Dual-process theory is Barbapapa.

The biggest benefit of dual-process theory lies in its role as a benchmark theory that, regardless of its empirical plausibility, serves as a starting point for better and more domain-specific models. In this sense, dual-process theory is the Barbapapa of psychological theory - a blob-shaped creature that can be reshaped and adapted to fit in the context of any human behavior.

Withdrawing or withholding treatments in health care rationing: an interview study on ethical views and implications.

BACKGROUND: When rationing health care, a commonly held view among ethicists is that there is no ethical difference between withdrawing or withholding medical treatments. In reality, this view does not generally seem to be supported by practicians nor in legislation practices, by for example adding a 'grandfather clause' when rejecting a new treatment for lacking cost-effectiveness. Due to this discrepancy, our objective was to explore physicians' and patient organization representatives' experiences- and perceptions of withdrawing and withholding treatments in rationing situations of relative scarcity. METHODS: Fourteen semi-structured interviews were conducted in Sweden with physicians and patient organization representatives, thematic analysis was used. RESULTS: Participants commonly express internally inconsistent views regarding if withdrawing or withholding medical treatments should be deemed as ethically equivalent. Participants express that in terms of patients' need for treatment (e.g., the treatment's effectiveness and the patient's medical condition) withholding and withdrawing should be deemed ethically equivalent. However, in terms of prognostic differences, and the patient-physician relation and communication, there is a clear discrepancy which carry a moral significance and ultimately makes withdrawing psychologically difficult for both physicians and patients, and politically difficult for policy makers. CONCLUSIONS: We conclude that the distinction between withdrawing and withholding treatment as unified concepts is a simplification of a more complex situation, where different factors related differently to these two concepts. Following this, possible policy solutions are discussed for how to resolve this experienced moral difference by practitioners and ease withdrawing treatments due to health care rationing. Such solutions could be to have agreements between the physician and patient about potential future treatment withdrawals, to evaluate the treatment's effect, and to provide guidelines on a national level.

Variation in the µ-Opioid Receptor Gene (OPRM1) Does Not Moderate Social-Rejection Sensitivity in Humans.

Given previous findings from animal studies and small-scale studies in humans, variation in the µ-opioid receptor gene (OPRM1) has been proposed as a strong biological candidate for moderating sensitivity to social rejection. Using a substantially larger sample (N = 490) than previous studies, a prospective genotyping strategy, and preregistered analysis plans, we tested the hypotheses that OPRM1 variation measured by the functional A118G polymorphism (rs1799971) moderates (a) dispositional sensitivity to rejection and feelings of distress following social exclusion and (b) decision making involving social cognition. In three experimental tasks commonly used to assess altruism, reciprocity, and trust in humans, we found no evidence in favor of the hypotheses; nine main tests were preregistered, and all of them yielded small and statistically insignificant estimates. In secondary analyses, we used Bayesian inference and estimation to quantify support for our findings. Taken together, our results strongly suggest that the link between OPRM1 A118G variation and social-rejection sensitivity is weaker than previously thought.

Risk preferences and attitudes to surgery in decision making.

Background and purpose - There is increasing evidence that several commonly performed surgical procedures provide little advantage over nonoperative treatment, suggesting that doctors may sometimes be inappropriately optimistic about surgical benefit when suggesting treatment for individual patients. We investigated whether attitudes to risk influenced the choice of operative treatment and nonoperative treatment. Methods - 946 Swedish orthopedic surgeons were invited to participate in an online survey. A radiograph of a 4-fragment proximal humeral fracture was presented together with 5 different patient characteristics, and the surgeons could choose between 3 different operative treatments and 1 nonoperative treatment. This was followed by an economic risk-preference test, and then by an instrument designed to measure 6 attitudes to surgery that are thought to be hazardous. We then investigated if choice of non-operative treatment was associated with risk aversion, and thereafter with the other variables, by regression analysis. Results - 388 surgeons responded. Nonoperative treatment for all cases was suggested by 64 of them. There was no significant association between risk aversion and tendency to avoid surgery. However, there was a statistically significant association between suggesting to operate at least 1 of the cases and a "macho" attitude to surgery or resignation regarding the chances of influencing the outcome of surgery. Choosing nonoperative treatment for all cases was associated with long experience as a surgeon. Interpretation - The discrepancy between available evidence for surgery and clinical practice does not appear to be related to risk preference, but relates to hazardous attitudes. It appears that choosing nonoperative treatment requires experience and a feeling that one can make a difference (i.e. a low score for resignation). There is a need for better awareness of available evidence for surgical indications.

Horizontal inequality in rationing by waiting lists.

The objective of this article was to investigate the existence of horizontal inequality in access to care for six categories of elective surgery in a publicly funded system, when care is rationed through waiting lists. Administrative waiting time data on all elective surgeries (n = 4,634) performed in Ostergötland, Sweden, in 2007 were linked to national registers containing variables on socioeconomic indicators. Using multiple regression, we tested five hypotheses reflecting that more resourceful groups receive priority when rationing by waiting lists. Low disposable household income predicted longer waiting times for orthopedic surgery (27%, p < 0.01) and general surgery (34%, p < 0.05). However, no significant differences on the basis of ethnicity and gender were detected. A particularly noteworthy finding was that disposable household income appeared to be an increasingly influential factor when the waiting times were longer. Our findings reveal horizontal inequalities in access to elective surgeries, but only to a limited extent. Whether this is good or bad depends on one's moral inclination. From a policymaker's perspective, it is nevertheless important to recognize that horizontal inequalities arise even though care is not rationed through ability to pay.

Intertemporal prosocial behavior: a review and research agenda.

Research on intertemporal and prosocial decisions has largely developed in separate strands of literature. However, many of the decisions we make occur at the intersection of these two dimensions (intertemporal and prosocial). Trust is an example, where a decision today is made with the expectation that another person will reciprocate (or betray) later. A new literature is emerging to explore the role of time in these types of situations, where time and social considerations are intertwined. In many cases, time introduces (or magnifies) an element of uncertainty about future outcomes and utility that people need to deal with - what will happen, how good will it be, how will it feel. We review this emerging literature on intertemporal prosocial decision-making and discuss how new research can fill existing knowledge gaps.

Bounded research ethicality: researchers rate themselves and their field as better than others at following good research practice.

Bounded ethicality refers to people's limited capacity to consistently behave in line with their ethical standards. Here, we present results from a pre-registered, large-scale (N = 11,050) survey of researchers in Sweden, suggesting that researchers too are boundedly ethical. Specifically, researchers on average rated themselves as better than other researchers in their field at following good research practice, and rated researchers in their own field as better than researchers in other fields at following good research practice. These effects were stable across all academic fields, but strongest among researchers in the medical sciences. Taken together, our findings illustrate inflated self-righteous beliefs among researchers and research disciplines when it comes to research ethics, which may contribute to academic polarization and moral blindspots regarding one's own and one's colleagues' use of questionable research practices.

Withdrawing versus Withholding Treatments in Medical Reimbursement Decisions: A Study on Public Attitudes.

BACKGROUND: The use of policies in medical treatment reimbursement decisions, in which only future patients are affected, prompts a moral dilemma: is there an ethical difference between withdrawing and withholding treatment? DESIGN: Through a preregistered behavioral experiment involving 1,067 participants, we tested variations in public attitudes concerning withdrawing and withholding treatments at both the bedside and policy levels. RESULTS: In line with our first hypothesis, participants were more supportive of rationing decisions presented as withholding treatments compared with withdrawing treatments. Contrary to our second prestated hypothesis, participants were more supportive of decisions to withdraw treatment made at the bedside level compared with similar decisions made at the policy level. IMPLICATIONS: Our findings provide behavioral insights that help explain the common use of policies affecting only future patients in medical reimbursement decisions, despite normative concerns of such policies. In addition, our results may have implications for communication strategies when making decisions regarding treatment reimbursement. HIGHLIGHTS: We explore public' attitudes toward withdrawing and withholding treatments and how the decision level (bedside or policy level) matters.People were more supportive of withholding medical treatment than of withdrawing equivalent treatment.People were more supportive of treatment withdrawal made at the bedside than at the policy level.Our findings help clarify why common-use policies, which impact only future patients in medical reimbursement decision, are implemented despite the normative concerns associted with thesepolicies.

Ghrelin decreases sensitivity to negative feedback and increases prediction-error related caudate activity in humans, a randomized controlled trial.

The stomach-derived hormone ghrelin plays not only a role in feeding, starvation, and survival, but it has been suggested to also be involved in the stress response, in neuropsychiatric conditions, and in alcohol and drug use disorders. Mechanisms related to reward processing might mediate ghrelin's broader effects on complex behaviors, as indicated by animal studies and mostly correlative human studies. Here, using a within-subject double-blind placebo-controlled design with intravenous ghrelin infusion in healthy volunteers (n = 30), we tested whether ghrelin alters sensitivity to reward and punishment in a reward learning task. Parameters were derived from a computational model of participants' task behavior. The reversal learning task with monetary rewards was performed during functional brain imaging to investigate ghrelin effects on brain signals related to reward prediction errors. Compared to placebo, ghrelin decreased punishment sensitivity (t = -2.448, p = 0.021), while reward sensitivity was unaltered (t = 0.8, p = 0.43). We furthermore found increased prediction-error related activity in the dorsal striatum during ghrelin administration (region of interest analysis: t-values ≥ 4.21, p-values ≤ 0.044). Our results support a role for ghrelin in reward processing that extends beyond food-related rewards. Reduced sensitivity to negative outcomes and increased processing of prediction errors may be beneficial for food foraging when hungry but could also relate to increased risk taking and impulsivity in the broader context of addictive behaviors.

Anger and disgust shape judgments of social sanctions across cultures, especially in high individual autonomy societies.

When someone violates a social norm, others may think that some sanction would be appropriate. We examine how the experience of emotions like anger and disgust relate to the judged appropriateness of sanctions, in a pre-registered analysis of data from a large-scale study in 56 societies. Across the world, we find that individuals who experience anger and disgust over a norm violation are more likely to endorse confrontation, ostracism and, to a smaller extent, gossip. Moreover, we find that the experience of anger is consistently the strongest predictor of judgments of confrontation, compared to other emotions. Although the link between state-based emotions and judgments may seem universal, its strength varies across countries. Aligned with theoretical predictions, this link is stronger in societies, and among individuals, that place higher value on individual autonomy. Thus, autonomy values may increase the role that emotions play in guiding judgments of social sanctions.

Priority setting in kidney transplantation: a qualitative study evaluating Swedish practices.

BACKGROUND: Transplantation is the treatment of choice for end-stage renal disease; it increases survival and quality of life, while being more cost-effective than dialysis. It is, however, limited by the scarcity of kidneys. The aim of this paper is to investigate the fairness of the priority setting process underpinning Swedish kidney transplantation in reference to the Accountability for Reasonableness (A4R) framework. METHODS: Fifteen semi-structured interviews were carried out with transplant surgeons (7), nephrologists (6) and coordinators (2) representing centers nationwide. Collected data was analysed using thematic analysis. To assess fairness in the priority setting process, identified factors were assessed in the reference to the four conditions (publicity, relevance, revision and appeal, enforcement) forming the accountability for reasonableness framework. RESULTS: Decision-making in assessment and allocation is based on clusters of factors. The factors appeal to various values, which are balanced against each other throughout the kidney allocation process: maximizing benefit, priority to the worst off and equality. The factors described by subjects and the values on which they rest satisfy the relevance condition of the accountability for reasonableness framework. However, two potential sources for unfair inequalities in access to treatment are identified: clinical judgment and institutional policies. CONCLUSIONS: The development of national guidelines both for assessing transplant candidacy, and for the allocation of kidneys from deceased donors, would contribute to standardize practices across centres; it will also help to better meet the conditions of fairness in reference to Accountability for Reasonableness. The benefits of this policy proposal in Swedish kidney transplantation merits consideration.

The effect of fast and slow decision-making on equity-efficiency tradeoffs and moral repugnance.

Fast-and-slow models of decision-making are commonly invoked to explain economic behaviour. However, past research has focused on human cooperation and generosity and thus largely overlooked situations where there are sharp conflicts between efficiency and equality, or between efficiency and more intuitive moral values (repugnance). Here, we contribute to fill this gap in the literature. We conducted a preregistered experiment (n = 1500 recruited from Prolific) to assess the effects of fast, intuitive decisions, under time pressure versus slow, deliberate decisions, under time delay, on (i) people's distributional preferences and (ii) their attitudes toward repugnant transactions. The results show increased preference for equality and decreased preference for efficiency under time pressure, but no effects on moral repugnance. Exploratory analyses revealed that most of the observed treatment effects in our data were accounted for by women. Our results provide some support for theories that associate controlled cognition with concern for efficiency, and intuitive, emotional responses with inequality aversion.

A randomized controlled experimental medicine study of ghrelin in value-based decision making.

BACKGROUNDThe stomach-derived hormone ghrelin stimulates appetite, but the ghrelin receptor is also expressed in brain circuits involved in motivation and reward. We examined ghrelin effects on decision making beyond food or drug reward using monetary rewards.METHODSThirty participants (50% women and 50% men) underwent 2 fMRI scans while receiving i.v. ghrelin or saline in a randomized counterbalanced order.RESULTSStriatal representations of reward anticipation were unaffected by ghrelin, while activity during anticipation of losses was attenuated. Temporal discounting rates of monetary reward were lower overall in the ghrelin condition, an effect driven by women. Discounting rates were inversely correlated with neural activity in a large cluster within the left parietal lobule that included the angular gyrus. Activity in an overlapping cluster was related to behavioral choices and was suppressed by ghrelin.CONCLUSIONThis is, to our knowledge, the first human study to extend the understanding of ghrelin's significance beyond the canonical feeding domain or in relation to addictive substances. Contrary to our hypothesis, we found that ghrelin did not affect sensitivity to monetary reward anticipation, but rather resulted in attenuated loss aversion and lower discounting rates for these rewards. Ghrelin may cause a motivational shift toward caloric reward rather than globally promoting the value of reward.TRIAL REGISTRATIONEudraCT 2018-004829-82.FUNDINGSwedish Research Council (2013-07434), Marcus and Marianne Wallenberg foundation (2014.0187) and National Institute on Drug Abuse/National Institute on Alcohol Abuse and Alcoholism Intramural Research Program.

Individual responsibility for healthcare financing: application of an analytical framework exploring the suitability of private financing of assistive devices.

OBJECTIVE: To operationalise and apply a conceptual framework for exploring when health services contain characteristics that facilitate individuals' ability to take individual responsibility for health care through out-of-pocket payment. In addition, we investigate if the levels of out-of-pocket payment for assistive devices (ADs) in Sweden are in line with the proposed framework. METHOD: Focus groups were used to operationalise the core concepts of sufficient knowledge, individual autonomy, positive externalities, sufficient demand, affordability, and lifestyle enhancement into a measurable and replicable rationing tool. A selection of 28 ADs were graded separately as having high, medium, or low suitability for private financing according to the measurement scale provided through the operationalised framework. To investigate the actual level of private financing, a questionnaire about the level of out-of-pocket payment for the specific ADs was administered to county councils in Sweden. RESULTS: Concepts were operationalised into three levels indicating possible suitability for private financing. Responses to the questionnaire indicate that financing of ADs in Sweden varies across county councils as regards co-payment, full payment, discretionary payment for certain healthcare consumer groups, and full reimbursement. According to the framework, ADs commonly funded privately were generally considered to be more suitable for private financing. CONCLUSIONS: Sufficient knowledge, individual autonomy, and sufficient demand did not appear to influence why certain ADs were financed out-of-pocket. The level of positive externalities, affordability, and lifestyle enhancement appeared to be somewhat higher for ADs that were financed out-of-pocket, but the differences were small. Affordability seemed to be the most influential concept.

Discounting, preferences, and paternalism in cost-effectiveness analysis.

When assessing the cost effectiveness of health care programmes, health economists typically presume that distant events should be given less weight than present events. This article examines the moral reasonableness of arguments advanced for positive discounting in cost-effectiveness analysis both from an intergenerational and an intrapersonal perspective and assesses if arguments are equally applicable to health and monetary outcomes. The article concludes that behavioral effects related to time preferences give little or no reason for why society at large should favour the present over the future when making intergenerational choices regarding health. The strongest argument for discounting stems from the combined argument of diminishing marginal utility in the presence of growth. However, this hinges on the assumption of actual growth in the relevant good. Moreover, current modern democracy may be insufficiently sensitive to the concerns of future generations. The second part of the article categorises preference failures (which justify paternalistic responses) into two distinct groups, myopic and acratic. The existence of these types of preference failures makes elicited time preferences of little normative relevance when making decisions regarding the social discount rate, even in an intrapersonal context. As with intergenerational discounting, the combined arguments of growth and diminishing marginal utility offer the strongest arguments for discounting in the intrapersonal context. However, there is no prima facie reason to assume that this argument should apply equally to health and monetary values. To be sure, selecting an approach towards discounting health is a complex matter. However, the life-or-death implications of any approach require that the discussion not be downplayed to merely a technical matter for economists to settle.

Medical Decision Style and COVID-19 Behavior.

Given the flood of health-related information stirred up by the coronavirus disease 2019 (COVID-19) pandemic, it is important to understand the factors that influence people to engage in protective public health measures so that medical communication can be tailored to be effective. Following the idea that people have a general inclination toward health care utilization, which is either more passive (i.e., medical minimizer) or more aggressive (i.e., medical maximizer), we assess if this inclination extends to being more or less willing to engage in protective public health behavior. We investigate the effect of individual differences in medical minimizing and medical maximizing orientation on COVID-19-related protective behaviors and attitudes. We used the validated Medical Maximizer-Minimizer Scale (MMS) and surveyed a diverse opt-in sample of the Swedish population (n = 806). Our results show that the MMS significantly predicts a wide range of self-reported behaviors and attitudes in relation to COVID-19. Participants with a stronger minimization orientation were significantly less likely to practice social distancing, follow hygiene recommendations, and be supportive of strict COVID-19 policies. Participants with a stronger maximization orientation had a larger discrepancy between perceived own risk and others getting infected. Thus, they perceived themselves as being less at risk for getting infected compared to the average person. Our findings imply that the MMS can be effectively used to predict who is more or less reluctant to follow public health recommendations.JEL codes: D70 E71 I12 I18.

Public Attitudes Toward Priority Setting Principles in Health Care During COVID-19.

What role should cost-effectiveness play in health care priority setting? We assess the level of acceptance toward different priority setting principles in health care during COVID-19 and in general, thereby exploring public support for principles presented at different levels of abstraction. An online survey was distributed to a diverse sample of the Swedish population (n = 1 553). The results show that respondents were generally more supportive of priority setting principles when expressed in general abstract terms than when expressed in more case specific concrete terms. However, prioritization based on cost-effectiveness was deemed as more acceptable when expressed in concrete terms related to health maximization rather than as an abstract principle. Respondents had a general inclination in support of physicians and other health care professionals the primary responsibility for the allocation of scarce resources in the healthcare during COVID-19, while being less supportive of health economists and politicians being involved in these decisions.

The effect of herd immunity thresholds on willingness to vaccinate.

Throughout the COVID-19 pandemic, media and policymakers openly speculated about the number of immune citizens needed to reach a herd immunity threshold. What are the effects of such numerical goals on the willingness to vaccinate? In a large representative sample (N = 1540) of unvaccinated Swedish citizens, we find that giving a low (60%) compared to a high (90%) threshold has direct effects on beliefs about reaching herd immunity and beliefs about how many others that will get vaccinated. Presenting the high threshold makes people believe that herd immunity is harder to reach (on average about half a step on a seven-point scale), compared to the low threshold. Yet at the same time, people also believe that a higher number of the population will get vaccinated (on average about 3.3% more of the population). Since these beliefs affect willingness to vaccinate in opposite directions, some individuals are encouraged and others discouraged depending on the threshold presented. Specifically, in mediation analysis, the high threshold indirectly increases vaccination willingness through the belief that many others will get vaccinated (B = 0.027, p = 0.003). At the same time, the high threshold also decreases vaccination willingness through the belief that the threshold goal is less attainable (B = -0.053, p < 0.001) compared to the low threshold condition. This has consequences for ongoing COVID-19 vaccination and future vaccination campaigns. One message may not fit all, as different groups can be encouraged or discouraged from vaccination.