Psychotherapy, placebos, and informed consent

Leder G
Journal of Medical Ethics 
Published Online First: 20 August 2020.
doi: 10.1136/medethics-2020-106453

Abstract

Several authors have recently argued that psychotherapy, as it is commonly practiced, is deceptive and undermines patients’ ability to give informed consent to treatment. This ‘deception’ claim is based on the findings that some, and possibly most, of the ameliorative effects in psychotherapeutic interventions are mediated by therapeutic common factors shared by successful treatments (eg, expectancy effects and therapist effects), rather than because of theory-specific techniques. These findings have led to claims that psychotherapy is, at least partly, likely a placebo, and that practitioners of psychotherapy have a duty to ‘go open’ to patients about the role of common factors in therapy (even if this risks negatively affecting the efficacy of treatment); to not ‘go open’ is supposed to unjustly restrict patients’ autonomy. This paper makes two related arguments against the ‘go open’ claim. (1) While therapies ought to provide patients with sufficient information to make informed treatment decisions, informed consent does not require that practitioners ‘go open’ about therapeutic common factors in psychotherapy, and (2) clarity about the mechanisms of change in psychotherapy shows us that the common-factors findings are consistent with, rather than undermining of, the truth of many theory-specific forms of psychotherapy; psychotherapy, as it is commonly practiced, is not deceptive and is not a placebo. The call to ‘go open’ should be resisted and may have serious detrimental effects on patients via the dissemination of a false view about how therapy works.

Conclusion

The ‘go open’ argument is based on a mistaken view about the mechanisms of change in psychotherapy and threatens to harm patients by undermining their ability to make informed treatment decisions. This paper has argued that the prima facie ethical problem raised by the ‘go open’ argument is diffused if we clear up a conceptual confusion about what, exactly, we should be
going open about. Therapists should be open with patients about the differing theories of the mechanisms of change in psychotherapy; this can, but need not involve discussing information
about the therapeutic common factors.

The article is here.

Note from Dr. Gavazzi: Using "deception" is the wrong frame for this issue.  How complete is your informed consent?  Can we ever give "perfect" informed consent?  The answer is likely no.

Why Being Kind Helps You, Too—Especially Now

Elizabeth Bernstein
The Wall Street Journal
Originally posted 11 August 20

Here is an excerpt:

Kindness can even change your brain, says Stephanie Preston, a psychology professor at the University of Michigan who studies the neural basis for empathy and altruism. When we’re kind, a part of the reward system called the nucleus accumbens activates—our brain responds the same way it would if we ate a piece of chocolate cake. In addition, when we see the response of the recipient of our kindness—when the person thanks us or smiles back—our brain releases oxytocin, the feel-good bonding hormone. This oxytocin boost makes the pleasure of the experience more lasting.

It feels so good that the brain craves more. “It’s an upward spiral—your brain learns it’s rewarding, so it motivates you to do it again,” Dr. Preston says.

Are certain acts of kindness better than others? Yes. If you want to reap the personal benefits, “you need to be sincere,” says Sara Konrath, a psychologist and associate professor at the Indiana University Lilly Family School of Philanthropy, where she runs a research lab that studies empathy and altruism.

It also helps to expect good results. A study published in the Journal of Positive Psychology in 2019 showed people who believed that kindness is good for them showed a greater increase in positive emotions, satisfaction with life and feelings of connection with others—as well as a greater decrease in negative emotions—than those who did not.

How can you be kind even when you may not feel like it? Make it a habit. Take stock of how you behave day to day. Are you trusting and generous? Or defensive and hostile? “Kindness is a lifestyle,” says Dr. Konrath.

Start by being kind to yourself—you’re going to burn out if you help everyone else and neglect your own needs. Remember that little acts add up: a smile, a phone call to a lonely friend, letting someone have the parking space. Understand the difference between being kind and being nice—kindness is genuinely helping or caring about someone; niceness is being polite. Don’t forget your loved ones. Kindness is not just for strangers.

The info is here.

Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter

Zulman DM, Haverfield MC, Shaw JG, et al.
JAMA. 2020;323(1):70–81.
doi:10.1001/jama.2019.19003

Key Points

Question  What are the most promising practices to foster physician presence and connection with patients?

Findings  This mixed-methods study identified 5 practices that may enhance physician presence and meaningful connection with patients in the clinical encounter: (1) prepare with intention; (2) listen intently and completely; (3) agree on what matters most; (4) connect with the patient’s story; and (5) explore emotional cues.

Meaning  For busy clinicians with multiple demands and distractions, 5 recommended practices have the potential to facilitate meaningful interactions with patients.

Abstract
Importance  Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction.

Objective  To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients.

Evidence Review  Preliminary practices were derived through a systematic literature review (fromJanuary 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n = 27 encounters); and qualitative interviews with physicians (n = 10), patients (n = 27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n = 30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (−4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their “top 5” practices from among those with median ratings of at least +2 for all 3 criteria. Finalrecommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes.

Findings  The systematic literature review (n = 73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient’s story (consider life circumstances that influence the patient’s health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient’s emotions).

Conclusions and Relevance  This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.

The research is here.

Hate Trumps Love: The Impact of Political Polarization on Social Preferences

Eugen Dimant
ssrn.com
Published 4 September 20

Abstract

Political polarization has ruptured the fabric of U.S. society. The focus of this paper is to examine various layers of (non-)strategic decision-making that are plausibly affected by political polarization through the lens of one's feelings of hate and love for Donald J. Trump. In several pre-registered experiments, I document the behavioral-, belief-, and norm-based mechanisms through which perceptions of interpersonal closeness, altruism, and cooperativeness are affected by polarization, both within and between political factions. To separate ingroup-love from outgroup-hate, the political setting is contrasted with a minimal group setting. I find strong heterogeneous effects: ingroup-love occurs in the perceptional domain (how close one feels towards others), whereas outgroup-hate occurs in the behavioral domain (how one helps/harms/cooperates with others). In addition, the pernicious outcomes of partisan identity also comport with the elicited social norms. Noteworthy, the rich experimental setting also allows me to examine the drivers of these behaviors, suggesting that the observed partisan rift might be not as forlorn as previously suggested: in the contexts studied here, the adverse behavioral impact of the resulting intergroup conflict can be attributed to one's grim expectations about the cooperativeness of the opposing faction, as opposed to one's actual unwillingness to cooperate with them.

From the Conclusion and Discussion

Along all investigated dimensions, I obtain strong effects and the following results: for one, polarization produces ingroup/outgroup differentiation in all three settings (nonstrategic, Experiment 1; strategic, Experiment 2; social norms, Experiment 3), leading participants to actively harm and cooperate less with participants from the opposing faction. For another, lack of cooperation is not the result of a categorical unwillingness to cooperate across factions, but based on one’s grim expectations about the other’s willingness to cooperate. Importantly, however, the results also cast light on the nuance with which ingroup-love and outgroup-hate – something that existing literature often takes as being two sides of the same coin – occurs. In particular, by comparing behavior between the Trump Prime and minimal group prime treatments, the results suggest that ingroup-love can be observed in terms of feeling close to one another, whereas outgroup hate appears in form of taking money away from and being less cooperative with each other. The elicited norms are consistent with these observations and also point out that those who love Trump have a much weaker ingroup/outgroup differentiation than those who hate Trump do.

The research is here.

Fallen Soldier Insults Give Trump a Lot to Fear

Cass Sunstein
bloomberg.com
Originally published 6 Sept 20

Here is an excerpt:

Building on Haidt’s work, Harvard economist Benjamin Enke has studied the rhetoric of numerous recent presidential candidates, and found that one has done better than all others in emphasizing loyalty, authority and sanctity: Trump. On the same scales, Hillary Clinton was especially bad. (Barack Obama was far better.) Enke also found that Trump’s emphasis on these values mattered to many voters, and attracted them to his side.

This framework helps sort out what many people consider to be a puzzle: Trump avoided military service, has been married three times, and has not exactly been a paragon of virtue in his personal life. Yet many people focused on patriotism, religious faith and traditional moral values have strongly supported him. A key reason is that however he has lived his life, he speaks their language — and indeed does so at least as well as, and probably better than, any presidential candidate they have heard before.

That’s why his reported expressions of contempt and disrespect for American soldiers threaten to be uniquely damaging — far more so than other outrageous comments he has made. When he said that Mexico is sending rapists to the U.S., made fun of the looks of prominent women, mocked disabled people, or said that protesters should be roughed up, people might have nodded or cringed, or laughed or been appalled.

As a matter of pure politics, though, saying that soldiers are “losers” or “suckers” is much worse for Trump because it attacks the foundation of his appeal: However he lives his life, at least he expresses deep love for this country and reverence for those who fight for it, and at least he speaks out for traditional moral values.

There are strong lessons here for both Trump and his Democratic challenger, former Vice President Joe Biden. Through both word and deed, the president needs to do whatever he can to make it clear that he respects and supports American soldiers.

The info is here.

Pharma drew a line in the sand over Covid-19 vaccine readiness, because someone had to

Ed Silverman
statnews.com
Originally posted 7 Sept 20

Here is an excerpt:

The vaccine makers that are signing this pledge — Pfizer, Merck, AstraZeneca, Sanofi, GlaxoSmithKline, BioNTech, Johnson & Johnson, Moderna, and Novavax — are rushing to complete clinical trials. But only Pfizer has indicated it may have late-stage results in October, and that’s not a given.

Yet any move by the FDA to green light a Covid-19 vaccine without late-stage results will be interpreted as an effort to boost Trump — and rightly so.

Consider Trump’s erratic and selfish remarks. He recently accused the FDA of slowing the vaccine approval process and being part of a “deep state.” No wonder there is concern he may lean on Hahn to authorize emergency use prematurely. For his part, Hahn has insisted he won’t buckle to political pressure, but he also said emergency use may be authorized based on preliminary data.

“It’s unprecedented in my experience that industry would do something like this,” said Ira Loss of Washington Analysis, who tracks pharmaceutical regulatory and legislative matters for investors. “But we’ve experienced unprecedented events since the beginning of Covid-19, starting with the FDA, where the commissioner has proven to be malleable, to be kind, at the foot of the president.”

Remember, we’ve seen this movie before.

Amid criticism of his handling of the pandemic, Trump touted hydroxychloroquine, a decades-old malaria tablet, as a salve and the FDA authorized emergency use. Two weeks ago, he touted convalescent blood plasma as a medical breakthrough, but evidence of its effectiveness against the coronavirus is inconclusive. And Hahn initially overstated study results.

Most Americans seem to be catching on. A STAT-Harris poll released last week found that 78% of the public believes the vaccine approval process is driven by politics, not science. This goes for a majority of Democrats and Republicans.

The info is here.

From sex robots to love robots: is mutual love with a robot possible?

S.R. Nyholm and L.E. Frank
Philosophy & Ethics

Some critics of sex-robots worry that their use might spread objectifying attitudes about sex, and common sense places a higher value on sex within love-relationships than on casual sex. If there could be mutual love between humans and sex-robots, this could help to ease the worries about objectifying attitudes. And mutual love between humans and sex-robots, if possible, could also help to make this sex more valuable. But is mutual love between humans and robots possible, or even conceivable? We discuss three clusters of ideas and associations commonly discussed within the philosophy of love, and relate these to the topic of whether mutual love could be achieved between humans and sex-robots: (i) the idea of love as a “good match”; (ii) the idea of valuing each other in our distinctive particularity; and (iii) the idea of a steadfast commitment. We consider relations among these ideas and the sort of agency and free will that we attribute to human romantic partners. Our conclusion is that mutual love between humans and advanced sex-robots is not an altogether impossible proposition. However, it is unlikely that we will be able to create robots sophisticated enough to be able to participate in love-relationships anytime soon.

From the Conclusion:

As with the development of any new technology that has the potential to be socially disruptive, we urge caution and careful ethical examination prior to and continuing through the research-and-development process. The consequences and techno-moral change that will potentially accompany the advancement of robots that can love and be loved is very difficult to predict. But a “no” answer to the question of whether we should invest in the creation of love robots should not be based on mere conservatism with respect to love relationships, unjustified preference for the natural over the artificial,  or an unsupported fear of the potential risks. Any such answer, in our view, should rather be based on an “opportunity cost” argument: that is, if it can be shown that the time, energy, and resources could be better spent on other, more easily attain-able endeavors, then those other projects should perhaps be favored over something as relatively far-fetched as sex robots advanced enough to participate in relationships of mutual love along the lines described in the previous sections.

A pdf can be downloaded here.

Our morally unserious president on display in Kenosha

Michael Sean Winters
National Catholic Reporter
Originally posted 4 September 20

President Donald Trump went to Kenosha, Wisconsin, this week to "survey the property damage" according to a White House transcript. He spoke a lot about law and order and very little about justice, as if the concepts are not necessarily related. To him, they probably are not.

A morally serious person would begin any examination of the damage in Kenosha with a look at an MRI of Jacob Blake's shattered torso. Blake was shot seven times in the back — reports said he was shot at "point blank range," but that phrase covers a range of distances — the gun only a few feet from his body. The video made the shooting look like a public execution.

Donald Trump is not a morally serious person.

A morally serious person would continue his survey of the damage in Kenosha by visiting with the family of Jacob Blake, especially his three young sons who witnessed the shooting. They are ages 3, 5 and 8, and the trauma to which they were exposed is horrific to contemplate. A morally serious person would express sympathy with the family and the community, mindful of how much more shocking the shocking video of Blake's shooting was if you knew the victim.

Donald Trump is not a morally serious person.

A morally serious person would understand that, while it is entirely fitting for the nation's chief magistrate to mourn the death of Aaron "Jay" Danielson, the 39-year old Trump supporter gunned down on the streets of Portland, Oregon, it is wrong to mourn his death publicly without mentioning the shooting of Blake, on the very day you are going to Kenosha. Such uneven treatment epitomizes the very reason it is still necessary to remind the nation that Black lives matter.

Donald Trump is not a morally serious person.

A morally serious person would inquire into the legacy of racism, structural racism, in Kenosha and elsewhere, the racism that made the shooting of Blake horrifying but not surprising. A morally serious person would not take refuge in chatter about "a few bad apples" but confront the police culture that permits such bad apples to poison the bushel. A morally serious person would work, and work hard, at finding ways to ameliorate the effects of racism and call fellow citizens to that deep examination of conscience every episode of police brutality against Black men demands.

Donald Trump is not a morally serious person.

The info is here.

Generosity without borders: The interactive effect of spatial distance and donation goals on charitable giving

A. Jing Xu, M. A. Rodas, C. J. Torelli
Organizational Behavior and 
Human Decision Processes
Volume 161, November 2020, Pages 65-78

Abstract

Although past research suggests that people are more likely to donate money to nearby causes to maximize their positive impact on others’ lives, donations to foreign causes are growing rapidly. Incorporating both other-focused impact goals and self-focused moral goals into our conceptualization, we propose that an interplay between the accessibility of impact/moral goals and the spatial distance between donors and recipients of charitable causes (e.g., faraway vs. nearby recipients) influences charitable behaviors (e.g., donation amounts and charitable choices). Specifically, when the goal to maintain a moral self-concept (impact recipients’ lives) is accessible, donors experience a more expansive conception of their moral circle (apply the “closeness-equals-impact” heuristic) and donate more money to faraway (nearby) causes. We further demonstrate that moral (impact) goals are more abstract (concrete) motivations, and their effects also emerge when priming an abstract (concrete) mindset. Five studies support these predictions while ruling out alternative interpretations.

Highlights

• The goal to maintain a moral self-concept leads to higher donations to faraway causes.

• This effect is mediated by perceived expansion of one’s circle of moral regard.

• The goal to impact recipients’ lives leads to higher donations to nearby causes.

• Moral goals are abstract and can be activated by an abstract mindset.

• Impact goals are concrete and can be activated by a concrete mindset.

• Self-importance of moral identity moderates the effect of spatial distance on donations.

The research is here.