Psychological interventions informed by behavioral economic theory have the potential to improve patient outcomes.1 In a dermatologic study of individuals with actinic keratosis, patients were significantly more likely to choose treatment when the condition was framed as a precancerous lesion by practitioners.2

Dr Elias Oussedik of the McGill University Faculty of Medicine in Montreal, Canada, explored the ethics of “manipulative interventions” in a publication for The Journal of the American Academy of Dermatology.3

Beneficence and autonomy are cornerstone concepts in the field of medical ethics. Beneficence necessitates medical intervention when possible: clinicians have an obligation to act in the patient’s best interest. According to principles of autonomy, however, medical professionals also may not infringe on the decision-making capacity of individuals. In the case of manipulating patient mindsets, these concepts are often at odds.

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Many practitioners, however, may not have a choice regarding manipulation; a medical intervention may naturally challenge a patient’s autonomy when suggested. Research indicates that patients are generally understanding when they learn that they were manipulated if such technique was employed to improve outcomes.4

Dr Oussedik emphasized the necessity of defining the circumstances under which behavioral interventions may be appropriate. An ethical deliberation framework may be appropriate for considering mindset manipulation to improve outcomes. Dr Oussedik presented the hypothetic case of a patient with severe keloids that have had a significant impact on his quality of life. Cortisone injections are recommended by the practitioner as the most effective course of action, but the patient is hesitant and has a fear of needles.

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After ethical deliberation, it may be assumed that a cortisone injection schedule is the preferred course of action, given the treatment-resistant nature of the keloids and their deleterious effect on patient quality of life. In this case, Dr Oussedik suggested an anchoring-based psychological technique, wherein patients are more likely to act based on the first piece of information they receive. The practitioner could compare cortisone injections to insulin injections, emphasizing that cortisone injections are taken just once-monthly while insulin injections — a well-known, standard intervention — must be administered daily. In this case, the patient is “anchored” by knowledge that insulin is once daily and may subsequently view cortisone injections as a more plausible treatment option.

The practice of manipulation remains controversial, and practitioners must work to draw the line before inappropriate violations of autonomy. It would be unethical to use anchoring or framing to “sell” treatments, for example, by presenting them initially as cheaper or intimating that the patient is receiving a discount. Dr Oussedik emphasized the necessity of proceeding with caution: if the intervention will benefit the patient, it should be used. However, in the interest of respecting autonomy, the discussion around manipulative medicine can and should remain active.


  1. Crum A, Zuckerman B. Changing mindsets to enhance treatment effectiveness. JAMA. 2017;317(20):2063-2064.
  2. Berry K, Butt M, Kirby JS. Influence of information framing on patient decisions to treat actinic keratosis. JAMA Dermatol. 2017;153(5):421-426.
  3. Oussedik E, Feldman SR. Manipulating mindsets to improve patient outcomes: is it ethical? Can it be avoided? [published online August 30, 2018]. J Eur Acad Dermatol Venereol. doi:10.1111/jdv.15224
  4. Diepeveen S, Ling T, Suhrcke M, Roland M, Marteau TM. Public acceptability of government intervention to change health-related behaviours: a systematic review and narrative synthesis. BMC Public Health. 2013;13(1):756.