Implicit Cognition and Gifts: How Does social Psychology help Us Think Differently about Medical Practice?

Abstract

This article takes the following two assumptions for granted: first, that gifts influence physicians and, second, that the influences gifts have on physicians may be harmful for patients. These assumptions are common in the applied ethics literature, and they prompt an obvious practical question, namely, what is the best way to mitigate the negative effects? We examine the negative effects of gift giving in depth, considering how the influence occurs, and we assert that the ethical debate surrounding gift-giving practices must be reoriented. Our main claim is that the failure of recent policies addressing gift giving can be traced to a misunderstanding of what psychological mechanisms are most likely to underpin physicians' biased behavior as a result of interaction with the medical industry. The problem with gift giving is largely not a matter of malicious or consciously self-interested behavior, but of well-intentioned actions on the part of physicians that are nonetheless perniciously infected by the presence of the medical industry. Substantiating this claim will involve elaboration on two points. First, we will retrace the history of policies regarding gift giving between the medical profession and the medical industry and highlight how most policies assume a rationalistic view of moral agency. Reliance on this view of agency is best illustrated by past attempts to address gift giving in terms of conflicts of interest. Second, we will introduce and motivate an alternate view of moral agency emerging from recent literature in social psychology on implicit social cognition. We will show that proper consideration of implicit social cognition paints a picture of human psychology at odds with the rationalistic model assumed in discussions of COIs. With these two pieces on the table we will be able to show that, without fully appreciating the social-psychological mechanisms (both cognitive and affective) of implicit cognition, policy-makers are likely to overlook significant aspects of how gifts influence doctors.

Association Between Open Payments–Reported Industry Transfers of Value and Prostaglandin Analog Prescribing in the US

“…The susceptibility of health care professionals to these influences can then be heightened by motivated reasoning and illusory superiority-the impulse to believe that physicians are as impartial as they would like to be and that society expects them to be. 45 This was shown in one study of 467 resident physicians wherein 61% believed they were unbiased by interactions with pharmaceutical companies but believed that the same was true for only 16% of their peers. 47 These forces work at an unconscious level, demonstrated in a study that found physicians' prescribing behavior changed in the months following industry-sponsored grand rounds, despite no longer remembering the sponsor, 48 and another that found that prescribing behaviors changed after physicians attended an industry-sponsored continuing medical education event, despite being queried beforehand whether they believed the event would change their behavior.…”

“…These are the exposure effect, which creates a preference for something seen before; the frequency effect, which creates greater willingness to accept an idea (like 1 drug is superior to another) if repeatedly exposed to the idea; and implicit social pressure toward reciprocity. 45,46 Reciprocity can certainly encompass the sense of collegiality that may emerge after repeated interactions and meals with sales representatives but can also be triggered by gifts and gestures between relative strangers. The susceptibility of health care professionals to these influences can then be heightened by motivated reasoning and illusory superiority-the impulse to believe that physicians are as impartial as they would like to be and that society expects them to be.…”

“…49 For these reasons, it has been suggested that the term conflicts of interest itself unhelpfully places undue emphasis on volitional decision-making and financial incentives. Instead, these processes could be considered part of human implicit social cognition, 45 which cannot be curbed by mere awareness or force of will. 45,50 So, while ophthalmologists and optometrists may feel that a meal or other small TOV may not influence their behavior, our data suggest that it might.…”

“…Instead, these processes could be considered part of human implicit social cognition, 45 which cannot be curbed by mere awareness or force of will. 45,50 So, while ophthalmologists and optometrists may feel that a meal or other small TOV may not influence their behavior, our data suggest that it might.…”

“…Work in social psychology provides some magnitude-independent explanations. These are the exposure effect, which creates a preference for something seen before; the frequency effect, which creates greater willingness to accept an idea (like 1 drug is superior to another) if repeatedly exposed to the idea; and implicit social pressure toward reciprocity . Reciprocity can certainly encompass the sense of collegiality that may emerge after repeated interactions and meals with sales representatives but can also be triggered by gifts and gestures between relative strangers.…”