by James Toomey
Imagine that you were to develop dementia and someone else had to make medical decisions on your behalf. How would you want them to decide? Then suppose that you had to make medical decisions on behalf of another person with dementia. Would you think about decision-making in the same way? A new study in AJOB Empirical Bioethics by myself, Jonathan Lewis, Ivar Hannikainen, and Brian Earp suggests that people may favor different decisions when deciding for others versus when deciding what they would want for themselves.
In the study, we presented a cohort of nearly 1,500 U.S. participants with a vignette based on one of the most persistent and difficult questions in bioethics. The vignette describes someone with ordinary, lifelong cognitive functioning considering the possibility that in the future they might develop dementia and need to make a significant medical decision. But many years later, after they have undergone cognitive decline sufficient to lose legal capacity, the very circumstances they had contemplated occur and they make the opposite decision.
Our results showed that when the person in these circumstances was a stranger, participants were significantly more likely to endorse following the stranger’s future, incapacitated preference over the contrary, capacitated preference, compared to when they were thinking about themselves. In other words, participants were comparatively more likely to insist that their own, present-day wishes be followed if they become incapacitated in the future, while deferring more to other peoples’ future incapacitated expressions.
Under traditional ethical and legal frameworks, whether one’s health care decisions ought to be followed is a function of the cognitive functioning with which the decisions were made — if you possess the cognitive abilities that the law requires, physicians must respect your decisions; if you don’t, others may intervene. In our study, the patient’s future cognitive abilities were described identically across conditions. Under the traditional way of thinking about which medical decisions ought to be followed, it shouldn’t make a difference whether the patient was described with first- or third-person language — the patient in both cases was likely incapacitated, and so most accounts would have us look to their prior, capacitated preference regardless of perspective. But our study reveals that it is not cognition, or at least not just cognition, that impacts how lay people make these decisions.
Moreover, we found that the decision to follow a preference expressed after cognitive decline correlated with the view that the patient was still their “true self” —participants who followed the future preference were also more likely to say that the patient in the future was still their “true self.” The higher levels of deference to future preferences in third-person cases correlated with more participants concluding the stranger was still their true self. In the psychological literature, the “true self” refers to an ordinary concept of who a person really is, deep down, that has been found to be explanatory in many different domains.
Our study suggests that the concept of the true self may play a role in medical decision-making as well. For many participants, it might be whether an expressed decision “is made by” or “reflects” a patient’s true self that entitles the decision to respect—the view that “true” or “authentic” decisions ought to be followed, regardless of the cognitive function with which they were made.
Of course, the correlation between true self judgments and treatment decisions would not itself explain why treatment decisions vary across first- and third-person perspectives. But it might offer a path to do so. Researchers in psychology have argued that the true self is ultimately a perspective-neutral concept—people think of the true selves of others as the same basic thing as their own.
At the same time, the epistemic access that we have to what constitutes (at least, what we think constitutes) our own true self is necessarily radically different than that which we have for others, since we experienced it subjectively, “from the inside.” Perhaps that is where the difference across perspectives lies. Maybe people know, or think they know, when a hypothetical future version of themselves is no longer “truly” themselves. But without the same kind of access when dealing with a stranger, they might be more likely to conservatively presume that the true self of a stranger is still there. In future research, my co-authors and I hope to explore this hypothesis.
In any event, regardless of its explanation, the difference across perspectives that our study reveals has several implications for research and practice. For one thing, it joins a growing chorus finding that ordinary people take the normative status of a decision to be more than a function of the cognitive abilities with which it was made. At the same time, the study raises ethical questions that experimental philosophy can’t answer: if people think about the question differently in first- and third-person contexts, or at least rely on different evidence, which, if either, is right? Should we aspire to make decisions for others as they would for themselves, make them based on how we, as third-persons, might intuitively think of the question, or neither? Further work on the normative side, then, must aim to answer these sorts of questions.
James Toomey is an Associate Professor of Law at the University of Iowa College of Law
