Article Figures & Data
Tables
Cognitive or Affective Bias/Heuristic Clinical Example Availability heuristic: being influenced by what is most readily available in memory—recent, rare, and vivid events hold exceptional sway A parent refuses to vaccinate her child after she sees an isolated media report of a child who developed autism after being vaccinated Feeling vulnerable effect: being influenced by affective risk perceptions instead of cognitive ones A smoker correctly estimates her probability of developing lung cancer to be high but reports that she nevertheless does not believe she is susceptible, and hence does not quit smoking Focusing effect/side-effect aversion: being influenced sub-stantially more by short-term concerns and interests than by long-term goals A patient chooses to forgo recommended colorectal screening because of its inconveniences despite wishing to live as long as possible Gambler’s fallacy: being influenced by unrelated past Occurrences A patient thinks that because she has developed so many incident health problems in the past year, she is unlikely to also develop breast cancer because she is “due for a break.” She thus skips her mammography Impact bias/affective forecasting error: being influenced by inaccurate projections of future states A patient delays getting a colostomy because he predicts that he will be extremely unhappy, even though studies show that those who have under- gone the procedure rate their quality of life as being the same as before, and report wishing they had done it sooner2 Omission bias: preferring inaction to avoid harm even though it may cause a similar or greater harm than the action A patient with atrial fibrillation refuses to take warfarin because she is concerned about causing a hemorrhagic stroke, despite the greater risk of ischemic stroke if she does not take the warfarin Escalation/cascade effect: preferring the path already taken in favor of other paths that might clearly produce better results but require a change of habit or routine Patients continue to make choices that produce negative health effects (eg, not exercising, smoking) because they have been doing it for so long already Sunk cost bias: continuing with a plan of action, even when it is clear that there is no payoff, just because resources have already been invested into that plan A patient with osteoarthritis continues taking a drug just because she already purchased a large supply even though after many months of taking it she notices no difference in her knee pain Persuasive Techniques Examples of Beneficent Persuasion COPD = chronic obstructive pulmonary disease; CT = computed tomography; HIV = human immunodeficiency virus; ICU = intensive care unit. Vivid depictions6 When discussing risks of continuing to smoke with patients, show them ventilated COPD patients in a medical ICU or a video of a patient with advanced lung cancer To offset parents’ concerns about the risks of vaccination, deploy your clinic’s waiting room television to show videos of children who have suffered from not being vaccinated Defaults7 Make it policy to schedule evidence-based screenings (eg, colorectal, mammography, HIV testing) for your patients automatically, framing these as the default option similarly to how you might frame cholesterol screening Regret8 Encourage your patients to think about the regret they may feel if they do not follow recommendations regarding cancer screening and an early cancer diagnosis is subsequently missed Encourage your patients to anticipate the regret they may feel (toward themselves, toward their children) if they continue to smoke and then develop lung cancer Framing9–13 When discussing mammography with patients for whom it is indicated, frame the associated risk reduction in mortality from breast cancer in terms of relative rather than absolute risks When counseling healthy patients with no risk factors who want a full-bodyCT scan “just to be sure,” explain risk reduction of CT scan in absolute terms rather than relative terms, or focus their attention on the risks of the CT scan, including the risks of receiving false-positive results List benefits first, side-effects next, and then repeat benefits again Frame results of self-neglect in terms of losses instead of discussing the gains of self-care. Refocusing14,15 Encourage newly disabled patients to think about how well they adapted to new challenges in the past and all the capacities for future happiness that they have retained despite their injury.
Additional Files
The Article in Brief
Beneficent Persuasion: Techniques and Ethical Guidelines to Improve Patients� Decisions
J.S. Swindell , and colleagues
Background Patients often make choices that work against their long-term goals (such as smoking) or that run counter to evidence and the clinician�s best judgment. Using concepts from behavioral economics, this essay argues that it is often ethical for physicians to rebias patients in ways that promote their health or other long-term goals.
