About

Zackary Berger, MD, PhD, is a professor at the Johns Hopkins Division of General Internal Medicine and a faculty member at the Johns Hopkins Berman Institute of Bioethics, with a joint appointment in the Johns Hopkins Bloomberg School of Public Health. He is an internist, clinical epidemiologist, and bioethicist whose clinical, educational, and research work is situated at the intersection of shared decision making, patient-centered care, and evidence-based medicine. His focus includes exploring how the sharing of the patient-physician relationship is affected by social and political inequities, especially among vulnerable and victimized populations. Dr. Berger maintains an active primary care internal medicine practice at Johns Hopkins and teaches residents and medical students at Johns Hopkins Hospital. He is involved in bioethics education for residents across various Johns Hopkins specialty programs and serves as a staff physician at the Esperanza Clinic Health Center, a free clinic serving undocumented Spanish-speaking immigrants. His research interests encompass clinical ethics, shared decision making, patient-physician communication, clinical epidemiology, systematic reviews, advocacy, health policy, and the social dimensions of health, including Jewish bioethics, religion and bioethics, immigrant health, race, and bioethics. He is also an author of two books aimed at the lay public on doctor-patient communication and patient preferences in the context of medical evidence.

Research topics

• Political Science
• Chemistry
• Biochemistry
• Medicine
• Economics
• Economic growth
• Family medicine
• Virology
• Biology
• Nursing

Selected publications

• End-of-life care among Koreans in critical care and community-dwelling Korean Americans: A cross-cultural scoping review

  Palliative & Supportive Care · 2025-01-01

  articleOpen access

  OBJECTIVE: End-of-life (EOL) care for critically ill individuals is shaped by socioeconomic, legal, and cultural factors for Koreans in South Korea and Korean Americans (KA) in the United States. This scoping review thematically synthesized critical care literature from Korea and community-based literature involving KAs to inform culturally tailored EOL and palliative care research and practice. METHODS: Following the updated JBI scoping review guidance, we reviewed English and Korean articles across seven databases. Due to the lack of critical care studies involving KAs, the scope of U.S. studies was broadened to all healthcare settings. We conducted a thematic synthesis to identify cross-context cultural insights that are potentially transferable from Koreans in critical care to KAs with similar needs. RESULTS: = 26) focused on hypothetical palliative care preferences among older, community-dwelling KAs, with limited attention to critical care. Both contexts revealed shared cultural preferences for family-centered decision-making, physician-led discussions, and indirect communication about diagnosis and prognosis. Further research is warranted to investigate within-group heterogeneity and preference shifts across illness trajectories to inform culturally tailored EOL interventions for KAs. SIGNIFICANCE OF RESULTS: Findings highlight the need for culturally and structurally informed approaches to improve EOL care in both Korea and the U.S. This cross-context analysis demonstrates how evidence from the heritage country can inform research and practice for immigrant and minoritized populations when domestic data are sparse. Strength-based approaches grounded in community values, combined with culturally specific insights from Korean literature, may enhance culturally responsive support for KA patients and families.

  PublisherOA PDFDOI

• Expanding Health Coverage Access Through State-Based Marketplaces: A Path Forward for Undocumented Immigrants

  Journal of General Internal Medicine · 2025-07-14

  editorialOpen access
  PublisherOA PDFDOI

• Health system mistrust, ultra-orthodox Jews in the US, and vaccine hesitancy

  Journal of Biosocial Science · 2025-03-01 · 2 citations

  articleOpen access1st authorCorresponding

  A minority of ultra-Orthodox (Charedi) Jews choose not to be vaccinated, and their refusal has assumed significant importance from a variety of perspectives. Clinicians often encounter patients whose beliefs are different from their own. Vaccine hesitancy within the US Charedi Jewish community is a factor contributing to outbreaks of disease, reflecting a growing mistrust between communities and arms of the State played out on the terrain of bodies and societies. Clinicians need to be aware of and understand this broader context as a foundation of empathetic listening and epistemic humility that might lead to improved health for the Charedi community based on reinforced trust.

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• Pandemics, populism and bioethics: A critical approach

  PLOS Global Public Health · 2025-05-20

  articleOpen access
  PublisherDOI

• The individual and social ethics of shared decision making

  2025-08-01

  book-chapter1st authorCorresponding

  Abstract This chapter begins with an overview of the ethical claims made for shared decision making (SDM) which can be framed as normative in ethical terms or as descriptive claims regarding the desires of patients. It then provides a critique of SDM as relevant to different realms of patient care. These critiques are organized considering the relationship of SDM to individuals, communities and institutions, and society. The chapter then considers the experience of patients with SDM as it is practised. Finally, it concludes with a consideration of SDM in historical context and some deliberation on potential alternatives to the approach.

  PublisherDOI

• How Gatekeepers Can Better Appreciate the Autonomy of Transgender Patients

  Journal of General Internal Medicine · 2025-02-18

  editorialOpen access1st authorCorresponding
  PublisherOA PDFDOI

• End‐of‐life care for the devout Jewish patient

  Journal of Evaluation in Clinical Practice · 2024-08-06 · 1 citations

  article

  RATIONALE: The Joint Commission emphasizes the importance of cultural competence and effective communication in quality medical care, particularly during end-of-life (EOL), when decisions are influenced by diverse cultural and religious backgrounds. For Orthodox Jewish patients, the philosophical framework used for EOL decision-making may conflict with that used in traditional Western medical ethics. In this paper, we explore the complexities of EOL decision-making for devout Jewish patients and highlight how approaches may differ from a Western ethical framework. AIMS AND OBJECTIVES: This paper aims to familiarize clinicians with EOL preferences of Orthodox Jewish patients, organized into an ethical framework called 'casuistic deontology'. Leading with an open-minded approach emphasizing cultural humility, we explore ways in which integrating this perspective can allow for culturally appropriate and compassionate EOL care. METHOD: Using a case study methodology, we focus on a 79-year-old Orthodox Jewish male hospitalized with severe injuries. The patient's medical course is analyzed, highlighting how the decisions made by his family in consultation with their Rabbi may differ from the decisions made with a philosophy of a Western ethical framework. RESULTS AND CONCLUSION: This case illustrates the ethical tensions that may arise when Western medical practices intersect with Orthodox Jewish beliefs, particularly regarding brain death, resuscitation, and artificial nutrition. We underscore the need for cultural sensitivity when approaching EOL decision-making, allowing for compassionate and comprehensive care that respects religious perspectives. This paper helps provide a structure for clinicians to navigate the complex EOL care needs for the devout Jewish patient in a manner consistent with their cultural and religious identity.

  PublisherDOI

• Figure accessibility in journals: analysis of alt-text in 2021–23

  The Lancet · 2023-11-28 · 2 citations

  letterOpen access

  An estimated 295 million people worldwide live with a visual disability and face a breadth of challenges associated with pervasive structural ableism.1GBD 2019 Blindness and Vision Impairment CollaboratorsTrends in prevalence of blindness and distance and near vision impairment over 30 years: an analysis for the Global Burden of Disease Study.Lancet Glob Health. 2021; 9: e130-e143Summary Full Text Full Text PDF PubMed Scopus (444) Google Scholar Owing to these challenges, people with disabilities are under-represented in both science and medicine and face additional difficulty in career progression.2Bernard MA ACD WGD subgroup on individuals with disabilities report. US National Institutes of Health, Bethesda, MD2022Google Scholar, 3National Academies of Sciences, Engineering, and MedicineDisrupting ableism and advancing STEM: cultivating accessible educational pathways and spaces.https://www.nationalacademies.org/event/06-15-2023/disrupting-ableism-and-advancing-stem-cultivating-accessible-educational-pathways-and-spacesDate: June 15, 2023Date accessed: October 2, 2023Google Scholar, 4National Center for Science and Engineering StatisticsWomen, minorities, and persons with disabilities in science and engineering: 2021. Special report NSF 21–321. National Science Foundation, Alexandria, VA2021Google Scholar Image alternative text (alt-text) could increase accessibility for people with visual disabilities. Standards from the Web Content Accessibility Guidelines (WCAG) advise that alt-text should serve the equivalent purpose of non-text content.5W3C Web Accessibility InitiativeWCAG 2 overview.https://www.w3.org/WAI/standards-guidelines/wcagDate: April 19, 2023Date accessed: October 1, 2023Google Scholar These guidelines are developed through international collaboration and are continually updated, with WCAG 1.0 published in 1999 and WCAG 2.1 updated in September 2023. Whether major academic journals adhere to these best practices is unknown. To investigate, we conducted a cross-sectional observational study assessing the use of alt-text in leading journals. We examined 100 clinical journals, 100 non-clinical journals, and 50 ophthalmology journals, selected on the basis of the highest 5-year impact factor in each category. Journal characteristics were obtained from Journal Citation Reports, provided by Clarivate. We used the five most recently published full-length online articles for each journal and evaluated alt-text practice for all figures within each article. Where institutional access was not possible, we selected the five most recently published open access articles. We did not examine supplementary material or unformatted manuscripts. Evaluation of journal websites was performed using the Google Chrome Web Developer extension, a tool used by accessibility experts for evaluation of website design elements (version 0.5.4). Alt-text practice was archived using screenshots. A list of included journals and details on the methods are shown in the appendix (pp 1–2, 7–12). We followed STROBE guidelines. This study did not require institutional review board approval because it surveyed data from public sources. Data for 1250 articles across 250 journals (five articles per journal) were collected from March 14 to Sept 30, 2023. Articles examined were published between Feb 2, 2021, and April 25, 2023. The most common alt-text practice observed across journals was replication of figure position, such as by listing "Figure 1" or "Figure 2" (150 [60·0%] of 250 journals). It was also common for alt-text to be absent (37 [14·8%] journals) or to contain no meaningful information, such as "Figure" or "Image" (24 [9·6%] journals). In some cases, alt-text replicated the figure title (14 [5·6%] journals) or figure caption (10 [4·0%] journals). Results were similar across clinical, non-clinical, and ophthalmology journals (table). We also noted variation in alt-text practices across journals managed by the same publisher. For example, the publisher with the second highest number of journals in our sample, Elsevier, published 39 journals with alt-text that replicated figure position and four journals that provided no alt-text. We did not observe variability in alt-text practice across different articles within the same journal. Our sample contained three (1·2%) journals that provided alt-text with some context and interpretation without serving the equivalent purpose of the non-text content (ie, limited degree of interpretation), all published by the US Centers for Disease Control and Prevention (CDC).TableAlt-text practices of leading academic journalsClinical journals (n=100)Non-clinical journals (n=100)Ophthalmology journals (n=50)Total (n=250)Replicates figure position*Where figure position refers to the numbering of the figure within the manuscript (eg, "Figure 1").66 (66·0%)55 (55·0%)29 (58·0%)150 (60·0%)Alt-text absent†Alt-text was either empty and contained no text or alt-text was an absent feature entirely.6 (6·0%)21 (21·0%)10 (20·0%)37 (14·8%)Alt-text uninformative‡Alt-text was provided but had no relevance or useful information (eg, "Figure", "Image", or indiscernible alt-text, such as an image file name).8 (8·0%)12 (12·0%)4 (8·0%)24 (9·6%)Replicates figure title8 (8·0%)3 (3·0%)3 (6·0%)14 (5·6%)Directs reader to caption3 (3·0%)6 (6·0%)3 (6·0%)12 (4·8%)Replicates figure caption6 (6·0%)3 (3·0%)1 (2·0%)10 (4·0%)Provides limited interpretation3 (3·0%)003 (1·2%)Provides meaningful interpretation§Meaningful interpretation was evaluated according to standards from the Web Content Accessibility Guidelines, which advise that alt-text should serve the equivalent informative purpose of non-text content. Existing literature has provided examples of alt-text that meet these standards for scientific figures.60000* Where figure position refers to the numbering of the figure within the manuscript (eg, "Figure 1").† Alt-text was either empty and contained no text or alt-text was an absent feature entirely.‡ Alt-text was provided but had no relevance or useful information (eg, "Figure", "Image", or indiscernible alt-text, such as an image file name).§ Meaningful interpretation was evaluated according to standards from the Web Content Accessibility Guidelines, which advise that alt-text should serve the equivalent informative purpose of non-text content. Existing literature has provided examples of alt-text that meet these standards for scientific figures.6Chiarella D Yarbrough J Jackson CA Using alt text to make science Twitter more accessible for people with visual impairments.Nat Commun. 2020; 115803Crossref PubMed Scopus (7) Google Scholar Open table in a new tab We conducted two additional analyses. We examined 375 PDF article copies downloaded from 75 of the 250 journals in the primary sample (five articles per journal), selected from the top 25 most-cited journals in each of the clinical, non-clinical, and ophthalmology categories. PDFs were examined using Adobe Acrobat Pro (version 2023). Alt-text in PDFs did not vary by journal category. Most commonly, PDFs had no alt-text (64 [85·3%] of 75 journals) or replicated figure position (ten [13·3%] journals). One (1·3%) journal, MMRW Recommendations and Reports, provided a limited degree of interpretation (appendix p 3). We also investigated whether journals with a scope including disability research might have different alt-text practices. Disability research is not a category in the Journal Citation Reports database, so we searched the database for "disability" and "accessibility" and evaluated the 19 results. None of these journals overlapped with the primary sample. Three (15·8%) of 19 journals had detailed and informative alt-text, although practice varied across articles within each journal. One (5·3%) journal did not provide alt-text but instead made use of MP3 and Digital Accessible Information System files to provide additional accessibility features, such as image descriptions available through audio recording (appendix p 4). We further examined accessibility statements and corresponding alt-text practices for the ten most represented publishers within our primary sample (constituting 166 [66·4%] of 250 journals). We identified that nine (90·0%) of these publishers, including Nature Portfolio (44 [17·6%] journals), Elsevier (43 [17·2%] journals), and Annual Reviews (18 [7·2%] journals), stated a commitment to following WCAG 2.0 or WCAG 2.1. However, alt-text practices across these publishers did not comply with either WCAG version. Leading journals failed to convey interpretation or summaries of figure findings that could have meaningfully improved accessibility for readers with visual disabilities. Results by publisher and URLs for accessibility statements are shown in the appendix (pp 5–6). Although our study catalogued figures specifically, we also documented an absence of informative alt-text for other manuscript elements, such as videos, tables, and equations. Our findings suggest that leading journals do not make use of alt-text to promote accessibility of scientific findings. Standards provided by WCAG for the past 24 years have advised that alt-text should serve the equivalent purpose of non-text content.5W3C Web Accessibility InitiativeWCAG 2 overview.https://www.w3.org/WAI/standards-guidelines/wcagDate: April 19, 2023Date accessed: October 1, 2023Google Scholar However, when alt-text was used by leading journal websites in our study, it did not meet these standards. Although captions and article text sometimes provide overlapping information, figures, videos, and equations, which are integral components of scientific literature, are widely inaccessible to clinicians, scientists, students, and patients with visual disabilities. We identified three journals on disability research that provided detailed alt-text that, at times, met WCAG guidelines. These journals were Disability and Rehabilitation, Disability and Rehabilitation: Assistive Technology, and the Scandinavian Journal of Disability Research, and they are valuable examples for the academic community. Existing alt-text practices that fail to meet WCAG standards could be non-compliant with the Americans with Disabilities Act of 1990 or other statutes.7US Department of Justice Civil Rights DivisionGuidance on web accessibility and the ADA.https://www.ada.gov/resources/web-guidanceDate: March 18, 2022Date accessed: April 27, 2023Google Scholar, 8Vu M Launey K Egan J The law on website and mobile accessibility continues to grow at a glacial pace even as lawsuit numbers reach all-time highs.https://www.americanbar.org/groups/law_practice/publications/law_practice_magazine/2022/jf22/vu-launey-eganDate: Jan 1, 2022Date accessed: October 1, 2023Google Scholar Previous work has outlined how scientific images can be paired with informative alt-text to improve accessibility, and at least one publisher provides guidance on the importance of alt-text.6Chiarella D Yarbrough J Jackson CA Using alt text to make science Twitter more accessible for people with visual impairments.Nat Commun. 2020; 115803Crossref PubMed Scopus (7) Google Scholar, 9Taylor and FrancisA picture is worth a thousand words: the importance of alt text.https://authorservices.taylorandfrancis.com/blog/mentoring-support/a-picture-is-worth-a-thousand-words-the-importance-of-alt-textDate accessed: October 1, 2023Google Scholar Journals and publishers should improve accessibility by evaluating their editorial and copyediting processes for alt-text and by providing the option for authors to submit detailed, purposeful alt-text for figures or other media accompanying a manuscript. Our research is limited by the scope of the journals and articles examined. Although our sample includes a wide array of major journals across scientific disciplines, it is possible that journals or articles that were not included in our sample might have different alt-text practices. MAC and MN conceptualised the study. MAC, MN, and AL collected and curated data. MAC and MN accessed and verified the data. MAC performed formal analysis. YMP acquired funding. All authors participated in development of the methodology. ZDB, YMP, JAR, and RRF provided resources and supervision. MAC and MN wrote the original draft. All authors contributed to review and editing of subsequent drafts. All authors had full access to all the data in the study and had final responsibility for the decision to submit for publication. We declare no competing interests. The data that support the findings of this study are available from the corresponding author (MAC) on reasonable request. This work was funded by grants from the National Eye Institute to YMP (grant number 1K08EY027458), unrestricted departmental support from Research to Prevent Blindness, and the generous support of the Helmut F Stern Career Development Professorship in Ophthalmology and Visual Sciences to YMP. The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. We thank Miyabi Saito (Massachusetts General Hospital, Boston, MA, USA) for contributing to data collection and Veronica Lewis (George Mason University, Fairfax, VA, USA) for contributing to interpretation of the findings. This Correspondence reflects the views of the authors and should not be construed to represent the views or policies of the US Food and Drug Administration, the US Department of Health and Human Services, or the US Government. Journal Citation Reports and Clarivate are trademarks of their respective owners and are used herein with permission. Download .pdf (.2 MB) Help with pdf files Supplementary appendix

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• An ethical approach to shared decision-making for adolescents with terminal illness

  Clinical Ethics · 2023-01-17

  articleSenior author

  Shared decision-making is a well-recognized model to guide decision-making in medical care. However, the shared decision-making concept can become exceedingly complex in adolescent patients with varying degrees of autonomy who have most of their medical decisions made by their parents or legal guardians. The complexity increases further in ethically difficult situations such as terminal illness. In contrast to the typical patient-physician dyad, shared decision-making in adolescents requires a decision-making triad that also includes the parents or guardians. The multifactorial nature of these cases can overwhelm treatment teams, with minimal guidance on how to best approach the patient–parents–physician dynamic in an ethically appropriate manner. Estimated time left to live is the paramount ethical consideration for such cases with respect to shared decision-making. This paper offers a sliding scale to serve as a grounding reference for clinicians who care for terminally ill adolescents and hospital ethics committee members for initiating and guiding the ethical discussion for these patients. This paper also elucidates several other ethically salient features inherent to many of these cases, including quality of life, treatability of disease, cultural influences, among others. Yet how each of these variables is weighed is dependent upon the specific circumstances of each individual case. Ultimately, shared decision-making in adolescent patients with terminal illnesses must be a collaborative and ongoing process that thoughtfully weighs the values and ethical responsibilities of the patient, parents, and physician to ideally reconcile differences and come to a consensus on the best management option for each individual patient.

  PublisherDOI

• Care and Covenant: A Jewish Bioethics of Responsibility

  Journal of Jewish Ethics · 2023-07-01

  article1st authorCorresponding

  Jason Weiner commands multiple fields of knowledge, and his ease in communication and expression at the intersection of these fields animates his compassionate book, which despite its accessible length and easy to read style touches on deep topics in Jewish and medical ethics. A rabbi well-versed in the intricacies of biomedical halachah, and a student of leading halachic decisors, he is also a practicing medical ethicist at a major hospital, clearly experienced in steering difficult conversations with empathy and care.This book, then, is written from the point of view of someone who tries to help individuals get the best care they can, in the context of an imperfect system. It is no surprise that wholesale change of such systems, or ways in which individualistic approaches might overlook larger trends, is not the emphasis of this book.The chapters address different, commonly discussed problems in medical ethics, from the point of view of a Jewish, halachic approach. The two words “Jewish” and “halachic” are not synonymous, of course. Recent literature (Henning 2021) has emphasized that Jewish biomedical ethics encompasses other approaches as well, which might supplement this book’s treatment of these issues. But halacha by itself is a rich system and a many-faceted literature; the footnotes in this book are worth the price of admission and are in some cases worthy introductions themselves in miniature to diverse areas of Jewish law.Contemporary halacha, especially outside the State of Israel, tends to focus on decisions rendered by individual poskim, for the benefit of individual questioners. Communal matters and institutional behavior are also accessible to a halachic analysis. In fact, recent literature in anthropology and ethics touches on these intersections and how individuals, as well as hospitals, navigate structures through negotiation on an individual, family, and institutional level with halacha and its authority (Raucher 2020, Taragin-Zeller 2023, Werren 2020).This book is a normative work of bioethics, not a descriptive study in medical anthropology or sociology. It is not surprising that the behavior of individuals, in isolation from social structures, tends to be emphasized in this book. This also tends to be the emphasis of the contemporary biomedical ethicist, who is asked to consult on decision-making in the context of the care of the individual patient, while embedded in institutions that determine the direction of much care.As a result of this emphasis in Weiner’s book, some forests are missed in the attention to individual trees. The chapter “Allocation and Distribution of Scarce Resources’’ focuses, legitimately, on distribution of life-saving technologies such as ventilators or preventive measures such as vaccines but does not address the larger issue of health care resources and their systematic maldistribution, about which Jewish ethical sources might have something to say (Jacobs 2010). (It is also worth noting that the “potential for full life,” which Weiner identifies as a Jewish emergency triage value, should certainly be confronted with the experience of people with disabilities, whose potential for “full life” has routinely been underestimated by the abled [Amesen and Nord 1999].)Weiner’s chapter on universal health care takes an approach beloved by halachists: what analog in rabbinic literature is there to the topic discussed? The potential comparison that Weiner brings (the return of lost objects) is a creative imagining of how a communal obligation regarding the health care of its members might be brought under the umbrella of halachic discussion. Whether health care access has been “lost” if large sectors of the population have never been granted it in the first place is perhaps a reason why the comparison feels stretched in places.Emphasis on Jewish values (as in the chapter on health care triage) leads immediately to asking whether these are descriptive or normative. The chapter “Jewish Hospitals in America” provides a rose-colored overview of how Jewish hospitals served both Jews and non-Jews and were progressive avant la lettre in terms of race. This is partially true, but it is unfortunate that in his discussion of the Hill-Burton Act (a federal law that funded hospitals and at the time reinforced separate-but-equal health care segregation), Weiner omits the fact that it was a Jewish-owned hospital, Moses H. Cone Memorial Hospital, that was sued in 1962 in a landmark health care discrimination case. In 1963, a federal court found that this hospital was in fact bound by antidiscrimination law. While the Civil Rights Act of 1964 made this legal decision moot, the fact remains that segregation on the part of a Jewish hospital was of moral, legal, and historical import; this hospital was no exception but was legally and ethically representative (Reynolds 1997).The strongest material in the book, drawing on Weiner’s ethical and halachic expertise, is to be found in the second half. His discussion of end of life care in the context of his halachic and ethical training (“Brain Death and Conflict Mitigation”) is a well constructed and lucid guide, and the chapter on unrepresented patients is quite useful. The chapter on self-care rests on a novel application of a halachic principle that determines the lower and upper bounds of one’s voluntary contributions to the poor, applying this to one’s own dedication to duty as a health care professional.However, such duty should also be seen in the context of institutions and societies, and the material (i.e., economic) and political interests that structure them. The chapter on self-care, and the related chapter on conscientious objection, encapsulate the virtues and lacunae of the book as a whole.Halacha is here wielded as a scalpel for the cure of maladies at the individual level. But this book, and a Jewish bioethics of responsibility, would only be strengthened by a discussion of the inequities and immiseration that characterize the experience of the ill and disadvantaged in our health care institutions (Sell 2020).

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Frequent coauthors

• Eric B Bass

  Johns Hopkins University

  119 shared

• Padmini D Ranasinghe

  Johns Hopkins Medicine

  83 shared

• Anastasia Rowland-Seymour

  MetroHealth Medical Center

  77 shared

• Madhav Goyal

  77 shared

• Sonal Singh

  University of Massachusetts Chan Medical School

  76 shared

• Hasan M Shihab

  Johns Hopkins University

  75 shared

• Dana Sleicher

  73 shared

• Jennifer A. Haythornthwaite

  71 shared

Education

• MD, PhD

  NYU School of Medicine

  2006