The moral psychology of rationing among physicians: the role of harm and fairness intuitions in physician objections to cost-effectiveness and cost-containment

Introduction

Physicians vary in their moral judgments about health care costs. Social intuitionism posits that moral judgments arise from gut instincts, called “moral foundations.” The objective of this study was to determine if “harm” and “fairness” intuitions can explain physicians’ judgments about cost-containment in U.S. health care and using cost-effectiveness data in practice, as well as the relative importance of those intuitions compared to “purity”, “authority” and “ingroup” in cost-related judgments.

Methods

We mailed an 8-page survey to a random sample of 2000 practicing U.S. physicians. The survey included the MFQ30 and items assessing agreement/disagreement with cost-containment and degree of objection to using cost-effectiveness data to guide care. We used t-tests for pairwise subscale mean comparisons and logistic regression to assess associations with agreement with cost-containment and objection to using cost-effectiveness analysis to guide care.

Results

1032 of 1895 physicians (54%) responded. Most (67%) supported cost-containment, while 54% expressed a strong or moderate objection to the use of cost-effectiveness data in clinical decisions. Physicians who strongly objected to the use of cost-effectiveness data had similar scores in all five of the foundations (all p-values?>?0.05). Agreement with cost-containment was associated with higher mean “harm” (3.6) and “fairness” (3.5) intuitions compared to “in-group” (2.8), “authority” (3.0), and “purity” (2.4) (p?<?0.05). In multivariate models adjusted for age, sex, region, and specialty, both “harm” and “fairness” were significantly associated with judgments about cost-containment (OR?=?1.2 [1.0-1.5]; OR?=?1.7 [1.4-2.1], respectively) but were not associated with degree of objection to cost-effectiveness (OR?=?1.2 [1.0-1.4]; OR?=?0.9 [0.7-1.0]).

Conclusions

Moral intuitions shed light on variation in physician judgments about cost issues in health care.

     

Neuroethics,confidentiality, and a cultural imperative in early onset Alzheimer disease: a case study with a First Nation population

The meaningful consideration of cultural practices, values and beliefs is a necessary component in the effective translation of advancements in neuroscience to clinical practice and public discourse. Society’s immense investment in biomedical science and technology, in conjunction with an increasingly diverse socio-cultural landscape, necessitates the study of how potential discoveries in neurodegenerative diseases such as Alzheimer disease are perceived and utilized across cultures. Building on the work of neuroscientists, ethicists and philosophers, we argue that the growing field of neuroethics provides a pragmatic and constructive pathway to guide advancements in neuroscience in a manner that is culturally nuanced and relevant. Here we review a case study of one issue in culturally oriented neuroscience research where it is evident that traditional research ethics must be broadened and the values and needs of diverse populations considered for meaningful and relevant research practices. A global approach to neuroethics has the potential to furnish critical engagement with cultural considerations of advancements in neuroscience.     

The place of words and numbers in psychiatric research

In recent decades, there has been widespread debate in the human and social sciences regarding the compatibility and the relative merits of quantitative and qualitative approaches in research. In psychiatry, depending on disciplines and traditions, objects of study can be represented either in words or using two types of mathematization. In the latter case, the use of mathematics in psychiatry is most often only local, as opposed to global as in the case of classical mechanics. Relationships between these objects of study can in turn be explored in three different ways: 1/ by a hermeneutic process, 2/ using statistics, the most frequent method in psychiatric research today, 3/ using equations, i.e. using mathematical relationships that are formal and deterministic. The 3 ways of representing entities (with language, locally with mathematics or globally with mathematics) and the 3 ways of expressing the relationships between entities (using hermeneutics, statistics or equations) can be combined in a cross-tabulation, and nearly all nine combinations can be described using examples. A typology of this nature may be useful in assessing which epistemological perspectives are currently dominant in a constantly evolving field such as psychiatry, and which other perspectives still need to be developed. It also contributes to undermining the overly simplistic and counterproductive beliefs that accompany the assumption of a Manichean “quantitative/qualitative” dichotomy. Systematic examination of this set of typologies could be useful in indicating new directions for future research beyond the quantitative/qualitative divide.     

Invited Address at the Occasion of the Bertelson Award 2005 Impairments in visual discrimination in amnesia: Implications for theories of the role of medial temporal lobe regions in human memory

A prominent and long-standing view of human long-term memory is that structures within the medial temporal lobe (MTL) work together to support the acquisition of memory for facts and events. In contrast to this view, recent studies in rats and non-human primates suggest dissociations in function between regions comprising the MTL. Evidence in support of such specialisation in humans, however, has been inconclusive, leading some researchers to propose that human MTL functions as a unitary system uniquely specialised for the acquisition and storage of long-term memory. This paper reviews some of the key studies from the animal and human literature that support an account of functional differentiation and discusses the different theoretical positions that have emerged from their findings. A series of recent experiments in humans designed to determine whether there is functional homogeneity in MTL regions across species are also reviewed and an alternative account of human memory—in which long-term memory is dependent upon representations distributed throughout the human brain rather than one specialised system—is proposed.     

The dilemma of localizing language: John Abercrombie's unexploited evidence

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Chronic psychological stress and the regulation of pro-inflammatory cytokines: a glucocorticoid-resistance model.

This study examined whether chronic stress impairs the immune system's capacity to respond to hormonal signals that terminate inflammation. Fifty healthy adults were studied; half were parents of cancer patients, and half were parents of healthy children. Parents of cancer patients reported more psychological distress than parents of healthy children. They also had flatter diurnal slopes of cortisol secretion, primarily because of reduced output during the morning hours. There was also evidence that chronic stress impaired the immune system's response to anti-inflammatory signals: The capacity of a synthetic glucocorticoid hormone to suppress in vitro production of the pro-inflammatory cytokine interleukin-6 was diminished among parents of cancer patients. Findings suggest a novel pathway by which chronic stress might alter the course of inflammatory disease.     

The effect of repeated experience on children's suggestibility across two question types

There is a discrepancy in the literature regarding the effect of repeated experience on children's suggestibility. Some researchers have concluded that repeated experience increases children's suggestibility for variable details whereas others have reported no detrimental effect. This study demonstrated that the type of question used to test memory (cued‐recall versus yes/no questions) could account for the different reported conclusions. Children aged 5–6 years took part in an event either once or four times. Three or 21 days later, they were given a suggestive interview about the single/final occurrence of the event during which half of the event details were inaccurately described. When later asked yes/no questions, the children with repeated experience agreed with more of the suggestions than did those in the single‐experience condition, especially at the longer delay. In relation to cued‐recall questions, however, experience did not mediate the number of times that false suggestions from the biasing interview were reported. This latter finding was revealed irrespective of the retention interval. Copyright © 2002 John Wiley & Sons, Ltd.     

Treatment Adherence in Children with Sickle Cell Disease: Disease-Related Risk and Psychosocial Resistance Factors

To identify disease-related risk factors and psychosocial resistance factors that impact adherence to prescribed treatment in the context of admission to a Hematology Acute Care Unit (HACU) designed to provide acute care for children with sickle cell disease (SCD) presenting with pain or fever. A total of 73 primary caregivers and 24 children (if age 8 or older) completed standardized forms during the HACU admission. Treatment adherence variables (medical staff rating, SCD-related care activities, percentage of agreement between treatment recommendations made and care activities, and attendance at hematology clinic) indicated moderate-to-high adherence. Based on regression analyses, the risk variable of disease-related stress and the resistance variables of family flexibility and less reliance on passive coping accounted for significant portions of the variance in treatment adherence. Empirical evaluation of interventions designed to improve communication regarding expectations for the care of children with SCD and to support active family problem solving during times of SCD-related stress must be ongoing.     

多动症儿童与认知事件相关电位的实验研究

本研究通过对29名多动症(MBD)儿童与正常儿童认知事件相关电位各成份的比较,结果发现多动症组与正常儿童组在反映大脑认知功能P300潜伏期有明显的差异,从而说明P300可以作为检测多动症儿童的参考性的客观指标。     

Influence of self-construals on the perception of different self-presentation styles in Korea

The present study investigated how perceivers' self-construals influence the perception of others who use self-enhancement or self-effacement in communication. It was predicated that independent self and interdependent self would differently affect the evaluation of self-enhancing presentation and self-effacing presentation. Two hundred and forty-six Korean college students read a scenario depicting a person using bragging, and positive and negative self-presentations for his/her accomplishment, and then evaluated the presenter in the scenario on intention of future interaction, satisfaction with conversation and likeability. Results showed that people with independent self evaluated the positive presentation more favorably than people with interdependent self, whereas people with interdependent self evaluated the negative presentation more favorably than people with independent self. No significant difference was found in the evaluation of bragging presentation. The results imply that although the purpose of self-presentation is to give positive self to others, it is differently expressed through self-enhancement in North American culture and through self-effacement in East Asian culture. The results also supported previous cross-cultural studies on self-enhancement and self-effacement by providing an examination from individual level analysis.