An analysis of ethics consultation in the clinical setting

Only recently have ethicists been invited into the clinical setting to offer recommendations about patient care decisions. This paper discusses this new role for ethicists from the perspective of content and process issues. Among content issues are the usual ethical dilemmas such as the aggressiveness of treatment, questions about consent, and alternative treatment options. Among process issues are those that relate to communication with the patient. The formal ethics consult is discussed, the steps taken in such a consult, and whether there should be a fee charged. We conclude with an examination of the risks and benefits of formal ethics consults.     

Risks and costs of a treatment litigation: Focus on the family

Decision-making in special educational settings is always based on an implicit process of assessing risks, costs, and benefits of proposed alternative program options. We urge decision-makers to make the process explicit. The hidden costs of IEP decisions are discussed in the context of the question of using aversive procedures to treat severe destructive behavior. Some agency decisions result in significant cost transfer to or generation of risks and costs for families. The experiences of one family involved in a due process proceeding with a school system are examined for evidence of burdensome psychological, social and financial consequences.     

Risks,choices and behavioral treatment

Recent arguments against the use of intrusive behavioral interventions in the treatment of handicapped people are examined. The anti-aversive position was found to be based on assumptions about the negative impact of aversive procedures, and to consider only a small subset of the variables that should be taken into account when treatment decisions are made. A preliminary application of formal decision-analysis techniques that have been developed in response to other controversial technologies had a number of benefits including: (a) sharpening the distinction between scientific and social criteria; (b) sensitizing decision-makers and scientists to the range of costs, risks, and benefits associated with treatment decisions; and (c) identifying critical areas of research. Decision-analysis techniques were found to be helpful in directing scientists and policy-makers towards more informed decision-making.     

Omission bias in vaccination decisions: Where’s the “omission”? Where’s the “bias”?

Several studies have reported that parents are often reluctant to vaccinate their own or other people’s children, even when the balance of health risks and benefits clearly favors vaccination. This reluctance has been interpreted as a manifestation of “omission bias”, a general tendency to prefer inactive to active options even when inaction leads to worse outcomes or greater risks. The research raises significant public health concerns as well as worries about human decision biases in general. In this paper we argue that existing research on vaccination decisions has not convincingly demonstrated any general reluctance to vaccinate nor has it made the case that such a tendency, if found, would constitute a bias. We identify several conceptual and methodological issues that, we argue, cloud interpretation of earlier studies. In a new questionnaire-based study (Experiment 1) we examined the vaccination decisions of undergraduate students (N=103) and non-student adults (N=192). In both groups a clear majority chose to vaccinate when disease and vaccination risks were balanced. Experiments 2 and 3 identify several problems associated with the measures used in earlier studies, and show how these problems could have led to the misleading appearance of majority anti-vaccination preferences. In our data, vaccination intentions appear to be less a function of generalized preferences for action or inaction than they are of the regret respondents expect to feel if vaccination or non-vaccination were to lead to a poor outcome. Regret-avoiding choices led some respondents to favor vaccination, others to oppose it. In two follow-up studies, few respondents mentioned action or inaction per se in explaining their choices. We conclude that there is no convincing evidence that a generalized “omission bias” plays any important role in vaccination decisions.     

Choosing Across Cultures: The Effect of Choice Complexity on Treatment Outcomes

Prior research has revealed that having choice over treatments can improve their efficacy. However, it is currently unknown if the benefits of treatment choice hold for complex decisions and different cultures. The effects of differing numbers of treatment options were explored across two cultural contexts: United States and Japan. Participants were exposed to an uncomfortable stimulus and provided with up to 15 placebo treatment options they believed would reduce discomfort. There was a significant interaction such that participants from Japan benefited most from fewer treatment options (2 and 5) compared with more treatment options (10 and 15). Participants from the United States, however, showed either no change in discomfort or less discomfort as the number of choices increased. Additionally, participants from Japan reported less satisfaction with the decision process when they had more treatment options to choose from whereas U.S. participants reported similar, if not slightly higher, satisfaction with more treatment options. Further, a second study indicated that a positive experience with the decision process mediated the relationship between choice complexity and treatment efficacy for Japanese participants. These data demonstrate the importance of culture and choice complexity when discussing treatment choice and resulting outcomes in the medical context. Copyright © 2015 John Wiley & Sons, Ltd.     

Blended courage: Moral and psychological courage elements in mental health treatment seeking by active duty military personnel

We propose that seeking mental health care in an environment with heightened stigma may combine elements of both psychological and moral courage. Interviews of 32 active duty US Army personnel about their process of seeking current mental health care were analyzed for themes of voluntary action, personal risk, and noble or worthwhile goals (benefits). Risks and benefits were divided into internal risks and benefits, characteristic of psychological courage; and external risks and benefits, characteristic of moral courage. Concerns about external risks were themes in all narratives, while concerns about internal risks were themes in only about half of narratives. Both internal and external benefits of treatment were themes in approximately three-quarters of the narratives, whereas doubts about internal (but not external) benefits were also expressed at a similar rate. Thus, participants described an act of blended courage, with social risks of moral courage taken for wellness goals of psychological courage.     

Risks and Benefits of Pediatric Bone Marrow Donation: A Critical Need for Research

Healthcare providers assume that there are minimal risks and potential psychosocial benefits for children who undergo a bone marrow harvest for the benefit of their critically ill siblings. Ethical justifications for the use of children as donors rely on there being minimal risks since donors receive no direct medical benefits from the intervention. There is little empirical research regarding psychosocial consequences. This article reviews relevant research in three contexts: a) psychosocial outcomes for adults and children who donate tissue and organs; b) psychosocial impacts on a sibling of a pediatric cancer patient; and c) children's decision-making regarding medical decisions. The relevant research literature supports the belief that the psychosocial impact on a child bone marrow donor will be influenced by the survival of the recipient, the age of the donor, and the donor's participation in the decision to donate. In order to empirically validate the actual psychosocial risks (and benefits) for donors, it is argued that direct research is needed so that a donor's well-being can be protected.     

The Impact of Depression on Self–Other Discrepancies in Decision Making

Although there is a small but growing body of literature on how people make risky decisions for others and predict others' decisions, results seem to be contradictory. The authors contribute to the understanding of these mixed results by investigating how depression affects self–other discrepancies in decision making and the psychological processes that underlie these discrepancies. In an experiment, depressed and nondepressed individuals read a series of scenarios involving decisions about health, money, and interpersonal relationships. They then indicated which of two options they would choose for themselves or for another person, or predicted which option this person would choose for himself or herself. Finally, participants reported benefits and drawbacks of the decisions (i.e., cognitions) and feelings about risk. Depressed individuals were less prone to bias when they predicted others' decisions than nondepressed individuals. Feelings about risk played a key role in determining the direction and the magnitude of this bias. In contrast, both depressed and nondepressed individuals showed bias when they made decisions for others. This bias affected their decisions in opposing ways and was determined by cognitions. This bias is consistent with literature showing that depression is associated with an increased sensitivity to social risks. The authors provide a theoretical explanation of self–other discrepancies in decision making in depressed and nondepressed individuals and conclude that the results support the assumption that depression is associated with psychological processes whose role is to increase sensitivity to social threats rather than with a more general negative bias in cognitive functioning. Copyright © 2014 John Wiley & Sons, Ltd.     

Decisions from experience: Why small samples?

In many decisions we cannot consult explicit statistics telling us about the risks involved in our actions. In lieu of such data, we can arrive at an understanding of our dicey options by sampling from them. The size of the samples that we take determines, ceteris paribus, how good our choices will be. Studies of decisions from experience have observed that people tend to rely on relatively small samples from payoff distributions, and small samples are at times rendered even smaller because of recency. We suggest one contributing and previously unnoticed reason for reliance on frugal search: Small samples amplify the difference between the expected earnings associated with the payoff distributions, thus making the options more distinct and choice easier. We describe the magnitude of this amplification effect, and the potential costs that it exacts, and we empirically test four of its implications.     

Management and treatment of stalkers: problems, options, and solutions

Legal sanctions alone are often ineffective in preventing stalking because, in the absence of treatment, the fundamental problems driving the stalker remain unresolved. Criminal justice interventions can be problematic because of difficulties in framing anti-stalking legislation and inconsistencies in their application. Civil remedies in the form of restraining orders may be ineffective or counterproductive. Treatment of stalkers involves pharmacotherapy when mental illness is present, but the mainstays of treatment for non-psychotic stalkers are programmes of psychological intervention. These depend on accurate assessment of the risks inherent in stalking and on the identification of psychological deficits, needs, and responsivity factors specific to the individual. Treatment can then be tailored to suit the stalker, thereby enhancing therapeutic efficacy. Developing a framework for identifying the risk factors and shaping the delivery of treatment is crucial. Two service innovations developed specifically to work with stalkers are presented as options to overcome current management deficiencies.     

A domain‐specific risk‐attitude scale: measuring risk perceptions and risk behaviors

We present a psychometric scale that assesses risk taking in five content domains: financial decisions (separately for investing versus gambling), health/safety, recreational, ethical, and social decisions. Respondents rate the likelihood that they would engage in domain‐specific risky activities (Part I). An optional Part II assesses respondents' perceptions of the magnitude of the risks and expected benefits of the activities judged in Part I. The scale's construct validity and consistency is evaluated for a sample of American undergraduate students. As expected, respondents' degree of risk taking was highly domain‐specific, i.e. not consistently risk‐averse or consistently risk‐seeking across all content domains. Women appeared to be more risk‐averse in all domains except social risk. A regression of risk taking (likelihood of engaging in the risky activity) on expected benefits and perceived risks suggests that gender and content domain differences in apparent risk taking are associated with differences in the perception of the activities' benefits and risk, rather than with differences in attitude towards perceived risk. Copyright © 2002 John Wiley & Sons, Ltd.     

Judgments about estrogen replacement therapy: the role of age, cognitive abilities, and beliefs.

This study investigated age, cognitive abilities, health beliefs, and other factors in women's judgments about effective treatments for menopause. Women (N = 102) ranging in age from 20 to 79 read a vignette about a woman facing a decision about Estrogen Replacement Therapy (ERT) and then made judgments about what should be done. Participants also completed a battery of questions pertaining to ERT and cognitive abilities. Path-analytic techniques were used to determine the role of specific cognitive abilities and the representation of menopause and its treatment in making judgments about ERT treatments. Cognitive abilities had direct effects on treatment decisions. Education affected the number of perceived options for treatment. Age and education indirectly affected treatment decisions, operating through cognitive abilities. Factors related to the mental representation of menopause had no direct effects and few indirect effects on treatment decisions. Potential mechanisms that can help older adults compensate for declines in cognitive abilities in medical decisions are discussed.     

Toward a Model Informed Consent Process for BRCA1 Testing: A Qualitative Assessment of Women's Attitudes

As an initial part of a project to develop a model informed consent process for BRCA1 testing, we conducted a series of focus groups. At the groups, women initially expressed great interest in testing, but their interest diminished after learning more. If offered testing, women would most want to learn about test accuracy, practical details of testing, and management options if the result was positive. Perceived benefits of testing included gaining information leading to risk reduction, relief of uncertainty, more responsible parenting, and assisting in research. Perceived risks included the discomfort and cost of the testing process itself, and anxiety after a positive result. The risk of possible insurance discrimination was rarely mentioned spontaneously. Many women would want their providers to make recommendations, rather than be nondirective about testing. We observed that women vary greatly in their informational and counseling needs, and suggest that the informed consent process should be individualized, taking into account a woman's perception and her preferences for how testing decisions should be made.     

The effects of accountability on bias in physician decision making: Going from bad to worse

Members of the Iowa Academy of Family Physicians participated in a survey study in which they were asked to make hypothetical decisions in either high- or low-conflict treatment conditions. In the low-conflict treatment condition the options were a common medication with a referral or a referral only. In the high-conflict treatment condition the same two options were given plus another attractive medication. In addition, we manipulated accountability by asking half of the participants to provide a written defense of their treatment options, which they would then agree to discuss at a later time. The results showed that physicians in the high-conflict condition chose the referral-only option significantly more than the physicians in the low-conflict condition, thus violating the normative rule of regularity. Moreover, that pattern was significantly amplified for physicians who were held accountable for their treatment decisions. These findings replicate and extend previous research and are discussed within the framework of reason-based choice.     

Understanding and predicting parental decisions about early childhood immunizations.

This research investigated the factors that influence decisions about immunizations. Women in the third trimester of pregnancy (N=195) rated their likelihood of immunizing their child; stated their reasons for and against immunizing; and rated their perceptions of the benefits and risks of immunization, feelings of responsibility, and anticipated regret if harm occurred. Immunization status was determined at follow-up. Stepwise regression analyses demonstrated that immunization decisions are strongly influenced by omission bias factors such as anticipated responsibility and regret variance (which explained more than 50% of variance). It is suggested that parents may benefit from antenatal decision aids that address omission bias and encourage them to assess benefits and risks of immunizations on the basis of scientific evidence.     

Can research influence clinical practice?1

After briefly reviewing the unfavourable reception accorded empirical research by parts of the psychoanalytic community, as well as some of the benefits to clinical practice of analysts being involved in research activities, the author examines whether the findings of process and outcome research in psychotherapy and psychoanalysis can help identify the most appropriate forms of intervention for producing therapeutic change, given the specific condition of the patient and the relationship that the individual establishes with the analyst. He argues that research findings can influence clinical practice on various levels and in different areas, and goes on to examine a number of related issues: the specificity of therapeutic interventions versus the relevance of common curative factors; the dyadic conception of technique and ways of understanding the therapeutic action of the treatment alliance; and the strategic or heuristic conception in psychoanalytic therapy. Finally, the author presents clinical material with the aim of illustrating how the knowledge acquired through research can be applied to psychoanalytic treatment.     

Better safe than sorry: Precautionary reasoning and implied dominance in risky decisions

In four studies, student and nonstudent participants evaluated the possible outcomes of binary decisions involving health, safety, and environmental risks (e.g., whether to issue a dam‐failure evacuation order). Many participants indicated that false positives (e.g., evacuation, but no dam failure) were better than true negatives (e.g., no evacuation and no dam failure), thereby implying that the more protective action dominated the less protective action. A common rationale for this response pattern was the precautionary maxim “better safe than sorry.” Participants apparently evaluated outcomes partly on the basis of the decisions that might lead to them, in conflict with consequentialist decision models. Consistent with this explanation, the prevalence of implied dominance decreased substantially when the emphasis on decisions was reduced. These results demonstrate that an initial preference for a decision alternative can alter the evaluation of possible consequences of both the preferred alternative and a competing alternative, suggesting positive feedback loops that reinforce the initial preference. The rationality of considering the decision itself as an attribute of possible outcomes is discussed. Copyright © 2009 John Wiley & Sons, Ltd.     

Therapist Self-disclosure and Culturally Competent Care with Mexican–American Court Mandated Clients: A Phenomenological Study

Therapist self-disclosure (TSD) is a skill with numerous potential benefits and risks for the therapeutic alliance. While its effects have been established, little empirical research has examined the impact of TSD in cross-cultural treatment settings with court-mandated clients, a context with unique considerations. In an effort to help fill this gap, results of a phenomenological study examining the effects of TSD on Mexican–American men working with Anglo American therapists in a mandated treatment setting are presented. The results of this study indicate that TSD is a culturally competent intervention with several benefits for mandated clients, including strengthening the therapeutic alliance, normalizing client problems, lessening the therapist-client hierarchy, and modeling the acceptability of self-disclosure. Clinical and marriage and family therapy educational implications are also discussed.     

Reasons and Justifications for Considering Pregnancy Among Women Living with HIV/AIDS

Despite the risks associated with pregnancy, available data suggest that HIV-infected women are no less likely to become pregnant than uninfected women. To understand HIV-infected women's reasons for wanting to have a child, focused interviews were conducted with a predominantly minority sample of 51 HIV-infected women in New York City. They were noted to actively weigh both the potential risks and benefits of their pregnancy decisions. Women reported three major reasons for wanting a child: (1) her husband/boyfriend really wants children, (2) having missed out on raising her other children, and (3) believing that a child would make her feel complete, fulfilled, and happy. Women also reported several justifications which they believed offset the risks of pregnancy, including: (1) other HIV-infected women were having healthy babies, (2) feeling optimistic about having a healthy baby due to the prophylactic effects of AZT (zidovudine), (3) having faith that God will protect the child, (4) being young and "healthy" will prevent transmission, and (5) feeling that she is better able to raise a child now. These findings suggest that to make fully informed pregnancy decisions, women should be encouraged to explore their reasons for wanting pregnancy, as well as discuss the potential risks.     

Guided Discovery

Guided discovery involves a therapeutic dialogue that is designed to assist clients in finding their own solutions to their problems. An integration of problem-solving therapy and the Socratic method can help clients to develop their own coping skills. Problem-solving therapy provides a useful framework for helping clients to manage many of the problems they typically encounter. The Socratic method provides a useful therapeutic style to promote self-guided discovery and self-regulation. Strategies from the Socratic method can be used to guide the process of the therapeutic dialogue, while the stages of problem-solving serve as the structure for the content of therapy sessions. Therapy can be structured according to five main stages: (1) Help clients establish a realistic and adaptive attitude toward common life problems; (2) Define problems in terms of specific and realistic goals; (3) Help clients to generate a wide variety of coping options; (4) Guide clients through a process of rational decision-making in order to select the best coping options, and (5) Implement the plan and evaluate its effectiveness. A systematic series of questions can be used to facilitate the client’s self-evaluation of different problems, goals, and coping efforts. The process helps to promote client autonomy and self-guided action. When problem-solving therapy is integrated within the Socratic method, clients can learn to approach most problems in a logical, thoughtful, and self-directed manner.