Jennifer (Swindell) Blumenthal-Barby
I am the Cullen Professor of Medical Ethics (philosophy/bioethics) and Associate Director for Medical Ethics in the Center for Medical Ethics and Health Policy at Baylor College of Medicine. I also have an adjunct appointment in philosophy at Rice University. I received my Ph.D. in philosophy, with a specialization in bioethics, from Michigan State University in May 2008. My dissertation was on ambivalence and its impact on autonomy and agency.My research focuses primarily on the philosophical and ethical questions raised by research on human judgment and decision-making. For example, what are we to make of autonomy and rationality given the many frailties in judgment and decision-making (e.g., cognitive biases and heuristics, weakness of will, ambivalence and indecision)? Is it morally permissible to use knowledge of these biases and weaknesses (in other words, principles from behavioral economics and decision psychology) to influence people’s decisions and behaviors? Under what conditions/circumstances? Is this manipulation? If so, what is the moral status of manipulation–might it sometimes be permissible or even morally desirable?My more applied work focuses on developing both practical and moral guidelines for the use of principles from behavioral economics and decisional psychology (e.g., framing effects, default options, incentives, focusing effects, commitment contracts and subconscious priming) to shape people’s medical decisions and behaviors.Two other secondary ares of research are ethical and philosophical issues in psychiatry/neurology ("neuroethics") and the intersection of bioethics and continental philosophy (esp. existentialism).I was a member of the American Philosophical Association Committee on Philosophy of Medicine (2014-2017), co-founder of the American Society for Bioethics and Humanities Medical Decision Making Affinity Group (2013), and a Greenwall Faculty Scholar in Bioethics (2011-2014). I am currently on the Board of Directors for ASBH, Editorial Committee at The American Journal of Bioethics, and Associate Editor at the Journal of Medical Ethics. I NO LONGER KEEP THIS SITE UPDATED. For up to date information please see my CV and my webpage: http://jenniferblumenthalbarby.wordpress.com
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Supervisors: Tom Tomlinson
Address: http://jenniferblumenthalbarby.wordpress.com
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virtue ethicists as having an “empirically inadequate” theory, arguing that much
of social science research suggests that people do not have robust character traits
(e.g., virtues or vices) as traditionally thought. By far, the most common response to
this challenge has been what I refer to as “the rarity response” or the “rarity thesis”.
Rarity responders (such as Ernest Sosa and Gopal Sreenivasan) deny that
situationism poses any sort of threat to virtue ethics since there is no reason to
suppose that the moral virtues are typical or widespread. But, far from being its
saving grace, I will argue, the rarity thesis forces virtue ethicists into positions that
are incompatible with their theoretical foundations or render their theory normatively
irrelevant. The more the virtue ethicists modify their thesis to fit the empirical
evidence and to be normatively relevant, the less they retain a virtue ethical theory.
This is also the case for virtue epistemologists.
after our own individual deaths) plays an essential role in us valuing much of what we
do. If a collective afterlife did not exist, our value structures would be radically different
according to Scheffler. We would cease to value much of what we do. In Part I of the
paper, I argue that there is something to Scheffler’s afterlife conjecture, but that
Scheffler has misplaced the mattering of a collective afterlife. Its significance lies not
in the realm of axiology but more importantly in coming to terms with the fact of death
and in viewing our lives as having meaning. In Part II of the paper, I outline three views
on the sort of collective afterlife that matters and argue in favor of the view that it must
involve creatures that recognize our existence, reasons, values, and contributions (The
Recognition Thesis) and the view that it must involve creatures that value similar
things to us (The Valuers Like Us Thesis)—but argue against the view that it
necessarily be a human collective afterlife (The Human Form Thesis).
naturally gather evidence about the risks and benefits of
each medical choice, apply their values to that evidence, and
reach a considered decision.” In other words, that patients
will generally make “autonomous” decisions, meaning decisions
that are 1) intentional rather than habitual, impulsive,
accidental, or forced; 2) involve substantial understanding of
the nature of the decision, the foreseeable consequences,
and possible outcomes; and 3) are not subject to controlling
influences.
Although this assumption has been challenged in other
areas of medical decision-making, herein we want to challenge
it within the context of treatment decision-making
regarding localized, low-risk prostate cancer.
medical decision making is of growing interest. The purpose
of this study was to determine whether studies on
cognitive biases and heuristics in medical decision making
are based on actual or hypothetical decisions and
are conducted with populations that are representative
of those who typically make the medical decision; to categorize
the types of cognitive biases and heuristics found
and whether they are found in patients or in medical personnel;
and to critically review the studies based on standard
methodological quality criteria. Method. Data
sources were original, peer-reviewed, empirical studies
on cognitive biases and heuristics in medical decision
making found in Ovid Medline, PsycINFO, and the CINAHL
databases published in 1980–2013. Predefined
exclusion criteria were used to identify 213 studies. During
data extraction, information was collected on type of bias
or heuristic studied, respondent population, decision
type, study type (actual or hypothetical), study method,
and study conclusion. Results. Of the 213 studies analyzed,
164 (77%) were based on hypothetical vignettes,
and 175 (82%) were conducted with representative populations.
Nineteen types of cognitive biases and heuristics
were found. Only 34% of studies (n = 73) investigated
medical personnel, and 68% (n = 145) confirmed the presence
of a bias or heuristic. Each methodological quality
criterion was satisfied by more than 50% of the studies,
except for sample size and validated instruments/questions.
Limitations are that existing terms were used to
inform search terms, and study inclusion criteria focused
strictly on decision making. Conclusions. Most of the studies
on biases and heuristics in medical decision making
are based on hypothetical vignettes, raising concerns
about applicability of these findings to actual decision
making. Biases and heuristics have been underinvestigated
in medical personnel compared with patients
Keywords: manipulation, influence, choice architecture, autonomy, libertarian paternalism, nudging, ethics
of mental disorders (DSM-5) in May 2013 is being
hailed as the biggest event in psychiatry in the last
10 years. In this paper I examine three important issues
that arise from the new manual:
(1) Expanding nosology: Psychiatry has again broadened
its nosology to include human experiences not previously
under its purview (eg, binge eating disorder, internet
gaming disorder, caffeine use disorder, hoarding
disorder, premenstrual dysphoric disorder). Consequencebased
ethical concerns about this expansion are
addressed, along with conceptual concerns about a
confusion of “construct validity” and “conceptual
validity” and a failure to distinguish between “disorder”
and “non disordered conditions for which we help
people.”
(2) The role of claims about societal impact in changes
in nosology: Several changes in the DSM-5 involved
claims about societal impact in their rationales. This is
due in part to a new online open comment period
during DSM development. Examples include
advancement of science, greater access to treatment,
greater public awareness of condition, loss of identify or
harm to those with removed disorders, stigmatization,
offensiveness, etc. I identify and evaluate four
importantly distinct ways in which claims about societal
impact might operate in DSM development.
(3) Categorisation nosology to spectrum nosology: The
move to “degrees of severity” of mental disorders,
a major change for DSM-5, raises concerns about
conceptual clarity and uniformity concerning what it
means to have a severe form of a disorder, and ethical
concerns about communication.
In this paper I argue for conceptual clarity with respect to the label “low-value care.” Thus far it has not been precisely defined, and I argue that there are actually 10 distinct categories of low-value care. I discuss the ethical challenges and considerations associated with each category. I also
provide arguments that can be used to justify the reduction of some of these categories of low-value care. These arguments rely on Rawlsian and Hegelian notions of justice, as well as on concepts about the fiduciary obligations of physicians. Finally, I outline the various mechanisms that could be utilized for the reduction of low-value care (i.e., incentives, punishments, nonrational influences such as appeals to social norms, emotions, or ego, and creation of conditions that make
avoidance easy such as defaults and reminders). I provide normative guidelines for the use of each.
treatment options for prostate cancer, are designed to help educate patients so that they can share in decisions about their care. Developers of these decision aids strive for balance, aiming to be as neutral, unbiased, and nondirective as possible. We argue that balance should not always be a goal, and we identify three situations where it should not be.
For example, men diagnosed with early-stage prostate cancer frequently are not advised by their physicians that active surveillance is a reasonable alternative to immediate surgery or radiation. It may be desirable to design decision aids that promote active surveillance as an option. We recognize that the arguments put forth in this article are controversial.
But they are also justified. We challenge medical decision makers and decision aid developers to determine if and when patients should be “nudged” toward one option or another.
economics and psychology to persuade people to change their health-related behaviors, lifestyles, and habits. In this article, we examine how principles from behavioral
economics and psychology are being used to nudge people (the public, patients, or health care providers) toward particular decisions or behaviors related to health or
health care, and we identify the ethically relevant dimensions that should be considered for the utilization of each principle.
their long-term goals. Behavioral economists have shown that irrationalities and
self-thwarting tendencies pervade human decision making, and they have identifi
ed a number of specifi c heuristics (rules of thumb) and biases that help explain
why patients sometimes make such counterproductive decisions. In this essay,
we use clinical examples to describe the many ways in which these heuristics and
biases infl uence patients’ decisions. We argue that physicians should develop
their understanding of these potentially counterproductive decisional biases and,
in many cases, use this knowledge to rebias their patients in ways that promote
patients’ health or other values. Using knowledge of decision-making psychology
to persuade patients to engage in healthy behaviors or to make treatment decisions
that foster their long-term goals is ethically justifi ed by physicians’ duties to
promote their patients’ interests and will often enhance, rather than limit, their
patients’ autonomy. We describe techniques that physicians may use to frame
health decisions to patients in ways that are more likely to motivate patients to
make choices that are less biased and more conducive to their long-term goals.
Marketers have been using these methods for decades to get patients to engage
in unhealthy behaviors; employers and policy makers are beginning to consider
the use of similar approaches to infl uence healthy choices. It is time for clinicians
also to make use of behavioral psychology in their interactions with patients.
ethics—analysis and argument—
to provide a reasoned account
of and to identify ethically
justified responses by the psychiatrist
to psychiatric inpatients’ refusal
of medical or surgical diagnostic
work-up. There are three
relevant ethical considerations
when psychiatric inpatients refuse
medical or surgical diagnostic
tests: balancing autonomy with
beneficence, surrogate decision
making and confidentiality, and
managing strong feelings. Assisted
decision making and assent are key
management strategies for promoting
patients’ autonomy and for
protecting against adverse consequences
of decision making.
virtue ethicists as having an “empirically inadequate” theory, arguing that much
of social science research suggests that people do not have robust character traits
(e.g., virtues or vices) as traditionally thought. By far, the most common response to
this challenge has been what I refer to as “the rarity response” or the “rarity thesis”.
Rarity responders (such as Ernest Sosa and Gopal Sreenivasan) deny that
situationism poses any sort of threat to virtue ethics since there is no reason to
suppose that the moral virtues are typical or widespread. But, far from being its
saving grace, I will argue, the rarity thesis forces virtue ethicists into positions that
are incompatible with their theoretical foundations or render their theory normatively
irrelevant. The more the virtue ethicists modify their thesis to fit the empirical
evidence and to be normatively relevant, the less they retain a virtue ethical theory.
This is also the case for virtue epistemologists.
after our own individual deaths) plays an essential role in us valuing much of what we
do. If a collective afterlife did not exist, our value structures would be radically different
according to Scheffler. We would cease to value much of what we do. In Part I of the
paper, I argue that there is something to Scheffler’s afterlife conjecture, but that
Scheffler has misplaced the mattering of a collective afterlife. Its significance lies not
in the realm of axiology but more importantly in coming to terms with the fact of death
and in viewing our lives as having meaning. In Part II of the paper, I outline three views
on the sort of collective afterlife that matters and argue in favor of the view that it must
involve creatures that recognize our existence, reasons, values, and contributions (The
Recognition Thesis) and the view that it must involve creatures that value similar
things to us (The Valuers Like Us Thesis)—but argue against the view that it
necessarily be a human collective afterlife (The Human Form Thesis).
naturally gather evidence about the risks and benefits of
each medical choice, apply their values to that evidence, and
reach a considered decision.” In other words, that patients
will generally make “autonomous” decisions, meaning decisions
that are 1) intentional rather than habitual, impulsive,
accidental, or forced; 2) involve substantial understanding of
the nature of the decision, the foreseeable consequences,
and possible outcomes; and 3) are not subject to controlling
influences.
Although this assumption has been challenged in other
areas of medical decision-making, herein we want to challenge
it within the context of treatment decision-making
regarding localized, low-risk prostate cancer.
medical decision making is of growing interest. The purpose
of this study was to determine whether studies on
cognitive biases and heuristics in medical decision making
are based on actual or hypothetical decisions and
are conducted with populations that are representative
of those who typically make the medical decision; to categorize
the types of cognitive biases and heuristics found
and whether they are found in patients or in medical personnel;
and to critically review the studies based on standard
methodological quality criteria. Method. Data
sources were original, peer-reviewed, empirical studies
on cognitive biases and heuristics in medical decision
making found in Ovid Medline, PsycINFO, and the CINAHL
databases published in 1980–2013. Predefined
exclusion criteria were used to identify 213 studies. During
data extraction, information was collected on type of bias
or heuristic studied, respondent population, decision
type, study type (actual or hypothetical), study method,
and study conclusion. Results. Of the 213 studies analyzed,
164 (77%) were based on hypothetical vignettes,
and 175 (82%) were conducted with representative populations.
Nineteen types of cognitive biases and heuristics
were found. Only 34% of studies (n = 73) investigated
medical personnel, and 68% (n = 145) confirmed the presence
of a bias or heuristic. Each methodological quality
criterion was satisfied by more than 50% of the studies,
except for sample size and validated instruments/questions.
Limitations are that existing terms were used to
inform search terms, and study inclusion criteria focused
strictly on decision making. Conclusions. Most of the studies
on biases and heuristics in medical decision making
are based on hypothetical vignettes, raising concerns
about applicability of these findings to actual decision
making. Biases and heuristics have been underinvestigated
in medical personnel compared with patients
Keywords: manipulation, influence, choice architecture, autonomy, libertarian paternalism, nudging, ethics
of mental disorders (DSM-5) in May 2013 is being
hailed as the biggest event in psychiatry in the last
10 years. In this paper I examine three important issues
that arise from the new manual:
(1) Expanding nosology: Psychiatry has again broadened
its nosology to include human experiences not previously
under its purview (eg, binge eating disorder, internet
gaming disorder, caffeine use disorder, hoarding
disorder, premenstrual dysphoric disorder). Consequencebased
ethical concerns about this expansion are
addressed, along with conceptual concerns about a
confusion of “construct validity” and “conceptual
validity” and a failure to distinguish between “disorder”
and “non disordered conditions for which we help
people.”
(2) The role of claims about societal impact in changes
in nosology: Several changes in the DSM-5 involved
claims about societal impact in their rationales. This is
due in part to a new online open comment period
during DSM development. Examples include
advancement of science, greater access to treatment,
greater public awareness of condition, loss of identify or
harm to those with removed disorders, stigmatization,
offensiveness, etc. I identify and evaluate four
importantly distinct ways in which claims about societal
impact might operate in DSM development.
(3) Categorisation nosology to spectrum nosology: The
move to “degrees of severity” of mental disorders,
a major change for DSM-5, raises concerns about
conceptual clarity and uniformity concerning what it
means to have a severe form of a disorder, and ethical
concerns about communication.
In this paper I argue for conceptual clarity with respect to the label “low-value care.” Thus far it has not been precisely defined, and I argue that there are actually 10 distinct categories of low-value care. I discuss the ethical challenges and considerations associated with each category. I also
provide arguments that can be used to justify the reduction of some of these categories of low-value care. These arguments rely on Rawlsian and Hegelian notions of justice, as well as on concepts about the fiduciary obligations of physicians. Finally, I outline the various mechanisms that could be utilized for the reduction of low-value care (i.e., incentives, punishments, nonrational influences such as appeals to social norms, emotions, or ego, and creation of conditions that make
avoidance easy such as defaults and reminders). I provide normative guidelines for the use of each.
treatment options for prostate cancer, are designed to help educate patients so that they can share in decisions about their care. Developers of these decision aids strive for balance, aiming to be as neutral, unbiased, and nondirective as possible. We argue that balance should not always be a goal, and we identify three situations where it should not be.
For example, men diagnosed with early-stage prostate cancer frequently are not advised by their physicians that active surveillance is a reasonable alternative to immediate surgery or radiation. It may be desirable to design decision aids that promote active surveillance as an option. We recognize that the arguments put forth in this article are controversial.
But they are also justified. We challenge medical decision makers and decision aid developers to determine if and when patients should be “nudged” toward one option or another.
economics and psychology to persuade people to change their health-related behaviors, lifestyles, and habits. In this article, we examine how principles from behavioral
economics and psychology are being used to nudge people (the public, patients, or health care providers) toward particular decisions or behaviors related to health or
health care, and we identify the ethically relevant dimensions that should be considered for the utilization of each principle.
their long-term goals. Behavioral economists have shown that irrationalities and
self-thwarting tendencies pervade human decision making, and they have identifi
ed a number of specifi c heuristics (rules of thumb) and biases that help explain
why patients sometimes make such counterproductive decisions. In this essay,
we use clinical examples to describe the many ways in which these heuristics and
biases infl uence patients’ decisions. We argue that physicians should develop
their understanding of these potentially counterproductive decisional biases and,
in many cases, use this knowledge to rebias their patients in ways that promote
patients’ health or other values. Using knowledge of decision-making psychology
to persuade patients to engage in healthy behaviors or to make treatment decisions
that foster their long-term goals is ethically justifi ed by physicians’ duties to
promote their patients’ interests and will often enhance, rather than limit, their
patients’ autonomy. We describe techniques that physicians may use to frame
health decisions to patients in ways that are more likely to motivate patients to
make choices that are less biased and more conducive to their long-term goals.
Marketers have been using these methods for decades to get patients to engage
in unhealthy behaviors; employers and policy makers are beginning to consider
the use of similar approaches to infl uence healthy choices. It is time for clinicians
also to make use of behavioral psychology in their interactions with patients.
ethics—analysis and argument—
to provide a reasoned account
of and to identify ethically
justified responses by the psychiatrist
to psychiatric inpatients’ refusal
of medical or surgical diagnostic
work-up. There are three
relevant ethical considerations
when psychiatric inpatients refuse
medical or surgical diagnostic
tests: balancing autonomy with
beneficence, surrogate decision
making and confidentiality, and
managing strong feelings. Assisted
decision making and assent are key
management strategies for promoting
patients’ autonomy and for
protecting against adverse consequences
of decision making.