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.     

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

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处在夹缝中的哲学

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选择性注意加工机制上学困生和学优生的比较研究

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由知识对伦理的辩护到伦理对知识的批判——论知识的伦理价值

古希腊哲学最早将美德与知识相联系,“真”的达到就是“善”的实现,人的合目的性是建立在其合规律性的基础上的,伦理学从此有了独立存在的根据。近代知识论提出“知识就是力量”,将获得知识与获得幸福视为同一,知识(理性)是建立伦理的绝对普遍的坚实基础,人的尊严和主体性成为伦理追求的最大价值。20世纪以来,由于科学知识的异化,“知识与人的幸福和命运问题”凸现在当代伦理学面前。为知识找寻一条“应然”的光明之路,不仅是伦理学的理论使命,也是人类自身的神圣使命。     

儿童早期数学认知能力的结构及其特点

从北京市10所幼儿园中选取234名3、4岁的儿童为被试,采用个别测查的方法对儿童早期数学认知能力的结构及其特点进行了考察。经验证性因素分析发现：(1)儿童早期数学认知能力的结构模型是合理的,可接受的,具有较好的构想效度,具体讲,数、计算、测量、空间／几何和模式认知能力五个维度共同解释着儿童早期的数学认知能力;(2)不同年龄儿童早期数学认知能力的结构具有稳定性,但是结构模型并不完全一致,某些项目的解释率有所不同;(3)男、女儿童早期数学认知能力的结构模型具有一致性。     

内外部线索对学习判断的影响

该研究针对Koriat和Dunlosky实验研究结果的不同,通过两个实验,进一步考察内外部线索对学习判断（judgment of learning,简称为JOL）的影响。被试为山东师大本科生63名。内部线索词对的语义联系,两种外部线索分别是呈现时间和呈现顺序。本研究结果表明：（1）无论在交替呈现还是区组呈现条件下,内部线索对JOL和回忆都产生了显著影响;（2）呈现顺序和呈现时间可能是两种不同类型的外部线索;（3）不同的内外部线索对JOL有不同的交互作用;（4）实验二中无意义词对先呈现组的JOL大于有意义词对先呈现组的JOL,这说明JOL可能存在“锚定效应”。