Why VIP Services Are Ethically Indefensible in Health Care

Denisse Rojas Marquez and Hazel Lever

AMA J Ethics. 2023;25(1):E66-71.

doi: 10.1001/amajethics.2023.66.

Abstract

Many health care centers make so-called VIP services available to “very important persons” who have the ability to pay. This article discusses common services (eg, concierge primary care, boutique hotel-style hospital stays) offered to VIPs in health care centers and interrogates “trickle down” economic effects, including the exacerbation of inequity in access to health services and the maldistribution of resources in vulnerable communities. This article also illuminates how VIP care contributes to multitiered health service delivery streams that constitute de facto racial segregation and influence clinicians’ conceptions of what patients deserve from them in health care settings.

Insurance and Influence

It is common practice for health care centers to make “very important person” (VIP) services available to patients because of their status, wealth, or influence. Some delivery models justify the practice of VIP health care as a means to help offset the cost of less profitable sectors of care, which often involve patients who have low income, are uninsured, and are from historically marginalized communities.1 In this article, we explore the justification of VIP health care as helping finance services for patients with low income and consider if this “trickle down” rationale is valid and whether it should be regarded as acceptable. We then discuss clinicians’ ethical responsibilities when taking part in this system of care.

We use the term VIP health care to refer to services that exceed those offered or available to a general patient population through typical health insurance. These services can include concierge primary care (also called boutique or retainer-based medicine) available to those who pay out of pocket, stays on exclusive hospital floors with luxury accommodations, or other premium-level health care services.1 Take the example of a patient who receives treatment on the “VIP floor” of a hospital, where she receives a private room, chef-prepared food, and attending physician-only services. In the outpatient setting, the hallmarks of VIP service are short waiting times, prompt referrals, and round-the-clock staffing.

While this model of “paying for more” is well accepted in other industries, health care is a unique commodity, with different distributional consequences than markets for other goods (eg, accessing it can be a matter of life or death and it is deemed a human right under the Alma-Ata Declaration2). The existence of VIP health care creates several dilemmas: (1) the reinforcement of existing social inequities, particularly racism and classism, through unequal tiers of care; (2) the maldistribution of resources in a resource-limited setting; (3) the fallacy of financing care of the underserved with care of the overserved in a profit-motivated system.

(cut)

Conclusion

VIP health care, while potentially more profitable than traditional health care delivery, has not been shown to produce better health outcomes and may distribute resources away from patients with low incomes and patients of color. A system in which wealthy patients are perceived to be the financial engine for the care of patients with low incomes can fuel distorted ideas of who deserves care, who will provide care, and how expeditiously care will be provided. To allow VIP health care to exist condones the notion that some people—namely, wealthy White people—deserve more care sooner and that their well-being matters more. When health institutions allow VIP care to flourish, they go against the ideal of providing equitable care to all, a value often named in organizational mission statements.22 At a time when pervasive distrust in the medical system has fueled negative consequences for communities of color, it is our responsibility as practitioners to restore and build trust with the most vulnerable in our health care system. When evaluating how VIP care fits into our health care system, we should let health equity be a moral compass for creating a more ethical system.

The info is here.

Abortion Access Tied to Suicide Rates Among Young Women

Michael DePeau-Wilson

MedPage Today

Originally posted 28 DEC 22

Restrictions on access to reproductive care were associated with suicide rates among women of reproductive age, researchers found.

In a longitudinal ecologic study using state-based data from 1974 to 2016, enforcement of Targeted Regulation of Abortion Providers (TRAP) laws was associated with higher suicide rates among reproductive-age women (β=0.17, 95% CI 0.03-0.32, P=0.02) but not among women of post-reproductive age, according to Ran Barzilay, MD, PhD, of the University of Pennsylvania in Philadelphia, and colleagues.

Nor was enforcement of TRAP laws associated with deaths due to motor vehicle crashes, they reported in JAMA Psychiatry in a new tab or window.

Additionally, enforcement of a TRAP law was associated with a 5.81% higher annual rate of suicide than in pre-enforcement years, the researchers found.

"Taken together, the results suggest that the association between restricting access to abortion and suicide rates is specific to the women who are most affected by this restriction, which are young women," Barzilay told MedPage Today.

Barzilay said their study "can inform, number one, clinicians working with young women to be aware that this is a macro-level suicide risk factor in this population. And number two, that it informs policymakers as they allocate resources for suicide prevention. And number three, that it informs the ethical, divisive debate regarding access to abortion."

In an accompanying editorial, Tyler VanderWeele, PhD, of Harvard T.H. Chan School of Public Health in Boston, wrote that while analyses of this type are always subject to the possibility of changes in trends being attributable to some third factor, Barzilay and colleagues did "control for a number of reasonable candidates and conducted sensitivity analyses indicating that these associations were observed for reproductive-aged women but not for a control group of older women of post-reproductive age."

VanderWeele wrote the findings do suggest that a "not inconsiderable" number of women might be dying by suicide in part because of a lack of access to abortion services, and that "the increase is cause for clinical concern."

But while more research "might contribute more to our understanding," VanderWeele wrote, its role in the legal debates around abortion "seems less clear. Regardless of whether one is looking at potential adverse effects of access restrictions or of abortion, the abortion and mental health research literature will not resolve the more fundamental and disputed moral questions."

"Debates over abortion access are likely to remain contentious in this country and others," he wrote. "However, further steps can nevertheless be taken in finding common ground to promote women's mental health and healthcare."

For their "difference-in-differences" analysis, Barzilay and co-authors relied on data from the TRAP laws index to measure abortion access, and assessed suicide data from CDC's WONDER database in a new tab or window database.

The info is here.

UCSF Issues Report, Apologizes for Unethical 1960-70’s Prison Research

Restorative Justice Calls for Continued Examination of the Past

Laura Kurtzman

Press Release

Originally posted 20 DEC 22

Recognizing that justice, healing and transformation require an acknowledgment of past harms, UCSF has created the Program for Historical Reconciliation (PHR). The program is housed under the Office of the Executive Vice Chancellor and Provost, and was started by current Executive Vice Chancellor and Provost, Dan Lowenstein, MD.

The program’s first report, released this month, investigates experiments from the 1960s and 1970s involving incarcerated men at the California Medical Facility (CMF) in Vacaville. Many of these men were being assessed or treated for psychiatric diagnoses.

The research reviewed in the report was performed by Howard Maibach, MD, and William Epstein, MD, both faculty in UCSF’s Department of Dermatology. Epstein was a former chair of the department who died in 2006. The committee was asked to focus on the work of Maibach, who remains an active member of the department.

Some of the experiments exposed research subjects to pesticides and herbicides or administered medications with side effects. In all, some 2,600 incarcerated men were experimented on.

The men volunteered for the studies and were paid for participating. But the report raises ethical concerns over how the research was conducted. In many cases there was no record of informed consent. The subjects also did not have any of the medical conditions that any of the experiments could have potentially treated or ameliorated.

Such practices were common in the U.S. at the time and were increasingly being criticized both by experts and in the lay press. The research continued until 1977, when the state of California halted all human subject research in state prisons, a year after the federal government did the same.

The report acknowledges that Maibach was working during a time when the governance of human subjects research was evolving, both at UCSF and at institutions across the country. Over a six-month period, the committee gathered some 7,000 archival documents, medical journal articles, interviews, documentaries and books, much of which has yet to be analyzed. UCSF has acknowledged that it may issue a follow-up report.

The report found that “Maibach practiced questionable research methods. Archival records and published articles have failed to show any protocols that were adopted regarding informed consent and communicating research risks to participants who were incarcerated.”

In a review of publications between 1960 and 1980, the committee found virtually all of Maibach’s studies lacked documentation of informed consent despite a requirement for formal consent instituted in 1966 by the newly formed Committee on Human Welfare and Experimentation. Only one article, published in 1975, indicated the researchers had obtained informed consent as well as approval from UCSF’s Committee for Human Research (CHR), which began in 1974 as a result of new federal requirements.

The pressor is here.

The pervasive impact of ignorance

Kirfel, L., & Phillips, J.

Cognition

Volume 231, February 2023, 105316

Abstract

Norm violations have been demonstrated to impact a wide range of seemingly non-normative judgments. Among other things, when agents' actions violate prescriptive norms they tend to be seen as having done those actions more freely, as having acted more intentionally, as being more of a cause of subsequent outcomes, and even as being less happy. The explanation of this effect continue to be debated, with some researchers appealing to features of actions that violate norms, and other researcher emphasizing the importance of agents' mental states when acting. Here, we report the results of two large-scale experiments that replicate and extend twelve of the studies that originally demonstrated the pervasive impact of norm violations. In each case, we build on the pre-existing experimental paradigms to additionally manipulate whether the agents knew that they were violating a norm while holding fixed the action done. We find evidence for a pervasive impact of ignorance: the impact of norm violations on non-normative judgments depends largely on the agent knowing that they were violating a norm when acting. Moreover, we find evidence that the reduction in the impact of normality is underpinned by people's counterfactual reasoning: people are less likely to consider an alternative to the agent's action if the agent is ignorant. We situate our findings in the wider debate around the role or normality in people's reasoning.

General discussion

Studies show that norm violations influence a wide range of domains, including judgments of causation, freedom, happiness, doing vs. allowing, mental state ascriptions, and modal claims. A continuing debate centers on why normality has such a pervasive impact, and whether one should attempt to offer a unified explanation of these various effects (Hindriks, 2014). In this study, we found evidence that the epistemic state of norm-violating agents plays a fundamental role in the impact of norms on non-normative judgments. Across a wide range of intuitive judgments and highly different manipulations of an agents' knowledge, we found that the impact of normality on non-normative judgments was diminished when the agent did not know that they were violating a norm. More precisely, the agent's knowledge of the norm violation determined the extent to which abnormal actions increased judgments of causation, decreased attribution of force, increased attributions of intentional action, and so on. In other words, the impact of ignorance appears to be as pervasive as the impact of normality itself. In addition, our study showed that the agent's epistemic state also influenced to what extent people engage in reasoning about alternatives to the agent's action. If the agent was ignorant when they violated a norm, people were less inclined to consider what the agent could have done differently.

At the broadest level, the current results provide evidence that the pervasive impact of normality likely warrants a unified explanation at some level: we considered a specific feature that had been shown to moderate the impact of normality in one domain (causation) and demonstrated that this same feature of the impact of normality can be found across a wide range of other domains. This finding suggests that the impact of norms arises from a shared underlying mechanism that is recruited across domains. Specific accounts may, of course, seek to incorporate agents' epistemic states into their respective theory of how normality influences judgments in one particular domain. However, such an approach will miss out on a generalization and will necessarily be less parsimonious. Accordingly, we turn now to considering two broad approaches to offering a unified account of the pervasive impact of ignorance.

A pdf of the research is here.

Moral foundations, values, and judgments in extraordinary altruists

Amormino, P., Ploe, M.L. & Marsh, A.A.

Sci Rep 12, 22111 (2022).

https://doi.org/10.1038/s41598-022-26418-1

Abstract

Donating a kidney to a stranger is a rare act of extraordinary altruism that appears to reflect a moral commitment to helping others. Yet little is known about patterns of moral cognition associated with extraordinary altruism. In this preregistered study, we compared the moral foundations, values, and patterns of utilitarian moral judgments in altruistic kidney donors (n = 61) and demographically matched controls (n = 58). Altruists expressed more concern only about the moral foundation of harm, but no other moral foundations. Consistent with this, altruists endorsed utilitarian concerns related to impartial beneficence, but not instrumental harm. Contrary to our predictions, we did not find group differences between altruists and controls in basic values. Extraordinary altruism generally reflected opposite patterns of moral cognition as those seen in individuals with psychopathy, a personality construct characterized by callousness and insensitivity to harm and suffering. Results link real-world, costly, impartial altruism primarily to moral cognitions related to alleviating harm and suffering in others rather than to basic values, fairness concerns, or strict utilitarian decision-making.

Discussion

In the first exploration of patterns of moral cognition that characterize individuals who have engaged in real-world extraordinary altruism, we found that extraordinary altruists are distinguished from other people only with respect to a narrow set of moral concerns: they are more concerned with the moral foundation of harm/care, and they more strongly endorse impartial beneficence. Together, these findings support the conclusion that extraordinary altruists are morally motivated by an impartial concern for relieving suffering, and in turn, are motivated to improve others’ welfare in a self-sacrificial manner that does not allow for the harm of others in the process. These results are also partially consistent with extraordinary altruism representing the inverse of psychopathy in terms of moral cognition: altruists score lower in psychopathy (with the strongest relationships observed for psychopathy subscales associated with socio-affective responding) and higher-psychopathy participants most reliably endorse harm/care less than lower psychopathy participants, with participants with higher scores on the socio-affective subscales of our psychopathy measures also endorsing impartial beneficence less strongly.

(cut)

Notably, and contrary to our predictions, we did not find that donating a kidney to a stranger is strongly or consistently correlated (positively or negatively) with basic values like universalism, benevolence, power, hedonism, or conformity. That suggests extraordinary altruism may not be driven by unusual values, at least as they are measured by the Schwartz inventory, but rather by specific moral concerns (such as harm/care). Our findings suggest that reported values may not in themselves predict whether one acts on those values when it comes to extraordinary altruism, much as “…a person can value being outgoing in social gatherings, independently of whether they are prone to acting in a lively or sociable manner”. Similarly, people who share a common culture may value common things but acting on those values to an extraordinarily costly and altruistic degree may require a stronger motivation––a moral motivation.

The research is here.

The AI Ethicist's Dirty Hands Problem

H. S. Sætra, M. Coeckelbergh, & J. Danaher

Communications of the ACM, January 2023, 

Vol. 66 No. 1, Pages 39-41

Assume an AI ethicist uncovers objectionable effects related to the increased usage of AI. What should they do about it? One option is to seek alliances with Big Tech in order to "borrow" their power to change things for the better. Another option is to seek opportunities for change that actively avoids reliance on Big Tech.

The choice between these two strategies gives rise to an ethical dilemma. For example, if the ethicist's research emphasized the grave and unfortunate consequences of Twitter and Facebook, should they promote this research by building communities on said networks? Should they take funding from Big Tech to promote the reform of Big Tech? Should they seek opportunities at Google or OpenAI if they are deeply concerned about the negative implications of large-scale language models?

The AI ethicist’s dilemma emerges when an ethicist must consider how their success in communicating an

identified challenge is associated with a high risk of decreasing the chances of successfully addressing the challenge.  This dilemma occurs in situations in which the means to achieve one’s goals are seemingly best achieved by supporting that which one wishes to correct and/or practicing the opposite of that which one preaches.

(cut)

The Need for More than AI Ethics

Our analysis of the ethicist’s dilemma shows why close ties with Big Tech can be detrimental for the ethicist seeking remedies for AI related problems.   It is important for ethicists, and computer scientists in general, to be aware of their links to the sources of ethical challenges related to AI.  One useful exercise would be to carefully examine what could happen if they attempted to challenge the actors with whom they are aligned. Such actions could include attempts to report unfortunate implications of the company’s activities internally, but also publicly, as Gebru did. Would such actions be met with active resistance, with inaction, or even straightforward sanctions? Such an exercise will reveal whether or not the ethicist feels free to openly and honestly express concerns about the technology with which they work. Such an exercise could be important, but as we have argued, these individuals are not necessarily positioned to achieve fundamental change in this system.

In response, we suggest the role of government is key to balancing the power the tech companies have

through employment, funding, and their control of modern digital infrastructure. Some will rightly argue that political power is also dangerous.   But so are the dangers of technology and unbridled innovation, and private corporations are central sources of these dangers. We therefore argue that private power must be effectively bridled by the power of government.  This is not a new argument, and is in fact widely accepted.

The info is here.

Outcome effects, moral luck and the hindsight bias

M. Kneer & I. Skoczen

Cognition

Volume 232, March 2023, 105258

Abstract

In a series of ten preregistered experiments (N = 2043), we investigate the effect of outcome valence on judgments of probability, negligence, and culpability – a phenomenon sometimes labelled moral (and legal) luck. We found that harmful outcomes, when contrasted with neutral outcomes, lead to an increased perceived probability of harm ex post, and consequently, to a greater attribution of negligence and culpability. Rather than simply postulating hindsight bias (as is common), we employ a variety of empirical means to demonstrate that the outcome-driven asymmetry across perceived probabilities constitutes a systematic cognitive distortion. We then explore three distinct strategies to alleviate the hindsight bias and its downstream effects on mens rea and culpability ascriptions. Not all strategies are successful, but some prove very promising. They should, we argue, be considered in criminal jurisprudence, where distortions due to the hindsight bias are likely considerable and deeply disconcerting.

Highlights

• In a series of ten studies (N = 2043) we examine the relation between moral luck, negligence and probability

• Most people deem outcome irrelevant for ascriptions of negligence & blame in WS studies, so there’s no “puzzle of moral luck”

• In between-subjects designs, the effect of luck on negligence and blame seems to be driven by the hindsight bias

• We examine three strategies to alleviate the hindsight bias on perceived probability, negligence and blame

• Two alleviation strategies significantly decrease the hindsight bias and could potentially be used in legal trials

Conclusion

In a series of experiments with 2043 participants, we explored the effect of outcome on judgments of subjective and objective probability, mens rea and culpability. For mens rea and blame attributions (though not for deserved punishment), the outcome effect constitutes a bias. The distorted assessment of mens rea and blame, we showed, is ultimately rooted in the hindsight bias: People tend to assess a potential harm as more likely when it does come to pass than when it does not; they therefore ascribe more negligence to the agent, and consequently consider him more culpable.

Echoing the literature from behavioral economics and legal psychology, we argued that the downstream effects of the hindsight bias constitute a serious threat to the just adjudication of legal trials, in particular in countries where mens rea is determined by lay juries (such as the US and the UK). And although it is well established that the hindsight bias is pervasive and difficult to overcome, we have shown that there are measures to reduce its impact. Among a series of different debiasing strategies we have put to the test, we showed that expert probability stabilizing (which, on occasion, is already in use in courts) and entertaining counterfactual outcomes hold considerable promise. We would strongly urge further research conducted jointly with legal practitioners that explores the most suitable ways of introducing (or further implementing) these techniques in the courtroom, so as to make the law more just and equal.

The research is here.

On the value of modesty: How signals of status undermine cooperation

Srna, S., Barasch, A., & Small, D. A. (2022). 

Journal of Personality and Social Psychology, 

123(4), 676–692.

https://doi.org/10.1037/pspa0000303

Abstract

The widespread demand for luxury is best understood by the social advantages of signaling status (i.e., conspicuous consumption; Veblen, 1899). In the present research, we examine the limits of this perspective by studying the implications of status signaling for cooperation. Cooperation is principally about caring for others, which is fundamentally at odds with the self-promotional nature of signaling status. Across behaviorally consequential Prisoner’s Dilemma (PD) games and naturalistic scenario studies, we investigate both sides of the relationship between signaling and cooperation: (a) how people respond to others who signal status, as well as (b) the strategic choices people make about whether to signal status. In each case, we find that people recognize the relative advantage of modesty (i.e., the inverse of signaling status) and behave strategically to enable cooperation. That is, people are less likely to cooperate with partners who signal status compared to those who are modest (Studies 1 and 2), and more likely to select a modest person when cooperation is desirable (Study 3). These behaviors are consistent with inferences that status signalers are less prosocial and less prone to cooperate. Importantly, people also refrain from signaling status themselves when it is strategically beneficial to appear cooperative (Studies 4–6). Together, our findings contribute to a better understanding of the conditions under which the reputational costs of conspicuous consumption outweigh its benefits, helping integrate theoretical perspectives on strategic interpersonal dynamics, cooperation, and status signaling.

From the General Discussion

Implications

The high demand for luxury goods is typically explained by the social advantages of status signaling (Veblen, 1899). We do not dispute that status signaling is beneficial in many contexts. Indeed, we find that status signaling helps a person gain acceptance into a group that is seeking competitive members (see Supplemental Study 1). However, our research suggests a more nuanced view regarding the social effects of status signaling. Specifically, the findings caution against using this strategy indiscriminately.  Individuals should consider how important it is for them to appear prosocial, and strategically choose modesty when the goal to achieve cooperation is more important than other social goals (e.g., to appear wealthy or successful).

These strategic concerns are particularly important in the era of social media, where people can easily broadcast their consumption choices to large audiences. Many people show off their status through posts on Instagram, Twitter, and Facebook (e.g., Sekhon et al., 2015). Such posts may be beneficial for communicating one’s wealth and status, but as we have shown, they can also have negative effects. A boastful post could wind up on social media accounts such as “Rich Kids of the Internet,” which highlights extreme acts of status signaling and has over 350,000 followers and countless angry comments (Hoffower, 2020). Celebrities and other public figures also risk their reputations when they post about their status. For instance, when Louise Linton, wife of the U.S. Secretary of the Treasury, posted a photo of herself from an official government visit with many luxury-branded hashtags, she was vilified on social

media and in the press (Calfas, 2017).

The research is here.

Moral Thin-Slicing

De Freitas, Julian and Hafri, Alon

(December 1, 2022).

Harvard Business School Marketing Unit

Harvard Business Working Paper No. 23-002

Abstract

Given limits on time and attention, people increasingly make moral evaluations in a few seconds or less, yet it is unknown whether such snap judgments are accurate or not. On one hand, the literature suggests that people form fast moral impressions once they already know what has transpired (i.e., who did what to whom, and whether there was harm involved), but how long does it take for them to extract and integrate these ‘moral atoms’ from a visual scene in the first place to decide who is morally wrong? Using controlled stimuli, we find that people are capable of ‘moral thin-slicing’: they reliably identify moral transgressions from visual scenes presented in the blink of an eye (< 100 ms). Across four studies, we show that this remarkable ability arises because observers independently and rapidly extract the atoms of moral judgment — event roles (who acted on whom) and harm level (harmful or unharmful). In sum, despite the rapid rate at which people view provocative moral transgressions online, as when consuming viral videos on social media or negative news about companies’ actions toward customers, their snap moral judgments about visual events can be surprisingly accurate.

From the General Discussion

How Is Moral Thin-Slicing So Fast?

Given that people are more accurate at snap moral judgments than one would think, how is this possible? The current work adds to the literature on how the mind computes moral judgments, by suggesting that such judgments do not have to be slow and effortful; rather, the human visual system in some cases rapidly extracts the high-level information on which moral judgment depends, such as role and harm. Furthermore, the visual system not only extracts such information, which previous literature in some cases has provided evidence for (Hafri et al., 2013; 2018; De Freitas & Alvarez, 2018), but it integrates these moral ‘atoms’ such that they inform moral judgments about events viewed at a brief glance. Notably, this integration was not a given, as there are many cases in other areas of psychology where disparate sources of visual or spatial information fail to be integrated towards a common behavioral goal (e.g., for grasping an object, or reorienting in an unfamiliar environment; Rossetti, 1998; Hermer-Vasquez et al., 1999).

Of course, despite the ability to make moral judgments quickly from a brief glance, this does not mean that people do not sometimes slowly deliberate over whether an event was causal, harmful, and so forth, which thought experiments like the trolley problem clearly illustrate (although such scenarios are overly contrived, and deliberately designed to stump readers; De Freitas, Anthony, Censi, & Alvarez, 2020; De Freitas et al., 2021). Yet the current results suggest that the visual system helps produce a rapid moral judgment when confronted with a range of typical social interactions, circumventing the need to deliberatively mull over this information.

As such, these findings stand in contrast to the characterization of moral judgment as reliant on purely rational inferences about inputs such as causation, harm, etc. without substantive contribution from sensory processing (Martinez & Jaeger, 2016; Olson, McFerran, Morales, & Dahl, 2016; Xie, Yu, Zhou, Sedikides, & Vohs, 2014). These characterizations suggest that visual processing is involved in moral judgment only in a rudimentary sense, e.g., to recognize colors or objects, and their spatial locations within an image.

The research is here.