Toomey, J., Lewis, J., Hannikainen, I. R., & Earp, B. D.
(2024). AJOB Empirical Bioethics, 1–9.
Abstract
Background
Advance healthcare decision-making presumes that a prior treatment preference expressed with sufficient mental capacity (“T1 preference”) should trump a contrary preference expressed after significant cognitive decline (“T2 preference”). This assumption is much debated in normative bioethics, but little is known about lay judgments in this domain. This study investigated participants’ judgments about which preference should be followed, and whether these judgments differed depending on a first-person (deciding for one’s future self) versus third-person (deciding for a friend or stranger) perspective.
Methods
A vignette-based survey was conducted (N = 1445 US Americans; gender-balanced sample), in a 3 (relationship: self, best friend, stranger) × 2 (T1 preference: treat, do not treat) × 2 (T2 contrary preference: ambiguous, unambiguous) design.
Results
Participants were more likely to defer to the incapacitated T2 preference of a third-party, while being more likely to insist on following their own T1 capacitated preference. Further, participants were more likely to conclude that others with substantial cognitive decline were still their “true selves,” which correlated with increased deference to their T2 preferences.
Conclusions
These findings add to the growing evidence that lay intuitions concerning the ethical entitlement to have decisions respected are not only a function of cognition, as would be expected under many traditional bioethical accounts, but also depend on the relationship of the decision to the decision-maker’s true self.
Here are some thoughts:
This study investigates how individuals judge which treatment preference should be followed when there is a conflict between a prior preference expressed with full mental capacity (T1) and a later preference expressed after cognitive decline (T2). It compares judgments made from a first-person perspective (deciding for oneself) versus a third-person perspective (deciding for others). The findings reveal that participants were more likely to defer to the T2 preference of others while insisting on following their own T1 preference for themselves. Additionally, people tended to view others with cognitive decline as still their "true selves," which correlated with increased deference to their T2 preferences. Notably, the discrepancy between first-person and third-person judgments was consistent regardless of how the preference was phrased.
These results have important ethical implications, highlighting a tension between lay moral intuitions and traditional bioethical accounts that typically prioritize decisions made with full cognitive capacity. The study suggests that surrogate decision-makers might systematically underestimate the circumstances in which a person would want their T1 preference followed. Furthermore, it adds to the growing body of evidence that entitlement to have medical decisions respected is not solely based on cognitive capacity but is also related to the continuity of one's "true self." The distinction between deciding for oneself and for others appears to drive the main effects observed, rather than the social distance between the decision-maker and the individual in question.
