Just Read: Moral Self-Licensing – a continual challenge to eliminating bias in health care

Earlier in my career, I remember a colleague saying to me, in a challenge to observed, biased behavior, “this is organization x, those things don’t happen here.” He said it with a dismissive chuckle. And yet, it did happen…

I have been intensely interested in the concept of “Illusion of Objectivity” especially in health care, and so have done a deep literature review. It brought me to several helpful papers and the concept of moral self-license (Merritt AC, Effron DA, Monin B. Moral Self-Licensing: When Being Good Frees Us to Be Bad. Soc Personal Psychol Compass [Internet]. Blackwell Publishing Ltd; 2010 May [cited 2016 Aug 13];4(5):344–57).

One of the authors, Daniel Effron now at London Business School (@lbs), has written another piece more recently which I’ll post on next.

It’s yet-another-place where the professions outside of medicine can teach us a lot, and why shouldn’t they, we need each other, and our patients need us to perform our best for them.

Moral Self-License, a fascinating concept that shapes our actions

When under the threat that their next action might be (or appear to be) morally dubious, individuals can derive confidence from their past moral behavior, such that an impeccable track record increases their propensity to engage in otherwise suspect actions. Such moral self-licensing (Monin & Miller, 2001) occurs when past moral behavior makes people more likely to do poten- tially immoral things without worrying about feeling or appearing immoral.

Several study situations of note (summarized here, you can review for control situations, etc):

  • When people expressed support for a Black presidential candidate (Barack Obama), they were more likely to subsequently express bias toward less-qualified White candidates for a police job.
  • People asked to describe a time in their past when they acted immorally were more likely to endorse prosocial activities such as giving to charities.
  • The converse situation, people describing a moral act in the past were more likely to cheat on a math task

So there is something about doing (or even thinking) about past behavior that causes people to engage in less-than-virtuous behavior or to minimize the less-than-virtuousness of the behavior.

What does this mean for health care?

A lot.

There is much public controversy presently around institutions and people who express commitment to an unbiased environment, and yet biased environments persist.

Interestingly, further research shows that there is greater sensitivity to what is seen as hypocrisy by people in the affected, targeted groups, which makes sense. The converse, however, is that people who are not in the targeted groups are less likely to see hypocrisy and license biased behavior, which allows it to persist. This is a difficult problem if the actors and the licensors are all part of the same ingroup – there will be less introspection.

Here’s a reason why this is important

Explicit attitudes among medical students 54441
Explicit attitudes among medical students 54441 (View on Flickr.com)

Explicit and implicit attitudes among medical students 54443
Explicit and implicit attitudes among medical students 54443 (View on Flickr.com)

Because, today, medical students feel comfortable explicitly stating bias against lesbian and gay individuals (and even more bias against obese individuals), an atmosphere of moral license (“we don’t do that here, our policies say so”) can allow this to continue.

Note that because of the concept of impression management, students (and physicians, other research) are much less likely to openly state bias toward African American individuals, even though their behavior may reflect it (see: Just Read: Eliminating physician biases against gay and lesbian people, don’t forget the “T” ) .

Who I am vs What I do

There appears to be a protective effect in the understanding of a person’s commitment (who they are and what they stand for) versus what they do (progress toward a goal). Labeling is tied into this:

several studies have found that labeling people as ‘‘helpful’’ after they agree to a small request increases their likelihood of acting consistently by agreeing to a subsequent, large request

Value of Listening, Introspection

There are a few more papers that I’m going to summarize here, because this is such a fascinating topic, and frankly, a head scratcher for people in vulnerable groups who observe repeated, biased behavior in people who otherwise are committed to being bias free.

The reconciliation of all of this is that we are all human, and the “this doesn’t happen here” turns out to be one of the most dangerous statements that can ever be made.

As I reflect on some of the most impressive leaders and concepts I have seen/heard, they involve listening better (“Just Read: Just 6 more seconds of listening needed to elicit the patient’s agenda“) and understanding that improvement is always possible (“There’s Always Something to Do Better” – Medical College of Georgia, home of patient and family centered care). In the latter concept, just think about the statements from people who say they always want to get better and how compelling they (and the people behind them) are.

Working to be an Ally

Right now, I think one of the most topic areas for this exploration is the work of being an ally, to a group of people that is not your own. This is a space where the research points to a great risk of moral license (because the actor and the target are not in the same ingroup), and where, consistency is needed the most for the persons an ally is working to support.

Maybe good advice here is to be introspective about actions, query those who you are working to be an ally for about actions, and listen to their answer. Otherwise, a person may be inadvertently licensing themselves to do things they will not notice are unhelpful, and later regret. It’s what all humans do, therefore, work with other humans to mitigate this risk :).

This is still one of my favorite quotes (from: Not using the term “Transgendered” and respecting people) :

**Don’t get defensive**

If you get defensive, notice it and accept the discomfort of unlearning and relearning

This requires a desire to know, motivation to become informed, willingness to correct mistakes

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