The Hype of Virtual Medicine

Ezekiel J. Emanuel
The Wall Street Journal
Originally posted Nov. 10, 2017

Here is an excerpt:

But none of this will have much of an effect on the big and unsolved challenge for American medicine: how to change the behavior of patients. According to the Centers for Disease Control and Prevention, fully 86% of all health care spending in the U.S. is for patients with chronic illness—emphysema, arthritis and the like. How are we to make real inroads against these problems? Patients must do far more to monitor their diseases, take their medications consistently and engage with their primary-care physicians and nurses. In the longer term, we need to lower the number of Americans who suffer from these diseases by getting them to change their habits and eat healthier diets, exercise more and avoid smoking.

There is no reason to think that virtual medicine will succeed in inducing most patients to cooperate more with their own care, no matter how ingenious the latest gizmos. Many studies that have tried some high-tech intervention to improve patients’ health have failed.

Consider the problem of patients who do not take their medication properly, leading to higher rates of complications, hospitalization and even mortality. Researchers at Harvard, in collaboration with CVS, published a study in JAMA Internal Medicine in May comparing different low-cost devices for encouraging patients to take their medication as prescribed. The more than 50,000 participants were randomly assigned to one of three options: high-tech pill bottles with digital timer caps, pillboxes with daily compartments or standard plastic pillboxes. The high-tech pill bottles did nothing to increase compliance.

Other efforts have produced similar failures.

The article is here.

Don’t Nudge Me: The Limits of Behavioral Economics in Medicine

Aaron E. Carroll
The New York Times - The Upshot
Originally posted November 6, 2017

Here is an excerpt:

But those excited about the potential of behavioral economics should keep in mind the results of a recent study. It pulled out all the stops in trying to get patients who had a heart attack to be more compliant in taking their medication. (Patients’ adherence at such a time is surprisingly low, even though it makes a big difference in outcomes, so this is a major problem.)

Researchers randomly assigned more than 1,500 people to one of two groups. All had recently had heart attacks. One group received the usual care. The other received special electronic pill bottles that monitored patients’ use of medication. Those patients who took their drugs were entered into a lottery in which they had a 20 percent chance to receive $5 and a 1 percent chance to win $50 every day for a year.

That’s not all. The lottery group members could also sign up to have a friend or family member automatically be notified if they didn’t take their pills so that they could receive social support. They were given access to special social work resources. There was even a staff engagement adviser whose specific duty was providing close monitoring and feedback, and who would remind patients about the importance of adherence.

This was a kitchen-sink approach. It involved direct financial incentives, social support nudges, health care system resources and significant clinical management. It failed.

The article is here.

Nobel Prize in Economics Awarded to American Richard Thaler

David Gauthier-Villars in Stockholm and Ben Leubsdorf in Washington
The Wall Street Journal
Originally posted October 9, 2017

Here are two excerpts:

Mr. Thaler “has given us new insight into how human psychology shapes decision-making,” the academy said.

Asked to describe the takeaway from his research, Mr. Thaler told the academy and reporters: “The most important lesson is that economic agents are humans and that economic models have to incorporate that.”

(cut)

“I’ll try to spend it as irrationally as possible,” Mr. Thaler said.

The article is here.

Nudges in a post-truth world

Neil Levy
Journal of Medical Ethics 
Published Online First: 19 May 2017

Abstract

Nudges—policy proposals informed by work in behavioural economics and psychology that are designed to lead to better decision-making or better behaviour—are controversial. Critics allege that they bypass our deliberative capacities, thereby undermining autonomy and responsible agency. In this paper, I identify a kind of nudge I call a nudge to reason, which make us more responsive to genuine evidence. I argue that at least some nudges to reason do not bypass our deliberative capacities. Instead, use of these nudges should be seen as appeals to mechanisms partially constitutive of these capacities, and therefore as benign (so far as autonomy and responsible agency are concerned). I sketch some concrete proposals for nudges to reason which are especially important given the apparent widespread resistance to evidence seen in recent political events.

The article is here.

Do the Right Thing: Preferences for Moral Behavior, Rather than Equity or Efficiency Per Se, Drive Human Prosociality

Capraro, Valerio and Rand, David G.
(May 8, 2017).

Abstract

Decades of experimental research have shown that some people forgo personal gains to benefit others in unilateral one-shot anonymous interactions. To explain these results, behavioral economists typically assume that people have social preferences for minimizing inequality and/or maximizing efficiency (social welfare). Here we present data that are fundamentally incompatible with these standard social preference models. We introduce the “Trade-Off Game” (TOG), where players unilaterally choose between an equitable option and an efficient option. We show that simply changing the labeling of the options to describe the equitable versus efficient option as morally right completely reverses people’s behavior in the TOG. Moreover, people who take the positively framed action, be it equitable or efficient, are more prosocial in a separate Dictator Game (DG) and Prisoner’s Dilemma (PD). Rather than preferences for equity and/or efficiency per se, we propose a generalized morality preference that motivates people to do what they think is morally right. When one option is clearly selfish and the other pro-social (e.g. equitable and/or efficient), as in the DG and PD, the economic outcomes are enough to determine what is morally right. When one option is not clearly more prosocial than the other, as in the TOG, framing resolves the ambiguity about which choice is moral. In addition to explaining our data, this account organizes prior findings that framing impacts cooperation in the standard simultaneous PD, but not in the asynchronous PD or the DG. Thus we present a new framework for understanding the basis of human prosociality.

The paper is here.

Preferences and beliefs in ingroup favoritism

Jim A. C. Everett, Nadira S. Faber, and Molly Crockett
Front. Behav. Neurosci., 13 February 2015

Ingroup favoritism—the tendency to favor members of one’s own group over those in other groups—is well documented, but the mechanisms driving this behavior are not well understood. In particular, it is unclear to what extent ingroup favoritism is driven by preferences concerning the welfare of ingroup over outgroup members, vs. beliefs about the behavior of ingroup and outgroup members. In this review we analyze research on ingroup favoritism in economic games, identifying key gaps in the literature and providing suggestions on how future work can incorporate these insights to shed further light on when, why, and how ingroup favoritism occurs. In doing so, we demonstrate how social psychological theory and research can be integrated with findings from behavioral economics, providing new theoretical and methodological directions for future research.

Across many different contexts, people act more prosocially towards members of their own group relative to those outside their group. Consequently, a number of scientific disciplines concerned with human cognition and behavior have sought to explain such ingroup favoritism (also known as parochial altruism). Here we explore to what extent ingroup favoritism is driven by preferences concerning the welfare of ingroup over outgroup members, vs. beliefs about the (future) behavior of ingroup and outgroup members.

The article is here.

What Make Us Cheat? Experiment 3

by Simon Oxenham
BigThink
Originally published January 13, 2016

Dan Ariely, the psychologist who popularised behavioral economics, has made a fascinating documentary exploring what makes us dishonest. I’ve just finished watching it and it’s something of a masterpiece of psychological storytelling, delving deep into contemporary tales of dishonesty, and supporting its narrative with cunningly designed experiments that have been neatly reconstructed for the film camera.

Social Norms

Whether or not we cheat has less to do with the probability of being caught, than whether or not we feel cheating is socially acceptable within our social circle.



The article is here.

Note: There is more research to show that those who witness unethical behavior in the workplace are more likely to engage in that unethical behavior if there are no consequences.

Way more Americans are drinking themselves to death. Here's why.

By German Lopez
The Vox
Originally published on December 28, 2015

Here are two excerpts:

For one, Americans are drinking more. According to the latest National Survey on Drug Use and Health, the number of Americans who reportedly drank in the previous month slightly increased as alcohol-induced deaths did: from 51 percent of all persons 12 and older in 2006, when deaths began to climb, to 52.7 percent in 2014.

(cut)

So for the US, boosting alcohol prices 10 percent could save as many as 6,000 lives each year. To put that in context, paying about 50 cents more for a six-pack of Bud Light could save thousands of lives. And this is a conservative estimate, since it only counts alcohol-related liver cirrhosis deaths — the number of lives saved would be higher if it accounted for deaths due to alcohol-related violence and car crashes.

Aside from raising taxes, a 2014 report from the RAND Drug Policy Research Center suggested state-run shops kept prices higher, reduced access to youth, and reduced overall levels of use. And a 2013 study from RAND of South Dakota's 24/7 Sobriety Program, which briefly jails people whose drinking has repeatedly gotten them in trouble with the law (like a DUI) if they fail a twice-a-day alcohol blood test, attributed a 12 percent reduction in repeat DUI arrests and a 9 percent reduction in domestic violence arrests at the county level to the program.

The article is here.

Fifty Shades of Manipulation

Cass R. Sunstein
Journal of Behavioral Marketing, Forthcoming
February 18, 2015

Abstract:    

A statement or action can be said to be manipulative if it does not sufficiently engage or appeal to people’s capacity for reflective and deliberative choice. One problem with manipulation, thus understood, is that it fails to respect people’s autonomy and is an affront to their dignity. Another problem is that if they are products of manipulation, people’s choices might fail to promote their own welfare, and might instead promote the welfare of the manipulator. To that extent, the central objection to manipulation is rooted in a version of Mill’s Harm Principle: People know what is in their best interests and should have a (manipulation-free) opportunity to make that decision. On welfarist grounds, the norm against manipulation can be seen as a kind of heuristic, one that generally works well, but that can also lead to serious errors, at least when the manipulator is both informed and genuinely interested in the welfare of the chooser.

For the legal system, a pervasive puzzle is why manipulation is rarely policed. The simplest answer is that manipulation has so many shades, and in a social order that values free markets and is committed to freedom of expression, it is exceptionally difficult to regulate manipulation as such. But as the manipulator’s motives become more self-interested or venal, and as efforts to bypass people’s deliberative capacities becomes more successful, the ethical objections to manipulation become very forceful, and the argument for a legal response is fortified. The analysis of manipulation bears on emerging first amendment issues raised by compelled speech, especially in the context of graphic health warnings. Importantly, it can also help orient the regulation of financial products, where manipulation of consumer choices is an evident but rarely explicit concern.

The entire article is here.

Interview with Dan Ariely

Featured Collaborator of the Month with www.ethicalsystems.org
Originally published on April 24, 2015

Here is an excerpt:

Why are cheating and dishonesty so widespread?

They are part of human nature. We have this incredible balance between honesty and dishonesty. We are taught from a young age to be dishonest in the social realm. We are taught not to tell people that they smell, or that it was the train that made us late instead of us being lazy, if people have a new haircut we say that it is very nice. We learn in the social realm that cheating is in fact desirable to some degree and then we move to the business / professional realm.

Now the rules are different. Now dishonesty is not as good. We don't separate those. Modern society creates a situation where the overlap between our social and professional lives are very high. All of a sudden, the people you interact with socially are the same as you interact with non socially, i.e. in your professional life. These tradeoffs become complex.

It is also important to realize that dishonesty is also about short term vs. long term. Saying something dishonest is a good solution in the short term but not necessarily in the long term, but we don't make this trade off correctly. For example, you say "I love your work" or "Your presentation as great," but then you get stuck with listening to, or having to fix, more of it. Much like other activities we over focus on the short term.

The entire article is here.

The Ethics of Nudging

By Cass Sunstein
Harvard Law School

Abstract:
 
This essay defends the following propositions. (1) It is pointless to object to choice architecture or nudging as such. Choice architecture cannot be avoided. Nature itself nudges; so does the weather; so do spontaneous orders and invisible hands. The private sector inevitably nudges, as does the government. It is reasonable to object to particular nudges, but not to nudging in general. (2) In this context, ethical abstractions (for example, about autonomy, dignity, and manipulation) can create serious confusion. To make progress, those abstractions must be brought into contact with concrete practices. Nudging and choice architecture take diverse forms, and the force of an ethical objection depends on the specific form. (3) If welfare is our guide, much nudging is actually required on ethical grounds. (4) If autonomy is our guide, much nudging is also required on ethical grounds. (5) Choice architecture should not, and need not, compromise either dignity or self-government, though imaginable forms could do both. (6) Some nudges are objectionable because the choice architect has illicit ends. When the ends are legitimate, and when nudges are fully transparent and subject to public scrutiny, a convincing ethical objection is less likely to be available. (7) There is, however, room for ethical objections in the case of well-motivated but manipulative interventions, certainly if people have not consented to them; such nudges can undermine autonomy and dignity. It follows that both the concept and the practice of manipulation deserve careful attention. The concept of manipulation has a core and a periphery; some interventions fit within the core, others within the periphery, and others outside of both.

The entire article is here.

SciCafe: The Evolution of Irrationality

SciCafe
Originally posted April 2014

Laurie Santos presented her research on the evolution of irrationality and insights from primates. Don't worry if you missed it: we have a video of her presentation, including clips of monkeys "shopping" for treats! Santos explores the roots of human irrationality by watching our primate relatives make decisions in "monkeynomics."

Behavioural economics and public policy

By Tim Harford
The Financial Times
Originally published March 17, 2014

Here is an excerpt:

Behavioural economics is one of the hottest ideas in public policy. The UK government’s Behavioural Insights Team (BIT) uses the discipline to craft better policies, and in February was part-privatised with a mission to advise governments around the world. The White House announced its own behavioural insights team last summer.

So popular is the field that behavioural economics is now often misapplied as a catch-all term to refer to almost anything that’s cool in popular social science, from the storycraft of Malcolm Gladwell, author of The Tipping Point (2000), to the empirical investigations of Steven Levitt, co-author of Freakonomics (2005).

Yet, as with any success story, the backlash has begun. Critics argue that the field is overhyped, trivial, unreliable, a smokescreen for bad policy, an intellectual dead-end – or possibly all of the above.

The entire article is here.

Three Shocking Truths About Lying At Work

By Keld Jensen
Forbes
Originally published June 24, 2013

Mark Twain famously said, “If you tell the truth, you don’t have to remember anything.” However, the benefit of a guilt-free conscious and a crystal-clear mind appears not to be a strong enough incentive to deter lying, especially in the workplace.

The pandemic of lying does not just refer to high-profile cases, such as Bill Clinton’s affair, Lance Armstrong’s denial of doping, and Bernie Madoff’s financial deceit. Workplace lying is a far more widespread issue and it is taking place in offices around the world. There is a steady undercurrent of dishonesty, “white lies,” cheating, and bending the rules, and it’s time we pull the rug out and expose three simple truths about lying.

1) You lie at work—so does everyone else. 

Most of us are willing to confess to it. According to a survey by psychotherapist and consultant Dr. Brad Blanton, 93% of respondents out of forty thousand Americans admitted to lying “regularly and habitually in the workplace.” Personally, I believe the other 7% are lying to themselves—and they probably believe it!

The entire story is here.

The 'Truth' About Why We Lie, Cheat And Steal

by NPR STAFF
All Things Considered
June 04, 2012

Chances are, you're a liar. Maybe not a big liar — but a liar nonetheless. That's the finding of Dan Ariely, a professor of psychology and behavioral economics at Duke University. He's run experiments with some 30,000 people and found that very few people lie a lot, but almost everyone lies a little.

Ariely describes these experiments and the results in a new book, The (Honest) Truth About Dishonesty: How We Lie To Everyone — Especially Ourselves. He talks with NPR's Robert Siegel about how society's troubles aren't always caused by the really bad apples; they're caused by the scores of slightly rotting apples who are cheating just a little bit.

Interview Highlights

On the traditional, cost/benefit theory of dishonesty

"The standard view is a cost/benefit view. It says that every time we see something, we ask ourselves: What do I stand to gain from this and what do I stand to lose? Imagine it's a gas station: Going by a gas station, you ask yourself: How much money is in this gas station? If I steal it, what's the chance that somebody will catch me and how much time will I have in prison? And you basically look at the cost and benefit, and if it's a good deal, you go for it."

On why the cost/benefit theory is flawed

"It's inaccurate, first of all. When we do experiments, when we try to tempt people to cheat, we don't find that these three elements — what do we stand to gain, probability of being caught and size of punishment — end up describing much of the result.

"Not only is it a bad descriptor of human behavior, it's also a bad input for policy. Think about it: When we try to curb dishonesty in the world, what do we do? We get more police force, we increase punishment in prison. If those are not the things that people consider when they think about committing a particular crime, then all of these efforts are going to be wasted."

The rest of the article is here.

Doctors Warned on ‘Divided Loyalty’

By ROBERT PEAR

The New York Times

Published: December 26, 2012

With hospitals buying up medical practices around the country and seeking to make the most of their investment, the American Medical Association reached out to doctors this week to remind them that patient welfare must always come first and not be overridden by the economic interests of hospitals that now employ doctors in ever-growing numbers.

“In any situation where the economic or other interests of the employer are in conflict with patient welfare, patient welfare must take priority,” says a policy statement adopted by the association.

“A physician’s paramount responsibility is to his or her patients,” the association said. At the same time, it added, a doctor “owes a duty of loyalty to his or her employer,” and “this divided loyalty can create conflicts of interest, such as financial incentives to over- or under-treat patients.”

The association is disseminating its policy to doctors at a time when more of them are becoming hospital employees. About one-third of new doctors say they would prefer to be employed by hospitals, rather than practice on their own. The association is urging hospitals and medical groups to adopt similar policies.

A major goal of the guidelines is to protect the professional autonomy of doctors. Hospital employment agreements often include provisions that discourage doctors from sending patients to providers of services that are not affiliated with the hospital.

The guidelines say that “physicians should always make treatment and referral decisions based on the best interests of their patients.” Moreover, the association says, patients should be told whenever a hospital provides financial incentives that encourage, discourage or restrict referrals or treatment options.  

The entire story is here.

Caregiving as moral experience

By Arthur Kleinman
The Lancet
Volume 380, Issue 9853, Pages 1550 - 1551
3 November 2012


Everyone who has been in love or built a family knows that there are things, essential things, that money can't buy. Patients with serious illness and their network of caregivers know this too, because those things that really matter to us are threatened and must be defended. And many clinicians, reflecting on what is at stake in health care not only for patients but for themselves, know the same thing: the market has an important role in health-care financing and health systems reform, but it should not reach into those quintessentials of caregiving that speak to what is most deeply human in medicine and in living. This is the moral limit of an economic paradigm. Or at least it should be.

But we live in a truly confused age. The market model seems to have infiltrated so thoroughly into human lives and medicine that in certain circles—policy making and analysis, hospital and clinic administration, and even clinical work—economic rationality with its imperative of containing costs and maximising efficiency has come to mute the moral, emotional, religious, and aesthetic expressions of patients and caregivers. Most take it for granted and accept its implications. Models from economic psychology, behavioural economics, and business studies, based on the narrowest calculations of what a “rational” person would choose as most cost-effective, are now routinely applied to clinical decision making and the organisation of care.

(cut)

The great failure of contemporary medicine to promote caregiving as an existential practice and moral vision that resists reduction to the market model or the clarion call of efficiency has diminished professionals, patients, and family caregivers alike. It has enabled a noisy and ubiquitous market to all but silence different motives, ideals, hopes, and behaviours that must be expressed, because they are as much who we are as economic rationality.

The entire piece is here.


doi:10.1016/S0140-6736(12)61870-4