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

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