Reframing Disease Contextually (Philosophy and Medicine)
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Cutter, Mary Ann. New York: Oxford University Press, Engelhardt, H. Tristram, Jr. Caplan, et al. Massachusetts: Addison-Wesley Publishing Company, Gruzolski and C. Nelson, Massachusetts: Ballinger, Nordenfelt and B. Lindahl, Netherlands: D. Reidel Publishing Company, The Foundations of Christian Bioethics.
Massachusetts: Scrivener Publishing, Engelhardt, Jr. Netherlands: Kluwer Academic Publishers, Tristram Engelhardt, Jr. Accessed December 7, Fleck, Ludwik. Genesis and Development of a Scientific Fact, edited by T. Editorial Preface. On the History of Medical Causality.
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Causality and Conditionality in medicine Around The Concept of the Art of Medicine. Intuition and Diagnosis: Commentary on Gross and Spicker. Technoscience and Medicine. Medicine: Explanation, Manipulation, and Creativity. While these studies do not tease out moral judgment from other cognitive and emotional processes, they illustrate the spectrum of methodologies that may prove useful. Articles on countertransference in clinical medicine are often insightful but famously lack systematic empirical data.
In one exception, Schwartz and colleagues showed trigger tapes of antisocial personality disorder and schizophrenia followed by use of a validated instrument that captures emotional and covert interpersonal responses [ 59 ]. Unsurprisingly, in this sample of 73 graduate level mental health professionals, the schizophrenic patient triggered warmth reactions and the antisocial patient triggered challenge and dread. In her qualitative study of a British hospital, Isabel Menzies Lyth observed, "The work situation arouses very strong and mixed feelings in the nurse: pity, compassion and love; guilt and anxiety; hatred and resentment of the patients who arouse these strong feelings; envy of the care given to the patient" [ 60 ].
Regan and colleagues studied unconscious defense mechanisms in nurses and found that immature defenses, including passive aggression, correlated with emotional exhaustion burnout , but they themselves had significant concerns about the instrument they used [ 61 ]. Smith and colleagues have developed a method of teaching personal awareness, specifically of previously unrecognized feelings and behaviors, by having expert medical educators question and probe trainees following observed clinical interactions.
Smith has been able to surface multiple fears, anxieties, and unhelpful behaviors, including unrecognized anger, disdain, and withdrawal [ 62 ]. The Implicit Attitude Test IAT , which has made its way from social psychology into healthcare settings, depends upon subjects' response time to distinguish positive from negative unconscious attitudes. Negative explicit attitudes regarding addiction, including moral blame, are well-documented among nurses and other healthcare professionals [ 63 , 64 ].
In studies of physicians and nurses treating hepatitis C in injection drug users, Brener and colleagues used a version of the IAT and found that greater contact with hepatitis C patients was associated with more positive explicit attitudes but less positive implicit unconscious attitudes [ 65 ]. Furthermore, implicit attitudes predicted intention to change jobs burnout independently from the effects of explicit attitudes and job satisfaction [ 66 ]. Multiple concerns have surfaced about the IAT and related priming techniques, however, suggesting that the relationship between explicit and implicit attitudes is not yet clear [ 67 — 69 ].
A vignette study using the IAT found that physicians had no explicit bias against black patients but did have implicit biases that predicted their decisions to use thrombolytic treatment in the scenario [ 70 ]. A study of actual cardiac patients found that surgical recommendations varied by race for Black men, but not Black women or Hispanics, and that the effects of race were mediated by physician perceptions of patients' education and activity levels [ 71 ].
The social and psychological dynamics producing racial disparities are as yet poorly understood [ 72 ]. Neuroscience studies have shown that automatic, unconscious attitudes are highly sensitive to new information and new contexts [ 73 ]. While the amygdala produces a rapid, stereotypical initial response to a stimulus, other brain regions including the prefrontal cortex can follow with iterative reprocessing at a rate of eight cycles per second, leading to more complex and nuanced responses [ 74 ].
People who are chronically committed to egalitarian goals can inhibit stereotype activation preconsciously, that is, without awareness or new effort [ 75 ]. Social and moral intuitions shaped by extensive experience and learning can operate without any conscious awareness [ 76 ]. Researchers no longer think of moral judgments as exclusively cognitive [ 77 ].
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Even those who minimize the emotional component acknowledge that emotions play a powerful role in motivating relevant action [ 78 ]. Using functional MRI, we can now visualize the neural substantiation of moral emotions.
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Guilt and compassion activate different distributed brain networks than do disgust and indignation [ 79 ]. The simple stimuli and vignette studies that are stock-in-trade for social psychologists and neuroscientists are appropriate for research on first impressions in healthcare, where encounters with strangers increasingly characterize the patient experience [ 80 ]. But negative appraisals may develop dynamically over the course of an encounter and may arise, change, or disappear as encounters become relationships, much as Goffman described for the discovery and management of stigma [ 81 ].
Fortunately, social psychologists themselves recognize the need for more naturalistic research strategies [ 82 , 83 ]. Subjects in an immersion virtual environment may respond as if the situation is real, as shown by a virtual replication of the Milgram obedience experiment [ 84 ]. Neuroscientists have begun to use videogames as stimuli for subjects in functional MRI scanners [ 85 ]. Within healthcare, Debra Roter and colleagues have called for more creative simulations to investigate emotion and non-verbal behavior, not only by using standardized patients but also by having patients or clinicians respond to vignettes and videotaped interactions [ 86 ].
Studies of clinician personalities, habits, and skills have offered only modest insights into variations in moral judgment. One study of medical student Machiavellianism--itself predicted by male gender, authoritarianism, intolerance of ambiguity, and external locus of control--found that Machiavellian students had more negative attitudes toward geriatric and hypochondriac patients [ 87 ].
Benjamin Chapman and colleagues studied community primary care physicians in Rochester, Minnesota, using personality tests and audiotaped standardized patient visits, and found that personality characteristics shaped their interviews of depressed patients [ 88 ]. The authors note that "patients who are belligerent, distressed, passively noncompliant, medically complex, or particularly knowledgeable, congenial, and appreciative" might thereby influence communication, but their study did not examine that influence. Emotional intelligence measures appear to be emerging from an infancy troubled by methodological concerns and popular hype [ 89 ], but their application in healthcare [ 90 — 92 ] has yet to focus on difficult patient relationships.
One pilot study of psychiatric patients and staff suggested that attachment theory may predict the success of therapeutic relationships: lower attachment anxiety and avoidance scores of staff members correlated with better relationships as rated by patients [ 93 ]. Medical students with secure attachment styles are more likely to seek relationship-focused primary care residencies [ 94 ]. Gender is often a factor in clinical relationships, as illustrated by Hall's reciprocal likability study cited above in which female physicians said they liked their patients more than male physicians did.
Patients agreed that female physicians liked them better and also said that they liked female physicians more than they liked male physicians [ 13 ]. We do not know, however, how gender may figure in clinicians' moral judgments of patients. Sonia Crandall found that female medical students had more favorable attitudes toward poor patients than male medical students [ 95 ], although later studies have not replicated this finding [ 44 , 96 ]. Women, including female physicians, generally score higher than men in empathy, but we still lack evidence that such differences are of consequence in clinical interactions [ 97 ].
In a laboratory study using emotional videos as triggers, women had greater responses than men in empathy, monetary generosity, and oxytocin levels [ 98 ].
Reframing Disease Contextually
In addition to its roles in birth, lactation, and mother-infant bonding, oxytocin has complex effects upon the brain and social behavior in females and males [ 99 ], but its roles in moral emotions are far from clear [ , ]. A single intranasal dose of oxytocin in male students increased their trust and social risk-taking in interactive dyads [ ]. Carole Gilligan's hypothesis that women and men employ different modes of moral reasoning care versus justice has failed to garner strong support [ ].
Indeed, Kohlberg's theory of developmental moral stages, on which Gilligan's work depended, has itself been significantly modified [ ] or abandoned [ 77 ]. Nevertheless, studies continue to appear with evidence of gender differences in emotionally-charged moral appraisals [ ].
Using functional neuroimaging, Carla Harenski found that even when women and men make similar moral judgments, they may do so via different dynamics, activating different brain circuitry [ ]. Diverse studies cited here demonstrate the folly of expecting unifactorial attributes of either patient or clinician to dominate moral judgments. Once the clinician is engaged in dyad and context, a complex system is in play. In the course of this review I asked colleagues how they managed their own moral judgments of patients.
Two simple examples illustrate these dynamic, often conflicted appraisals. An experienced midwife working in public sector explained that she felt little moral judgment while caring for wayward pregnant women and girls. But upon learning that a patient had a prison background, "I had to ask why. It was alright with me if he lied about it, but I had to ask. In response to continual invasive questioning, patients routinely withhold, distort, and otherwise injure the truth, either consciously or not, and yet within the clinical relationship and its contextual frame, such violations usually do not merit moral notice and do not trigger moral appraisals.
Organizational factors may weigh more than individual skills and attitudes in the salience of moral judgments, as suggested in Bowers' study of facilities for criminal patients with personality disorders [ 20 ]. In the University of Colorado teaching program described above, frustration with the poor and behaviorally difficult patients occasionally escalated into hostility from students and teaching staff [ 42 ]. The researchers noted that such hostility was "almost always temporary," however. The importance of setting was obvious in my informal survey of colleagues.
After all, a cooperative and appreciative patient with Nazi tattoos is still a cooperative, appreciative patient. For those in middle-class or well-to-do clinical settings, on the other hand, the issue of morally reprehensible patients rarely arises. I did not find evidence in the literature to support Jodi Halpern's assertion that, once physicians have invested in caring for patients, they then "invest a great deal in idealizing" them so as to avoid their own negative emotional reactions [ ].
Halpern may be right nevertheless. Clinicians with middle-class practices generally do not ponder what percentage of those men and women have molested children, whereas moral issues are quite salient where convicted criminals come labeled as such. Idealizing distorts clinicians' perceptions and thus limits biopsychosocial comprehension, but it may help motivate clinicians to provide good care. In some cases, it may also protect patients from clinicians who would be unprepared for their own reactions to a more complete picture.
The landscape between prison and polite suburbia, based on the literature reviewed above and confirmed by my own interviews, is one of great variation. I certainly heard people assert that moral appraisals were off-limits and best avoided. We know little about when such judgments occur, what impact they have, which corticolimbic "gears" get "switched," how, and why.
Progress in understanding professional development and skills often emerges from close studies of experts [ ]. Recent empirical studies have focused on clinicians chosen for expertise in de-escalating aggressive psychiatric patients [ ], in role-modeling humanistic bedside behavior [ ], and in discussing advance directives [ ]. Expertise may be largely tacit [ ] and embodied in habits that operate automatically without conscious intention [ ]. Such expertise may be more or less reliable [ , ]. William Branch and colleagues, noting that well-intentioned traditional ways of teaching respect to students generally fail, have begun gathering empirical data on expert approaches to modeling and teaching humanistic behavior [ , , ].
They have not, however, addressed issues of moral judgment, nor have they focused on challenging safety-net and other stigmatized settings. Even without knowing exactly what should happen, understanding what actually happens in such settings would be invaluable. Safety-net settings concentrate extreme outgroups, e. Who decides to work in such settings, who performs well there, and who survives over the long haul?