Topoi DOI 10.1007/s11245-015-9343-2 Clinical Decision-Making, Gender Bias, Virtue Epistemology, and Quality Healthcare James A. Marcum1  Springer Science+Business Media Dordrecht 2015 Abstract Robust clinical decision-making depends on valid reasoning and sound judgment and is essential for delivering quality healthcare. It is often susceptible, however, to a clinician’s biases such as towards a patient’s age, gender, race, or socioeconomic status. Gender bias in particular has a deleterious impact, which frequently results in cognitive myopia so that a clinician is unable to make an accurate diagnosis because of a patient’s gender—especially for female patients. Virtue epistemology provides a means for confronting gender bias in clinical decisionmaking and for correcting or even preventing its impact. The medical literature on cardiovascular and coronary heart disease is used to illustrate the role intellectual virtues can play in redressing the deleterious impact of gender bias on clinical decision-making and practice. Finally, questions are considered surrounding the pedagogy of intellectual virtues for medical students and practicing clinicians in order to provide quality care for patients, regardless of gender. Keywords Cardiovascular disease
Clinical decisionmaking
Gender bias
Intellectual virtues
Quality healthcare
Virtue epistemology 1 Introduction Quality healthcare (QHc) is a major concern in contemporary medicine, especially in terms of patient satisfaction and safety (Dentzer 2011; Scott and Jha 2014). & James A. Marcum James_Marcum@baylor.edu 1 Department of Philosophy, Baylor University, Waco, TX 76798, USA Unfortunately, QHc is difficult to define and measure since it depends on multiple factors, such as a clinician’s technical competence or a patient’s access to healthcare resources (Healy 2011; Institute of Medicine 2001). Fundamental to delivering QHc, however, is the ability and capacity of clinicians to make robust clinical decisions, which depend on valid reasoning and sound judgment (Albert et al. 1988; Downie and Macnaughton 2000; Kassirer and Kopelman 1991). In other words, clinicians must be critical thinkers, especially in terms of reasoning analytically and reflectively about how they deliberate and make diagnostic and therapeutic judgments (Croskerry 2000, 2005; Gambrill 2005; Groopman 2007; Gupta and Upshur 2012; Montgomery 2006). Detrimental to such clinical decision-making are cognitive biases, such as those based on a patient’s age, gender, race, or socioeconomic status, which often cloud reasoning and lead to errors in judgments (Graber et al. 2012; Payne and Patel 2014). A cognitive bias is basically a ‘‘faulty belief’’ about something (Elstein 1999, 791). The result is generally a ‘‘flaw in judgment’’ (Hicks and Kluemper 2011, 298). Often, a cognitive bias represents ‘‘a cognitive disposition to respond’’ and to act quickly (Croskerry 2002, 1201). As such, it is thought to influence predominantly, but not exclusively, system I heuristic processes, according to the dual-process theory of cognition (Croskerry 2009; Norman and Eva 2010; Norman et al. 2014). Croskerry (2002) has identified over 40 cognitive biases, such as anchoring, aggregate, commission, confirmation, omission, and overconfidence biases, within clinical medicine that may lead to delivery of poor QHc—such as faulty or missed diagnoses and inappropriate or ineffective treatment. Gender bias, in particular, has a deleterious impact on clinical decision-making and especially on 123 J. A. Marcum women’s health (Hamberg 2008; Politi et al. 2013; Risberg et al. 2009). It frequently results in cognitive myopia or blind spots in which clinicians are unable to reason clearly and to judge soundly because of faulty beliefs about the relationship between a patient’s illness and gender. Although several strategies are available for de-biasing or confronting bias in clinical decision-making (Croskerry 2002; Graber et al. 2012; Norman and Eva 2010), I propose virtue epistemology, both reliabilist and responsibilist versions of it (see below), as a means to address gender bias in clinical decision-making and to correct or prevent its deleterious impact on women’s health. Besides the traditional intellectual virtues, including nous, phronesis, techne, episteme, and sophia, contemporary intellectual virtues, such as epistemic humility, honesty, curiosity, open-mindedness, courage, and fair-mindedness (only responsibilist epistemic virtues are utilized for brevity’s sake), can be used to analyze and address gender bias in clinical decision-making. To that end, the medical literature on cardiovascular disease (CVD), especially coronary heart disease (CHD), is used to illustrate the role intellectual virtues can play in redressing the detrimental impact of gender bias on clinical decision-making and practice. Finally, questions are entertained surrounding the pedagogy of virtue epistemology for medical students and practicing clinicians in order to provide QHc for patients, regardless of gender. 2 Gender Bias in Clinical Reasoning Although gender bias can have an impact on healthcare for either men or women, women have often been disadvantaged historically, compared to men, in healthcare practice and clinical research (Dijkstra et al. 2008; Hamberg 2008). In general, gender bias in clinical reasoning and practice pertains to ‘‘difference in the treatment of women and men with the same diagnosis, which may be positive, negative or neutral to the health of these’’ (Chilet-Rosell 2014, 2). There are several types of gender bias that can influence healthcare delivery to patients and investigation of their health-related issues (Ruiz and Verbrugge 1997; Risberg et al. 2009). One type pertains to a male bias or perspective for defining health and illness. In other words, males are considered the standard for what is normal physiologically and abnormal pathologically. For example, women are often excluded from clinical trials; and, data from such trials that include only men are then extrapolated to diagnose and treat women (Melloni et al. 2010; Tsang et al. 2012). In response, feminists championed a new health paradigm in which women took an active role in healthcare issues other than traditional mental or reproductive issues (Nettleton 1996; Moore 2008). Indeed, Sarah Moore insists 123 that there has been a reversal in which ‘‘femininity, once seen as an indication of sickliness, has come to be associated with healthiness, while masculinity is now deemed to be detrimental to health’’ (2008, 274–5). But for many, males still represent what constitutes the normal. Another type of gender bias manifests itself in terms of gender inequality and inequity with respect to healthcare access (Doyal 2000; Hammarström et al. 2014; Sen et al. 2002; van Wijk et al. 1996). But, it must be noted, that other factors besides gender, such as ethnicity or socioeconomic status, can also have an impact upon access to healthcare resources and delivery of QHc. Two additional types of gender bias—gender blindness and gender stereotyping—although closely related to one another, are often regarded as separate within the literature (Hamberg 2008; Risberg 2004). The assumption behind gender blindness is that there is no differences in health and illness between men and women, when differences do exist. In other words, the healthcare professional is blind, either unintentionally or intentionally, to physiological or pathological differences between male and female patients because of the belief that the disease in terms of etiology and symptoms is the same for either gender. Gender stereotyping, however, assumes differences in health and illness between men and women because of the patient’s gender, when differences do not exist. In other words, gender stereotyping clouds both the clinician’s ability to observe and capacity to process salient clinical evidence not because of gender blindness but because of preconceived or faulty beliefs about the patient’s illness based on gender alone (Marcus-Newhall et al. 2001). As such, this bias is grounded on stereotypes that prevent a clinician from considering the specific characteristics of the gendered patient and how these characteristics influence clinical outcomes. Moreover, the clinician is not blind to the patient’s gender and the impact of the patient’s gender on the illness experience but rather is aware of it to the extent that the clinician wrongly incorporates the patient’s gender into diagnosing and treating the patient. Although regarded as different, yet the two gender biases are related to some extent in that a disease might be misdiagnosed either because the clinician assumes that a patient could not have the disease since the disease is not gender-specific (blindness), or the patient has a disease because of the patient’s gender only (stereotype). Gender bias can also be associated with other cognitive biases (Walton 1999). For example, it is certainly related to anchoring bias in which salient or relevant clinical symptoms are locked onto early in the decision-making process. Once locked onto, these symptoms often prohibit additional information from having an impact on revising a clinical decision. Moreover, they may shape the interpretation of the evidence to confirm the decision, i.e. the Clinical Decision-Making, Gender Bias, Virtue Epistemology, and Quality Healthcare confirmation bias. Thus, the clinician may unintentionally permit a patient’s gender to anchor the clinical decisionmaking process in terms arriving at a diagnosis and prescribing treatment and then is unable to revise either the diagnosis or treatment upon additional clinical information that might disconfirm the initial diagnosis and treatment (Payne and Patel 2014). One final example is the overconfidence bias in which too much assurance is consigned to personal opinion. The clinician then might place too much reliance on the fact that the patient’s gender provides salient evidence for supporting a specific clinical decision, when it does not. In terms of clinical reasoning and decision-making, then, gender bias refers to the impact the gender of either the patient or clinician has on diagnosing a disease condition or treating it. ‘‘True gender bias’’, according to Croskerry, ‘‘arising from specific attitudes toward a particular gender has to be distinguished from a mistaken belief that gender is a factor in the etiology of a disease’’ (Croskerry 2002, 1191). In other words, biological differences certainly exist based on biological and physiological differences between men and women; but gender bias in clinical practice generally reflects either gender blindness or stereotype, and it should not be a factor involved in the clinical decision-making process. Gender bias often leads either to over or under diagnosis, or even to misdiagnosis, especially with respect to women patients. For example, more women are diagnosed with depression than men; and, even when either men or women are diagnosed with depression the former are diagnosed as organic mental disorder and the latter as severe depressive disorder (Garb 1997; Möller-Leimkühler 2007). 3 Cardiovascular and Coronary Heart Disease CVD, including CHD, is the leading cause of death for women worldwide, killing more women annually than cancer, HIV/AIDS, malaria, and tuberculosis combined (Pilote et al. 2007; World Heart Federation 2012). It accounts for approximately one-third of women’s deaths, with the majority dying from either ischemic heart disease or stroke. Moreover, women residing in low- and middleincome countries who develop CVD are more likely to die from it than women residing in high-income countries. Even in high-income countries, the rise of CVD and of ensuing deaths is alarming (American Heart Association 2013, 2015). For example, in 2009 over 400,000 women in the United States died from CVD; and, the death rate from CHD was 116.1 and it has been steadily increasing annually for women aged 35–54. In addition, the prevalence of CVD in African American women in the United States is significantly higher (48 %) compared to Caucasian women (32 %). CHD is a prominent example of the impact gender bias has had on women’s cardiovascular health, particularly in terms of under diagnosis, ineffective treatment, and lack of preventive care (Anspach 2010; Bönte et al. 2008; Simmons et al. 2011; Robertson 2001; Xhyheri and Bugiardini 2010). One reason for this bias is that CHD is considered a man’s disease, historically, even though in 2009 just as many—if not slightly more—women died from heart disease in the United States than men (Kochanek et al. 2011). Another reason is that women who present with symptoms of the disease are often under or missed diagnosed, whether the clinician is male or female (Adams et al. 2008; Bird and Rieker 2008; Martin et al. 2005; Mikhail 2005). For example, women are less likely to present with chest pain during a heart attack (Canto et al. 2007). Moreover, only one in five clinicians knows that CHD kills more women than men (Lloyd-Jones et al. 2010). An additional reason is what Nanette Wenger (2004, 2012) calls the ‘‘bikini approach’’ to women’s health issues. In other words, clinicians often focus on breast or reproductive diseases. Finally, as Wenger (2012) points out even women themselves—whether patients or clinicians—do not consider CHD a major health risk, with over 50 % of women surveyed in one study were unaware of their CHD risk. Clinicians underutilize procedures and measures for treating and preventing CVD in women and they often refer women later for therapies, as compared to men (Zusterzeel et al. 2015). For example, women suffering from coronary artery disease, as compared to men, experience reduced rates for referral and completion of cardiac rehabilitation—even though they exhibit greater reduction in mortality after completing rehabilitation, as compared to men (Colbert et al. 2015). During heart failure, women—as compared to men—are not as likely to receive angiotensinconverting enzyme inhibitors or b-blockers (Baumhäkel et al. 2009). Moreover, male physicians—as compared to female physicians—when treating women suffering from heart failure—as compared to men—use lower doses of medication. During 2010, only one-third of percutaneous coronary interventions were performed on women (Mozaffarian et al. 2015). And, lastly, implantable cardioverter-defibrillator therapy for preventing heart failure, especially caused by left ventricular arrhythmias, was used two to three times more in men than in women (Sahni and Fonarow 2014). Wenger (2012) makes several recommendations for addressing the impact of gender bias on diagnosing and treating women with CVD. The first is to include women in clinical trials and to analyze and report the clinical data in a gender-stratified manner. Another recommendation is to investigate gender differences in terms of pathophysiology 123 J. A. Marcum of CVD, especially with respect to microvascular pathophysiology. Wegner also recommends social and political initiatives to raise awareness of and to regulate the impact of gender bias on treating women with CVD and CHD. She also recommends continued application of evidenced-based guidelines for providing women with QHc, which the American Heart Association stipulates (Mosca et al. 2007, 2011). 4 Virtue Epistemology Although Wenger’s recommendations above are important for addressing gender bias with respect to CVD, especially CHD, they would be better implemented by informing clinicians about the importance of epistemic or intellectual virtues in clinical reasoning and decision-making and by equipping them with the skills needed to incorporate these virtues in making robust and unbiased decisions. Specifically, virtue epistemology offers a critical means for addressing gender bias in clinical medicine. It would provide the clinician with the cognitive resources to identify and correct gender bias either personally or within others. In this section the two main versions of virtue epistemology are introduced and briefly discussed, followed by a discussion of several of the relevant intellectual virtues for addressing gender bias in treating CVD in women. Contemporary virtue epistemology arose to address the perceived failure of traditional epistemology to account for justified true beliefs, by focusing on the epistemic agent’s character (Sosa 1980). Two main versions of contemporary virtue epistemology are reliabilism and responsibilism (Baehr 2011; Battaly 2008; Napier 2011). Reliabilist virtue epistemology pertains to an epistemic agent’s dependable perceptual or sensory and conceptual or cognitive faculties or powers (Goldman 2012; Sosa 2009). The virtues associated with this version are required for securing and justifying true beliefs or certain knowledge. The types of reliabilist virtues include, for example, hearing or sight for the sensory faculties, and intuition and memory for cognitive faculties. On the other hand, responsibilist virtue epistemology involves an epistemic agent’s virtuous traits or characteristics (Roberts and Wood 2007; Zagzebski 1996). The virtues associated with this version of virtue epistemology are critical for delivering the epistemic goods. The types of responsibilist virtues include the traditional virtues of nous, phronesis, techne, episteme, and sophia, and the contemporary intellectual virtues, such as epistemic humility, honesty, curiosity, open-mindedness, courage, and fair-mindedness. How might intellectual virtues operate to correct or even prevent gender bias, especially with respect to treating CVD in women? Although both versions of virtue 123 epistemology are applicable and necessary to the task of preventing gender bias, only responsibilism is discussed in the remainder of this section for brevity’s sake. To that end, the role of responsibilist epistemic virtues in clinical medicine and practice, clinical research trials and biomedical research, and clinical community and culture, is examined and discussed separately. For addressing gender bias in clinical medicine and practice, two of the more relevant traditional epistemic virtues of responsibilism are nous and phronesis. Although both involve practical intelligence, nous pertains to intuitive or insightful apprehension while phronesis to good or sound judgment. In other words, nous is akin common sense, while phronesis to prudence (Pellegrino and Thomasma 1993). As for contemporary epistemic virtues, intellectual humility and honesty are crucial for tackling gender bias in clinical practice. As an intellectual virtue, humility pertains to an epistemic unpretentiousness or modesty when confronted with uncertainty and the unknown. It straddles the two vices of over-confidence and under-confidence (Schwab 2011). Epistemic honesty, briefly, involves a disposition to communicate truthfully or candidly and not to deceive or mislead. Finally, the above epistemic virtues go hand-in-hand in gaining the patient’s trust that the clinician is striving to deliver the best QHc possible (Schwab 2008). In terms of addressing gender bias associated with CVD in clinical medicine and practice, the clinician utilizing the traditional virtues of nous and phronesis, as well as the contemporary virtues of humility and honesty, realizes and acknowledges that differences exist between men and women in terms of the chief complaint and presenting symptoms associated with heart disease. The epistemic virtues of nous and phronesis, in particular, assist the clinician in making accurate observations and in drawing plausible and relevant diagnosis from such observations. They are invaluable for gaining insight into the intelligibility of a patient’s symptoms and signs, as well as into evidence from clinical trials and laboratory investigations, and for formulating the necessary facts in order to make robust and practical clinical decisions concerning diagnosis and therapeutic options. Moreover, epistemic humility is specifically useful in addressing gender bias in clinical decision-making concerning female patients with CVD, since the clinician approaches the patient’s presenting symptoms unpretentiously realizing that often intuitions might need to be tempered with further inquiry into the patient’s chief complaint. And, epistemic honesty permits the clinician to communicate effectively and openly about the possible diagnoses and therapeutic options, especially given ever present clinical uncertainty. In sum, the traditional and contemporary intellectual virtues operate together to allow the clinician to recognize the Clinical Decision-Making, Gender Bias, Virtue Epistemology, and Quality Healthcare pathophysiological dissimilarities between the two sexes vis-à-vis CVD in order to deliver QHc. They are important for overcoming gender bias concerning the differences and similarities associated with CVD in men and women, particularly blindness (based on the assumption that presenting symptoms for CVD are the same for either gender) and gender stereotype (based on the assumption that a female patient cannot be suffering from CVD because she is a woman). For addressing gender bias in clinical trials and biomedical research, two of the more relevant traditional epistemic virtues of responsibilism are techne and episteme. Epistemic techne encompasses the technical knowing involved in performing clinical studies and biomedical research, including their mechanical and methodological operations. The intellectual virtue of episteme, however, pertains to a theoretical knowing of the pathophysiological mechanisms of disease. Although techne concerns the art of research and episteme its science, the two complement one another to provide a comprehensive investigation into disease mechanisms. With respect to contemporary virtues, curiosity and open-mindedness are essential for confronting gender bias in clinical and biomedical research. Epistemic curiosity pertains to the researcher’s disposition to ask questions about the nature of natural phenomena underlying disease. It motivates the researcher to strive towards making the unknown know. The intellectual virtue of open-mindedness involves being receptive to novel approaches to formulating theories to understand diseases, developing therapies to treat them, and conducting trials and investigations to test those theories and therapies. In terms of addressing gender bias in CVD in clinical trials and biomedical research, the intellectual virtues of techne and episteme equip the clinical researcher with the skills necessary to develop novel studies and research strategies to explore the disease mechanism associated with CVD in either gender. Episteme is particularly crucial for enabling the researcher to identify and explain theoretically the differences that exist between males and females concerning CVD etiology and to account practically for their expression and presentation clinically. Moreover, epistemic curiosity motivates the clinical researcher to ponder impartially about CVD phenomena and mechanisms in order to advance understanding and knowledge about them and how to treat them. And, epistemic open-mindedness allows the clinical researcher to consider viable technical and theoretical options to investigate CVD in either gender. Finally, these intellectual virtues collectively are imperative for overcoming the gender bias in CVD of using only males in clinical trials and excluding females. In other words, men are not the standard of health for women— biological differences do exist. In sum, these virtues have an impact not only on the clinical decision-making process but also on a community’s priorities to conduct both basic and clinical research on CVD in women. Both traditional and contemporary responsibilist intellectual virtues must not only define the practice of clinical medicine and the investigation of clinical trials and biomedical research but also the clinical community and its culture vis-à-vis gender bias associated with CVD— forming a virtuous epistemic community that supports its members to provide patients with QHc, regardless of gender. Probably the most relevant traditional epistemic virtue of reliabilism is sophia, which pertains to wise judgment and not just sound judgment in terms of phronesis. Moreover, sophia includes more than just the practical good of the individual but also the utmost good of the community. Specifically, it can assist in shaping a clinical community’s efforts to provide QHc by confronting gender biases that preclude, for example, including women in clinical trials investigating CVD. As for contemporary epistemic virtues, both justice and courage are important for addressing gender bias associated with CVD. The intellectual virtue of justice pertains to equal contribution epistemically from every member of the healthcare system, including patients (Anderson 2012; Carel and Kidd 2014). In other words, there is a fairmindedness or even-handedness to include relevant voices, in contrast to epistemic injustice in which select voices, especially women suffering from CVD, are marginalized or ignored (Fricker 2007). Again, as noted above, women in particular must be included in clinical trials for investigating CVD. Without the inclusion of women, the community jeopardizes its ability to provide the QHc needed for treating women suffering from CVD. And, epistemic courage pertains to a commitment to speak the truth and to encourage it when it confronts resistance, especially within the professional community in terms of justifying medical knowledge and within the lay community with respect to policy formation (Celik et al. 2011; Medina 2012; Risberg et al. 2006). In sum, these intellectual virtues work cooperatively to produce an epistemically virtuous community in which gender is an important factor in formulating policies to treat illness and to overcome gender equality and equity (Hammarström et al. 2014). One important avenue for incorporating these intellectual virtues and others into the medical community, in order to shape its culture, is through education. 5 Medical Education The inclusion of gender medicine into medical curriculum has not been as successful as originally anticipated (Hochleitner et al. 2013; Verdonk et al. 2009; Wong 2009). Part of the problem is how best to incorporate such 123 J. A. Marcum medicine into a curriculum that is already severely overcrowded in terms of courses, uncertainty surrounding the practical implementation of gender medicine, and to some extent institutional resistance to change (Henrich 2004; Risberg et al. 2011). Another problem raised concerning gender medicine is its content; however, a comprehensive textbook on gender medicine is currently in its second edition (Legato 2010). Although virtue epistemology, whether reliabilist or responsibilist, cannot address every issue confronting the implementation of gender medicine into the medical curriculum, it can assist in replacing gender bias with gender awareness and sensitivity, and especially in eliminating errors associated with gender bias. Although virtue epistemology offers a robust means for addressing gender bias in clinical decision-making, the question arises as to how best to equip both medical students and practicing clinicians with virtue epistemic skills. Confronting gender bias pedagogically should begin in the premedical curriculum. The current addition of CARS (Critical Analysis and Reasoning Skills) to the MCAT provides an opportunity to equip premedical students interested in a medical career with the critical thinking skills needed to address gender bias in medicine. Inclusion of virtue epistemology, especially the responsibilist version, into a critical thinking course, for example, would facilitate the replacement of gender bias with gender awareness (Gupta and Upshur 2012). In terms of medical school, both reliabilist and responsibilist virtue epistemology can provide a framework to continue confronting gender bias, especially in a gender medicine course. Specifically, courses in patientphysician relationship would enhance the reliabilist virtues of students as clinical mentors would assist students in learning the skills needed to listen effectively to a patient’s illness narrative (Dielissen et al. 2009; Lipworth et al. 2012; Marcum 2012). Lastly, workshops in gender medicine offered for Continuing Medical Education credit can also be embedded in a virtue epistemology framework to reinforce critical thinking skills that address issues surrounding gender bias. Importantly, at each level of the educational curriculum the material must be age and experience appropriate to be effective optimally. Finally, a need exists for confronting gender bias at the community or social level. As Moira Howes concludes about the role of virtue epistemology in regulating biases in scientific reasoning, intellectual virtues can ‘‘create more intellectually virtuous communities by supporting people in their pursuit of a good cognitive life’’ (2012, 751). What is needed to achieve the ‘‘good cognitive life’’ for the clinical community and its members is a clinical decisionmaking process that is embedded in and informed by virtue epistemology—both reliabilism and responsibilism. This is particularly important not only for the clinical encounter but also for clinical and basic biomedical research. Virtue 123 epistemology can shape the intellectual life of the clinical community to prevent gender bias from harming patients because of their gender and more importantly by raising gender awareness to include gender differences for diagnosis and treatment. 6 Conclusion Gender bias in clinical decision making and judgment represents a serious impediment to the delivery of QHc, especially for women suffering from CVD. Virtue epistemology, including both reliabilist and responsibilist versions, provide a robust means for addressing such bias and its impact on women’s health. 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