ryanodine receptor gene. When people with this mutation are exposed to halothane, they can experience malignant hyperthermia, an often-fatal reaction that can cause the body's core temperature to reach 106 degrees Fahrenheit.

The hospital's information system used the demographic person–person relationship between the father and his daughter and embedded pharmacogenomics decision support capabilities to infer that Jean had a 50 percent risk of also possessing this rare mutation. The system flashed an interactive alert to the surgeon, who was unaware of this genetic association. The surgeon responded to the alert by activating an alternative surgical plan that did not include the use of halothane. It was only by taking advantage of the genetic information about Jean's father that a potentially catastrophic clinical event was averted!

Sandy: But you make my case for me. The potential for abuse of genetic data is magnified by the existence and use of sophisticated healthcare information systems. There's no mystery about the potential for abuse. Jean's father was the one who had the test, not Jean. Yet the information produced by the test was also about Jean. Sure, revealing that information happened to help Jean, but the principle is that the information was about Jean as much as it was about her father. And Jean never gave her permission for that information to be used or revealed! It's her body and her genome, not her father's, right? So it's her right to privacy that was violated.

Grace: It might be her body, Sandy, but given the genetic data and information, we are bound by our Hippocratic oath to do no harm—primum nil nocere in Latin.¹ In practice and in effect, Jean's life was ours to save. What other choice did we have?

Sandy: What about consent and protecting her privacy? And what about Jean's father? Did he give permission to release the information from his genetic test to be used in ways other than for his diagnosis and treatment? How is that different from the Havasupai tribe's lost-blood case?

Grace: Remind me about that case.

Sandy: Arizona State University researchers asked the Havasupai if they would provide blood for studies to discover clues about the tribe's incredible rate of diabetes, presumably to help the Havasupai. But the researchers used the collected blood for other purposes. They used the extracted DNA for studies on mental illness. The initial diabetes studies seem to have led nowhere, but even if that effort helped save lives, it would have been lives saved without the Havasupai's consent.

Grace: Sandy, for goodness sake, it was only blood!

Sandy: Not at all, Grace, not at all.

Note

1.The following Hippocratic oath is reprinted from North (2002):

I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement: To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art. I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion. But I will preserve the purity of my life and my arts. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves. All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal. If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.

Critical Thinking Exercise: Hostility, Depression, and Heart Disease

Now that you have completed Chapter 10, take your learning a step further by testing your critical thinking skills on the following practical problem-solving exercise.

Although everyone feels angry from time to time, when everyday anger turns destructive or occurs with increasing frequency, it can have a variety of unhealthy effects. In addition to reducing the overall quality of a person’s life, uncontrolled anger can damage relationships and make people feel as though they are at the mercy of an unpredictable force.

Hostility and anger may also directly affect the health of a person’s heart. In one study, Duke University researchers asked patients with ischemia to wear wireless heart monitors for 48 hours, and to keep a diary of their emotions—sadness, tension, frustration, happiness, and feelings of control—during that time period. The researchers found that the patients who had stressful feelings were twice as likely to have a bout of ischemic pain an hour later as the patients who didn’t have stressful feelings.

In another, long-term prospective study of medical students at Johns Hopkins University, researchers found that those who experienced depression during their time at Johns Hopkins were, on average, twice as likely to develop cardiovascular disease or suffer a heart attack 15 years later, as students who didn’t experience depression. Other studies that examined the effects of depression on the heart have found that depressed people who already have heart disease are up to eight times more likely to develop ventricular tachycardia—a dangerous heart arrhythmia—than heart disease patients who are not depressed.

The effect of positive emotions on the heart is also a subject of research. One ongoing study at the Institute of HeartMath has reported that feelings of love and gratitude in coronary patients may actually make the beating of their hearts more uniform and consistent. This change is similar to the “relaxation response”—a state that is physiologically the opposite of the “fight-or-flight” response, in which blood pressure is reduced and blood flow to the heart is increased.

The American Psychological Association’s Web site includes an outstanding series of essays called “Psychology and Everyday Life,” which offer solid and direct advice on hostility and the heart, based on the latest research. It also discusses strategies for anger management, such as cognitive restructuring. As part of this exercise, check out the information at www.apa.org/pubinfo/anger.html and then prepare answers to the questions that follow.

Question 1

In what ways is anger like other emotions? In what ways is anger unique?

Question 2

What are the common triggers of anger? How often does a typical person become angry? Who tends to become angry more often?

Question 3

What do researchers believe to be the causes of an “anger-prone” temperament?

Question 4

Researchers believe that hostility is one of several emotions that force the heart to work overtime, and, that, after a while, may promote the development of heart disease. For example, hostility may increase blood clotting and the levels of sugar and fats in the blood. Physiologically, what other emotion-induced changes may account for this relationship between hostility and heart disease?

Question 5

How can cognitive restructuring be used to help anger-prone individuals gain control of their anger? What are several other strategies for keeping anger and hostility under control?

True or False Questions:

Please answer true or false.

1. Even when care is free at the point of service, we would expect low and high-income individuals with the same level of need to demand different quantities of health care.

2. We would expect the demand curve for physician visits to be more price elastic than the demand curve for inpatient hospital care.

3. A decision by the provincial governments to include counseling by psychologists within the public insurance plan would decrease the demand for physician services.

4. The actuarially fair premiums are the same for two individuals who have identical probabilities of being ill and identical monetary losses associated with being ill, but who have differing risk preferences.

5. A risk-averse individual prefers all situations with certainty compared to a risky prospect.

6. A community-rated premium is always less than a risk-adjusted premium.

7. Designing a funding system necessitates a trade-off between encouraging productive efficiency and discouraging strategic selection.

8. Changing from fee-for-service payment to capitation payment transfers risk from the funder to the funded provider.

9. Because participation is mandatory for all residents within a universal, public insurance system, risk selection is not a concern when providers in such a system are funded using capitation payment.

10. Variables used to risk-adjust capitation payments should be under the control of providers.

Louise works in a foreign branch of her employer's business. She earned $5,000 per month throughout the relevant period. Which of the following is correct?

a.If Louise worked in the foreign branch from May 1, 2019 until October 31, 2020, she may exclude $40,000 from gross income in 2019 and exclude $50,000 in 2020.

b.If Louise began work in the foreign country on May 1, 2019, she must work through November 30, 2020 in order to exclude $55,000 from gross income in 2020 but none in 2019.

c.If Louise worked in the foreign branch from May 1, 2019 until October 31, 2020, she cannot exclude anything from gross income because she was not present in the country for 330 days in either year.

d.Louise will not be allowed to exclude any foreign earned income because she made less than $107,600.

[1] Normally cash sales are recorded daily, these are representative to reduce the number of repetitive entries.

Video Transcript

>> If someone wants to be successful in life, there are certain obligations that they're going to have to themselves in terms of making the right decisions. And if you want to work for the rest of your life, then you won't really have to worry about planning in terms of financially speaking. If you are concerned, and you don't want to work for the rest of your life, then you'll have to be concerned about your finances. In doing so, that's where investing comes into play. It's doing the right thing with your money over time.

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People tend to confuse the topic. That has a lot to do with the media, the grapevine individuals. The typical individual learns about investing through the grapevine. I think the most important thing for a young individual is education. Learning the proper techniques and the proper components about investing. Where they should have their money, why certain things work the way they do. What's the difference between a stock and a bond? Things of this nature. As you become more comfortable about investing, you will make better financial decisions. In 1997, Morgan Stanley and Dean Witter merged. They took the top talent from both organizations and created a global financial institution. They have investment banking, which is kind of like the Morgan Stanley side, and they have retail investing, or the individual investing section, which is the Dean Witter side. The organization focuses on all aspects of the financial markets, whether it be lending, investments, investment banking, merchant banking. It's really unlimited when it comes to the resources that Morgan Stanley has to offer an individual client. There are many different types of investments. A new investor, or a young investor, could utilize when making, starting off a portfolio. One of the most popular investments, and the one that I would probably recommend would be a mutual fund. A mutual fund gives you two very important things. The first thing, and the most important thing, is diversification. Mutual funds can invest in a basket of different types of investments. They could invest in stocks and bonds. They could invest in just stocks. They could invest in just bonds. It's a multi-faceted type of product that the mutual fund manager has the ability to invest in any type of investment that they want based on the prospectus. So you, as an average investor, or a new investor who is not really sure what stocks do I buy, which bond do I buy, you relieve that responsibility to the mutual fund manager. And within the scope of mutual funds, there's hundreds of different types of mutual funds. Number two, I would say would be an individual stock for a growth investor. With an individual stock, you have direct ownership in the company that you're buying. If it's a common stock, which a typical investor buys, you have one share if you buy one share, you have one share of the, of ownership of that company, and you're buying that one share because you feel that this stock is going to be a good investment, the company's going to do well, and the share price of that stock is going to grow over time. That's appreciation. That's the reason why you're buying an individual stock. It could be more risky than another type of investment, because if that company doesn't do well, unfortunately its stock price is not going to do well, and you know, negatively affect your portfolio. On the flipside of that, you have a bond type of investment. This investment typically is a little less risky in the sense that it's giving you the opportunity to put a certain amount of money up to the individual issuing the bond. That individual, the issuing company, or corporation, or whomever is issuing the bond, pays you an interest rate over the duration of the bond. At the end of the bond, they give you your money back, however much you originally put into it. So you have somewhat of a fixed idea of the exact dollar amount of money that you're going to be receiving from that type of an investment, whereas with a stock, you're putting money in, you could lose money, you could make money, there's really no set idea of exactly how much money you're going to be getting. With a bond, typically, you have a set idea of exactly how much, in terms of return, you're going to be receiving. After you make a decision, and you decide you want to start investing. There's three things that you need to focus on before you make any type of investment decision. The first thing is to determine your goals and objectives. Your goals and objectives will give you an idea of what exactly you want to do, whether it be your retirement. You could usually set sort term goals, medium term goals, and long-term goals. That's kind of like the blueprint for your financial future. The second thing is your time horizon. And that's your duration in investment terms. How long do you have to reach those goals? The earlier you start as an investor, the more of an opportunity you have to obtain your goals. You want to buy something like a house, you might want to wait three years. Medium term, you might be thinking about starting a business. That might be 5 to 10 years. You're usually, your longest term goal is retirement, that might be 20 to 25 years. With the effects of compounding interest. What that means is money doubles by certain percentages every year, or every number of years. By giving yourself the opportunity to have more years in the pipeline, that gives yourself, with the effects of compounding interest, the opportunity for your money to double more often. The third thing is your risk tolerance. I call it your sleep-ability. That is, how are you going to invest your money and be comfortable, and be able to put your head on the pillow at night and be able to sleep. That is something that is not easy to figure out as a new investor because you don't have the education or the experience with the overall market. One of the things that I use to kind of gauge an individual is, if you invested in a stock or a bond, and that stock went down by 20%, what would you do? The typical investor, early on, because they're not educated and experienced, they tend to do the exact opposite of what they're supposed to do. The old theory goes, buy low, sell high. The typical individual does not invest that way. This is how it works. An individual makes a decision to invest. He starts to talk to a couple of his friends. One of his friends says, "Oh, I invested in this mutual fund last year, it did 75% return in one year." Investor's delighted to hear those terms. What type of fund was it? Gets the name, runs home, puts X amount of dollars into the mutual fund, buying it high, because it was up 75%. What happens, because the market is cyclical, typically the mutual funds that did well this year, do poorly the following year. The fund drops down. Now he's losing money. He thinks about it for a second and says, what was I thinking. I just rushed into this. I should have never bought this fund. I don't even like any of the investments in this fund. He sells the fund. He or she sells the fund. Then they say, "Okay, now what am I going to do with the money?" They do a little of their own research, based on performance, and short-term thinking, they buy another fund that was up 50, 60%. For whatever reason, they put more money into that fund. You can see this cycle starting to develop. They're buying high, selling low. Buying high and selling low. That's the exact opposite from what you want to be doing. An old saying goes is buy straw hats in December because it's the winter time, that's when they're cheap. When prices are low, and things don't look good, that's when you want to be investing in them. Not when everything looks really good, corporate profits are high, you know, the CEO of the company is on the cover of every magazine. That's typically when you sell the stock, not when you buy it. As a result of the bull market that happened in the late '90s, we saw double-digit returns many years in a row, it drew a lot of investors into the market because they thought it was going to be a quick hit. That they were going to be able to make a lot of money in a very short period of time, which a lot of individuals did. Kind of like the gold rush in California, the market drew thousands and hundreds of thousands of investors all looking for that quick, that quick rich hit. Basically, what happened was, that pushed equity prices well above what the fundamentals warrant for these stocks and that went on for a few years. And unfortunately, as some of the economic numbers didn't work out the way they were supposed to, the economy slowed down a little bit, corporate earnings fell a little short, it burst that bubble. The individual that was able to get out ahead of time did okay. Unfortunately, probably the majority of the people did not. And it's that short-term, kind of day trading mentality that could force you not to make the right investment decisions in terms of short-term thinking, irrational type thinking. When you're investing, it's for the long-term. If you invest for the short-term, that's like basically gambling. That's what not we're trying to achieve. I conduct seminars all the time. The typical individual thinks that when they retire, social security is going to be their means of retirement income. Number one, we don't know if social security's going to be around and number two, if it is around, that's not going to really be the sum of money you want to have available for yourself in retirement. The responsibility of savings relies on you. It's not necessarily savings starting off with the right dollar amount. I'm sure we could all attain to this because we've all been young at one time, but it's not necessarily managing your assets, it's managing your liabilities. When you graduate, you have huge student loans, you have huge credit card bills, maybe a personal loan, you have your car loan, and that is going to prevent you from investing the right way. So the first, my first recommendation would be to manage your debt. Focus on acting somewhat prudently when you're at a younger age. In terms of the investment end, what I would recommend would be to start off small. Typically, I say to someone that your checkbook, every month you're balancing your checking, hopefully, if you have one. Usually, every month you'll have that dollar amount at the bottom of the registry that you're not using that's kind of carrying over every month, whether it be $100 or, take that dollar amount and invest that into maybe a mutual fund or some type of investment that makes sense for your overall profile. That's called dollar cost averaging. That's a strategy that we use that allows you to slowly put money into the market at highs and lows, and over the long-term, you'll get a better average price. It's never too early to start investing. Even if you start with $100, $200 a month, a week, whatever you could afford in your budget, those small dollar amounts over time will grow to be the money that you'll need in terms of a nest egg to retire on when you hit your retirement age.

Chapter 10

Securities Markets: Trading Financial Resources

Video Case: Morgan Stanley Builds Its Future One Client at a

Time

Founded as an investment bank in 1935, Morgan Stanley has a long history and a strong brand identity, ranking among Wall Street’s elite. The company also has a number of securities industry “firsts” to its credit, including the first computer model for financial analysis, the introduction of automated processing for securities trading, and the creation of innovative new types of securities.

In 1997 Morgan Stanley merged with Dean Witter, combining that company’s strong retail brokerage services with its own investment banking and institutional securities operations. Today the combined firm is global, with about 54,000 employees in more than 600 offices in 30 countries, and client assets under management totaling more than $622 billion.

Morgan Stanley is highly regarded for its financial advice and market execution, offering clients a wide range of services through four business segments: Institutional Securities (investment banking, institutional sales and trading, research), Individual Investor Group (investor advisory services, wealth management, individual investor services),Investment Management (global asset management products and services for individual and institutional investors), and Credit Services (Discover-branded cards and other consumer finance products and services). The firm continues to be on the cutting edge in its use of technology.

During the high-flying 1990s, Morgan Stanley and its Wall Street peers enjoyed a period

of fast growth and increasing profitability as the stock market soared and corporate financing

activity flourished. As the new century started, however, the 10-year bull market ended, bringing very different and volatile economic conditions. Few companies wanted to issue securities, merger activity fell off sharply, and individual investors retreated to the sidelines as stock prices tumbled.

Along with many other financial institutions, Morgan Stanley reduced its staff and closed offices in response to lower revenues from the financial markets. The Institutional Securities unit focused its resources on building stronger relationships with top clients. It developed its own systems to automate its NASDAQ and options trading, which offered clients improved execution at lower cost. The Individual Investor Group began emphasizing fee-based accounts rather than transactional arrangements.

As the markets improved, Morgan Stanley focused on building up relationships “one client at a time.” Whether working with large corporations looking to raise financing or individual investors saving for college or retirement, Morgan Stanley evaluates clients’ needs, develops

financial plans, and implements strategies to reach objectives. Current chairman and chief executive officer John J. Mack states, “We have the right team, the right assets, and the right business mix in place. Now we must maintain a relentless focus on one priority—performance…We will tear down any barriers that impede our ability to create a cohesive ‘one firm’ culture in which every employee acts and feels like an owner of the firm.” It is clear that Morgan Stanley has every intention of maintaining its position at the forefront of the securities industry.

1. Explain why it is important for Morgan Stanley’s clients to understand their personal investment objectives. What might some of these be for a corporate client?

2. As a potential individual client, list several of your personal financial goals. Visit the Morgan Stanley website, www.morganstanley.com, and explore the pages for individual investors. Which of the features and benefits presented on the site appeal to you most? Would you feel comfortable choosing Morgan Stanley as your investment adviser, and why?

A pollster would like to survey 500 students to determine the percentage that would vote for Ben Carson. If the pollster surveyed 500 students who worked directly with Carson will the results be meaningful to depict the thinking of the entire US population of students? Answer yes or no with explanation.

Why was Marilyn Vos Savant's calculation of having breast cancer given a positive mammogram test flawed?

A. Hubble telescope sees a dime sized view of the universe which represents an accurate sample

B. Jhon Hickley is insane

C. Fibonacciseries appears eveerywhere in nature

D.Women who get mammograms have a higher probability of breast cancer than the random American and Marilyn used the random American probabillity in her calculation.

1. What are the advantages and disadvantages of setting up trade barriers?  Are trade barriers effective?  As part of this question, also answer what might be the advantages and disadvantages of a US company moving the manufacturing of a product, such as sneakers, into the United States?