Principles of influence

Neil Shear's letter is one more development in a memorable series of exchanges over our article.¹ We agree completely with his insights: the basic point is that advanced training in medicine does not immunize clinicians against the forces of social influence. In this response, we focus on this last issue.

Before we submitted our manuscript to CMAJ we had received 5 dissenting external reviews at other journals. One reviewer said, “employing tactics of social influence violates principles of biomedical ethics.” Another wrote, “medicine does not usually operate this way.” And a third said, “social influence techniques will ultimately undermine autonomous motivation.”

We recognize that researchers have not attempted to replicate these studies in real medical settings, that influence strategies are only one factor in human decision-making and that ethicists could raise major concerns about the potential for abuse. None of these limitations, however, justifies a lack of awareness.

The science of social influence is a new field, and our review is not the final word. Furthermore, this science emerged from the military education programs of World War II and is biased generally toward techniques that are effective on healthy people. More nuanced research about medical care may now be considered legitimate as the focus of this science shifts from military conflict to the war against disease.

A tendency exists to become overly enthusiastic about solutions to difficult problems when faced with positive results from psychology. The studies show, however, that influence strategies rarely make all the difference. Concrete barriers and supports are crucial (e.g., inconvenience, incentives and information). As Shear implies, clinicians should have no aspirations of becoming wizards who can govern a person's behaviour.

Donald A. Redelmeier Department of Medicine University of Toronto Toronto, Ont.