Just Read: Moral Self-Licensing Part 2 – Challenge to Eliminating Bias in Health Care

It gets better.

This is a 2015 update from Author Daniel Effron at London Business School (@lbs) – and yet another reminder that the business profession has done as much if not more work in the area of behavioral health as the medical profession.

Continuing from the previous post on this topic (Just Read: Moral Self-Licensing – a continual challenge to eliminating bias in health care), this update adds more information about human motivation.

I’m framing this post through the perspective of bias, but the principles apply to health behavior, consumer behavior, etc….


  • Counterfactual transgressions – humans will license biased behavior even if they didn’t do something bad in the past (as opposed to doing something good)
  • Prefactual virtues – when a human plans to do something good in the future, they may act biased today
  • Counterfactual virtues – when a human would have planned to do something in the future, they may act biased today
  • Vicarious virtues – the one that concerns me most in health care – when humans reflect on good deeds that the group they are in performed. Why the concern? The general posture of health care as a healing profession and the way organizations inhabit this space provides a tremendous amount of license. It explains, in my mind, why I have seen very UN-virtuous behavior in my career, almost implausibly so, in the profession and in the organizations in this space (well described in this TEDx talk I did with @ReginaHolliday).

This paper adds a scientific lens and the validation that these are human behaviors, with an effect size of 0.31 to be exact, which is

modest in size but robust … (As benchmarks, the average effect sizes in the fields of motivation, social influence, and attribution have been estimated as, respectively, d = .30, .28, and .26; Richard, Bond, & Stokes-Zoota, 2003).

The overall picture, then, is of multiple avenues, real and imagined, that humans use to support biased behavior while engaging in impression management – the view of others and their view of themselves that they are virtuous. It turns out the view of ones’ self is more important than the view of others, which is an asset to leveraged, see below.

And as I wrote about in the last piece, the managed impression tends to be seen as more virtuous by people in the ingroup, and less so by the people in the outgroup, which are often the most vulnerable populations in health care. This would be something along the lines of the scantily clad emperor ….

Impression Management – Leveraging bad for good

Science is great because it can be used to support good as well as not-so-good.

As I have seen in clinical medicine, even the most intractable, frustrating conditions that physicians treat can become less so when they understand the science. Actually, especially those because they are the ones that many practitioners don’t investigate as much, which only increases frustration (I am thinking about things like pain syndromes, musculoskeletal issues, nutrition, etc…).

Here, the fact that human beings are driven by impression management is an asset as much as a liability. Allowing employees opportunities to license themselves (which they will seek anyway) may increase their honest engagement in topics around bias, or to identify compliance issues more readily.

Who you are vs What you do

The other finding in the research is that

For example, framing a past virtue as demonstrating commitment to a virtuous goal (“who I am and what I believe”) compels people to act more virtuously, whereas framing it as progress towards that goal (“what I’ve done”) leads to licensing (Fishbach & Dhar, 2005; Susewind & Hoelzl, 2014).

My interpretation of this data is that linking a person to who they are may limit their tendency to search for evidence that they are “good” and center the impression of their deeds on who they are as a person, which the research points out is a most powerful motivator (vs. if other people think they are virtuous).

These are the pieces of good news – that these mechanisms exist because people want to be virtuous – they are not looking for excuses not to be virtuous.

It is this motive to protect a moral self-image that inhibits people from acting in ethically questionable ways without a license – and that drives them to execute a variety of mental gymnastics when they anticipate that they will need a license.

As usual, many implications for me, for clinical medicine, for health and society

As I mentioned in the last piece, there are well documented, significant biases in health care directed toward groups of patients by their doctors and doctors in training, and the research also shows that physicians have the same level of bias as those in the communities they inhabit. Not more, not less, the same amount. They/we are human.

The way I operationalize this research in my life (and I am human too, so I license) is to

  • Check my licensing with others not in my ingroup
  • Help others check their license, especially those not in my ingroup. An example of this is the conflation of free speech with moral virtue.
  • Avoid licensing opportunities like clicktivism or monetary donation to causes – I tend to give of my mind rather than my money

2017 will be my 5th Capital TransPride (@TransPrideDC), where I serve on the production team, working to be an ally, acutely aware of all the things I have access to because of my place in society, and at the same time as a member of another vulnerable population (LGBTQ) in need of allies. I also look for opportunities to bring leadership from the outgroup into the ingroup, and then leave the ingroup (“the physician role is to bring the patient story into every conversation, then to get out of the way and let the patient tell their own story”)

Always a work in progress. It’s not what you do, it’s what you tolerate.

Reference: Effron, Daniel A., Beyond ‘Being Good Frees Us to Be Bad:’ Moral Self-Licensing and the Fabrication of Moral Credentials (April 14, 2015). P. A. M. Van Lange & J. W. Van Prooijen Van Prooijen, (Eds.), Cheating, corruption, and concealment: Roots of unethical behavior. Cambridge, UK: Cambridge University Press, Forthcoming. Available at SSRN: https://ssrn.com/abstract=2594403

Ted Eytan, MD