The Challenges of Compassion Bias in Clinical Decision-Making: A Case-Based Ethical Analysis

Bias in clinical decision-making is commonly understood as arising from negative stereotypes or cognitive shortcuts that undermine patient-centered care. Less attention has been paid to forms of bias that emerge from clinicians' well-intentioned efforts to alleviate suffering. This article introduces the concept of compassion bias, defined as a distortion in clinical judgment that occurs when empathy and a desire to avoid harm unintentionally constrain objectivity, patient autonomy, or the range of treatment options offered. We present the case of a young woman with advanced neurologic decline secondary to HIV-associated progressive multifocal leukoencephalopathy, in whom artificial enteral nutrition was initially deferred based on clinicians' assumptions regarding quality of life and suffering. Despite good intentions, this approach delayed engagement with the patient's legal surrogate and limited exploration of family values regarding life-prolonging care, as well as likely shortening her life. Through a structured ethical analysis, we examine how compassion bias interacted with cognitive heuristics, implicit bias, and moral distress, contributing to paternalistic decision-making. Drawing on literature from cognitive bias, disability ethics, and quality-of-life assessment, we argue that compassion bias represents a distinct and underrecognized ethical challenge in hospital-based care. We propose that recognizing compassion bias requires deliberate engagement in reflective, Type 2 reasoning, attention to surrogate decision-making processes, and early incorporation of palliative care to support both families and clinicians. By naming and critically examining compassion bias, clinicians and ethics consultants may better balance beneficence and nonmaleficence while preserving autonomy, trust, and ethically sound decision-making in serious illness care.