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

Thou Shalt Not Stand Idly By – Yet our health care system does – Kait and Ted’s story

“Thou Shalt Not Stand Idly By.” Click to enlarge, courtesy Iris Eytan, Esq.

My sister, who I wrote about recently, took the photograph in this post when I asked her, “What inspired you?” because she inspired me. I remembered visiting her a year ago, while she was working on the case, and how resolved she was to make sure that Tyler would not be imprisoned unjustly because of his disability. Last week, she was successful.

This picture hangs on her office wall – you can see the Denver skyline in the background. On the bottom of the photo you can see 3 years of work to save one person, Tyler Sanchez. On the top of the photograph is the inspiration (read more about the origin of the expression here).

The picture shows what it takes to save a life. Sometimes it doesn’t take much work. All of the time, it takes the ability to care.

The people who serve in the health care system, who are uniformly exceptional in my experience (you have to be to do a job this hard), have an incredible ability to care. 

Why does our health care system not let them?

What happened last week – Kait and Ted’s story

On Tuesday, Kait sent me an e-mail with just the subject : “Advice?” In it, she described acute withdrawal symptoms she was having from her anti-depressant because her mail-order refills had not arrived in time, and did I have any ideas that did not involve an emergency room. There were a few complications – she was not in DC at the time, she was in Baltimore visiting her girlfriend.  Her primary care physician, based in Maine, was not available because of a state holiday there.

I immediately called her and proceeded to do my best to help her get care urgently.

I contacted the Baltimore Medical System and reached a medical center manager, who said Kait could not be seen that day. She escalated the issue to the Medical Director of the entire system – could she be evaluated quickly and given a refill of her prescription to arrest the acute withdrawal until her regular supply arrived? 

She called me back and said the answer was no.

I was told that all of the care providers were full that day and a new patient would not be seen that day. Now, I have been to Baltimore Medical System (see my blog post from the experience: “A resilient population” – Baltimore Medical System”)  and I believed what they told me. I was told that she would need to go an Emergency Room or attempt to book for the next day, with no guarantees.

I gave these options to Kait. Johns Hopkins ER it was going to be. Again, I tried to assist by calling the Johns Hopkins ER to facilitate the care for them and for Kait. It usually makes things easier/faster for everyone, if the receiving physician can know what’s going on – the “warm handoff.”

I called the Johns Hopkins Physicians Access Line, for an emergency physician referral, which is what I could find on their web site. I was transferred and then hung up on. 

I asked Kait to keep the communication up by texting me her experience as it happened. Here’s the interaction between us:

Kait:: I fear the fix is a very long way away. Until we get parity through govt, no insurance will bother to cover it properly. 3:13 PM
Kait:: In a room. Eye exams happen here. But I’m guessing they just want me to be seen. Hahaha 3:24 PM
Kait:: No idea what will happen here. No one has asked me for proof of meds, taken a hx or asked any pertinent questions. 3:25 PM
Kait:: They did ask if I had any pain. But they didn’t mean emotional- I don’t think. 3:26 PM
Kait:: They did a survey. Do I want more info on depression, high blood pressure, and several other things I’M ALREADY BEING treated for. 3:27 PM
Kait:: I answered no. They also asked if I wanted an HIV test. And they tried to tell me it would be anonymous, even though it would be in my record. 3:32 PM
Kait:: They also asked if I would be willing to use a kiosk to check my med record and make sure the info/med lists were correct. I said YES! 3:38 PM
Kait:: Ok, now have seen an NP. She is really good. I may have to be really nice about this experience. 3:39 PM
Kait:: Script in hand 3:51 PM
Kait:: Seeing about a voucher for $ for meds 3:54 PM
Me: Cool! I’m saving these texts. 3:54 PM
Kait:: Amazingly kind. 3:56 PM
Kait:: ER security totally dropped the ball and sent me on a snipe hunt for the wrong social worker. Heading back to ED to get the RIGHT social worker. 4:00 PM
Kait:: Apparently the correct SW is in a trauma room right now. Left hand, right hand – get familiar. 4:03 PM
Me: Omg this is getting hilarious. 4:36 PM
Me: It may be more therapeutic than the medication 🙂 4:36 PM
Kait:: Yes. And I saw the SW finally, but -get this. The vouchers can’t be used for Psych Meds. 4:41 PM
Kait:: So I have two discount cards. My girlfriend will front the $ if I need more than I have to fill the 15 pills. 4:42 PM
Kait:: Laughter IS the best MED. 4:42 PM
Me: Totally! I am on board but my gvoice will store the SMS for storytelling purposes. Keep laughing. 4:43 PM
Kait:: When I’m not sobbing… 4:44 PM
Kait:: 🙂 4:45 PM
Me: Laughter always wins. Send the serotonin soaring. So does love. 4:45 PM
Kait:: Yes, that too. 4:46 PM

See something interesting? As she gets closer to a human being in the system, the “care” part of health care becomes more apparent.

If you think this only happens to people without access to care, you’re wrong. 

I am breaking the silence on an almost identical incident with someone very close to me, my mother, who, as a medicare beneficiary has access to too much care.

She was referred to a sub specialist for a superficial nerve block for severe pain – the kind of nerve block that a family physician can easily do (I have done many myself). When the injection did not work and she called the office of the sub-specialist in severe pain, she was told by the office staff, “Go to the emergency room, we are full this afternoon.” They were adamant, she told me.

I know what would have happened if she went to the emergency room -> narcotics, maybe an admission to the hospital, maybe an infection, a medication error, a fall. All because of a failed superficial nerve block.

I called the sub specialist’s office from 2,500 miles away, got the physician on the phone and asked him if it was possible that the injection was misplaced and could he try again (it is possible to miss the nerve). He agreed this was possible and pleasantly and helpfully said he would be happy to and could my mother come right in. She did, he performed a re-injection and the pain was completely relieved. 

Commonalities – amazing people, less than amazing system

With all of the talk that the emergency room is overused and medical homes are the answer, where’s the walk?

In Kait’s case it was made clear to us that this medical emergency, easily treated in the outpatient setting, would not be managed anywhere but an emergency room, against her wishes, and really against appropriateness. What if she was hemorrhaging blood instead of serotonin, would the outpatient system turn her away before stabilizing her? Acute anti-depressant withdrawal due to lack of medicine is a complete waste of Kait’s time. It could have wasted her life. 

My family’s entire experience could have started and ended in a family physician’s office, without any intervention from me.

Making every day count

I’m going to reveal something in this post that Kait doesn’t know yet. I was able to receive her e-mail and act on her behalf because of a mistake I made right before she contacted me. I read the time wrong on a flight and arrived too late to the airport. I missed the flight, I would lose a day of travel, and it was all my fault. As I walked away, I said to myself that I would make sure that this day counted for something. Now, I am so happy that it did.

People who know me know that I do not use my physician credentials to facilitate care for myself – I don’t even like being called “Dr.” When it comes to other people, though, I will leverage the credentials to the max (just the “MD” part, which I own, not my employer’s name, which I don’t own). That’s why society provides those credentials to us, to be used to lessen suffering. 

Not standing idly by.

I really want more than to lessen suffering for just Kait or my family, though. I want our health care system to change. For real, not pretend.

And…. the only solution I have found, the only one, after 20 years in medicine, that will solve this problem, is to have the patient in the room.

Kait Roe has given explicit permission to share details of her care experience on this blog:

Ted, I LITERALLY have no secrets. If someone doesn’t hire me because I have a mental illness (which this episode clearly shows is controlled phenomenally by medications) I don’t want to work for them. And wouldn’t that be a fun post! As for the choices. Print it all, again. I mean that – and I’ve been back on my meds for two days and feel quite myself again. No crying for two days!