Nicholas Makins argues persuasively that medical decisions should be made with consideration for patients’ higher order risk attitudes.1 I will argue that an understanding of risk attitudes in medical decision-making is incomplete without critical engagement with emotions and affects (feelings associated with something good or bad). The primary aim of this commentary is to emphasise that clinical decisions are often emotionally charged, and it is crucial to engage closely with emotions and affects that shape these decisions, particularly when navigating complex (...) and uncertain situations. In the face of uncertainty, emotions such as fear, sadness or anxiety play a significant role in risk attitudes and medical decisions. I contend that recognising risk as a feeling is crucial to respecting patients’ values, preferences and decisions in light of the substantial body of research on risk perception and attitudes that suggests individuals make decisions based not only on what they think, but also on how they feel. In recent years, scholars have begun to acknowledge the value of emotions in understanding medical decisions and healthcare decision-making processes,2 especially under uncertainty. Furthermore, some philosophers and social scientists in field of risk research acknowledge emotions as both affective and cognitive in nature, and influence risk perceptions and attitudes.3 Risk …. (shrink)

In ‘Patients, doctors and risk attitudes,’ Makins argues that, when physicians must decide for, or act on behalf of, their patients they should defer to patient risk attitudes for many of the same reasons they defer to patient values, although with a caveat: physicians should defer to the higher-order desires of patients when considering their risk attitudes. This modification of what Makins terms the ‘deference principle’ is primarily driven by potential counterexamples in which a patient has a first-order desire with (...) one risk attitude (either risk-seeking or averse) and a second-order desire that this risk attitude not be effective in guiding their choices.1 There are two reasons we might think people with obsessive–compulsive disorder (OCD) are particularly relevant patients for evaluating Makins’ proposal. Not only might their first-order risk attitudes be irrational, but many people with OCD also judge their own OCD behaviours to be excessive or unwarranted making them structurally similar to the counterexamples outlined above. Yet, I argue that recent research about risk and decision-making under uncertainty for those with OCD complicates Makins’ proposal by raising questions of whether and to what degree their risk attitudes are irrational such that they should not play a part in the surrogate decisions made by physicians. This places more …. (shrink)

Makin argues that doctors1 should defer to each patient’s attitude to risk, over and above standard, utility-based and outcome-focussed medical decision-making models, in selecting treatment options for that patient.1 Although Makin articulates the problem as a dilemma of whether ‘to give the treatment or to withhold it’, it can be assumed that his question is whether the doctor should offer a certain treatment; because both the General Medical Council and law require doctors to engage patients in shared decision-making (SDM) and (...) to obtain consent before ‘giving’ any treatment. Yet, Makin is correct in asserting that doctors ‘make choices on behalf of their patients on a daily basis’ insofar that doctors do have to make certain a priori decisions. SDM requires a starting point—a range of clinically appropriate or reasonable options—on which patients and doctors can collaboratively deliberate in order to reach a treatment decision; and the doctor has to set out this starting point.2 Thus, Makin’s reductive claim is that doctors should take each patient’s risk attitude into account in setting out the starting points for SDM. In this commentary, I will explore UK case law in response to Makin’s proposal; because, ultimately, doctors have to work within the legal framework. Makin relies on the bioethical principles of respect …. (shrink)

In his paper, ‘Patients, doctors and risk attitudes,’ Nicholas Makins1 argues that healthcare professionals should defer to a patient’s higher-order risk attitudes (ie, the risk attitudes they desire to have or endorse within themselves upon reflection) when making medical decisions. We argue against Makins’ deference to higher-order risk attitudes on the basis that (1) there are significant practical concerns regarding our ability to easily and consistently access and verify the higher-order risk attitudes of patients, (2) there is a lack of (...) a theoretical limit on higher-order risk attitudes (eg, second, third, fourth order), and (3) the consideration of higher-order risk attitudes is actually more paternalistic than Makins suggests because it narrows what counts as an autonomous preference to the limited occasions in which an individual actually reflects on his or her own risk attitude. On the issue of practicality, we can reasonably expect that healthcare professionals would find difficulty eliciting the higher-order risk attitudes of their patients. Take for example the patient who has never expressed his higher-order desire to be more risk adverse and who is not willing nor comfortable expressing this desire. What is the healthcare professional expected to do in this situation? This is even more of a concern for the incapacitated patient, to which Makins seems to imply that …. (shrink)

In my feature article in this issue, ‘Doctors, patients and risk attitudes’, I argue that considerations of both autonomy and beneficence support the practice of healthcare professionals deferring to their patients’ reflectively endorsed risk attitudes when making decisions under uncertainty.1 The commentaries written in response to this article present many interesting criticisms, limitations and applications of the view, and I am grateful to all of the commentators for their engagement with this topic. I cannot possibly do justice to all of (...) the points they have raised in this brief response, so I will address two common themes that appear in a number of the commentaries: first, whether the view I have proposed goes too far or not far enough in deferring to individual patients; and second, the epistemic challenge that would be faced when trying to put this approach into practice. Theoretical accounts of the link between preferences and either well-being or autonomy face a familiar tension: if well-being or autonomy are tied too closely to individuals’ actual preferences, one must contend with examples of preferences that seem obviously bad for a person or disconnected from their status as …. (shrink)

In his featured article, Makins suggests that healthcare professionals ought to defer to patients’ higher-order attitudes towards their risk attitudes when making medical decisions under uncertainty.1 He contends that this deferential approach is consistent with widely held antipaternalistic views about medicine. While Makins offers novel, insightful and provocative perspectives, we illustrate in this commentary that the theory suffers from some weaknesses and shortcomings that limit its persuasiveness and applicability and professionals should take a cautious approach when applying it to their (...) healthcare practice. While Makins does not provide a clear and consistent definition of higher-order risk attitudes, in mathematics, higher-order attitudes should be defined by the sign and shape of the derivatives of the utility or value function beyond the second order. Prudence is defined by a positive third derivative (convex marginal utility), while temperance is defined by a negative fourth derivative (concave second derivative).2 It is worth noting that higher-order attitudes are domain-specific, context-dependent and situation-sensitive. They vary depending on the framing, wording, format or presentation of the choice problem, …. (shrink)

Nicholas Makins makes a valuable contribution to the literature on medical decision-making, highlighting the role that risk attitudes play in deliberation and subsequently arguing that, in medical choices under uncertainty, if considerations of autonomy and beneficence support deference to patient values and outcome preferences then they also support deference to patients’ attitudes to risk.1 Crucially, however, Makins suggests that it is not simply first-order risk attitudes that are the appropriate target of deference but, rather, patients’ higher-order risk attitudes. In other (...) words, Makins argues that if considerations of autonomy and beneficence support deference in medical decision-making, this deference should include the risk attitudes that individuals desire to have or reflectively endorse. This commentary draws out a morally relevant and overlooked distinction between: (1) deferring to patients’ higher-order attitudes that endorse the first-order risk attitudes they currently hold. and (2) deferring to patients’ higher-order attitudes that endorse risk attitudes that are at odds with the first-order risk attitudes they currently hold (which equates to a higher-order desire to change one’s first-order risk-attitudes). I agree with Makins that if respect for autonomy and beneficence support deference to patient preferences, then these considerations may also support deference to at least some higher-order risk attitudes, namely, those of type (1). But I think that whether they support deference to those of type (2) is less clear. In particular, it does not …. (shrink)

Makins’s analysis of the philosophical justification of decision-making understates and so misinterprets the importance of patient values to ‘the deference principle.’ (Makins N,1, p1) He assesses autonomy and beneficence as two separate arguments in support of deferring to patient preferences, but they only work well considered together. Further, neither the constitutive nor the evidential view of beneficence fully recognises the importance of patient values to understanding the patient’s worldview, which in turn determines what risks and benefits matter most. Revising these (...) arguments enables a much fuller understanding of the importance of patient values to the practice of medicine, which will in turn improve the refinement of the deference principle. Autonomy requires beneficence, and vice versa, for either of them to be sufficient arguments for deferring to patient choices. Focusing on autonomy alone to justify deference overstates the value of choice in and of itself, as good medicine does not pursue just any choices. It seeks informed consent, which means that the choices we truly value are those made while understanding what is importantly relevant to the choice. A well-informed decision includes data about expected side effects and likelihood of beneficial effects; but it also includes knowing the patient’s values and goals. One must know what is actually valuable …. (shrink)

Nicholas Makins proposes that doctors should take a deferential attitude towards their patients’ preferences when making decisions, and this includes their risk attitudes.1 He grounds this proposal in the principles of autonomy and beneficence. Makins appears to hold autonomy as a good in and of itself, and so for him it follows that deferring to patients must also be good. He also seems to hold that the satisfaction of personal preferences inevitably leads to improved well-being, and so deferring to patients’ (...) risk attitudes upholds the principle of beneficence. Unfortunately, Makins explicitly avoids defining well-being. His account seems to ignore the possibility of an objective measure of health that could contravene patient preferences, and therefore, challenge a deferential approach. While it is true that medicine is replete with complex decisions and significant uncertainty which require value judgements to navigate, it is not true medicine is purely about satisfying preferences. Patient preferences should always guide clinical decisions, but it seems to me Makins is making the far stronger claim that a doctor should act as a substitute decision-maker of sorts, doing their best to make the decision as if they were the patient themselves. I would contend this is not a good idea, as it would clearly impact a doctor’s …. (shrink)

Makins1 formulates a deference principle which states that patients’ attitudes towards the health outcomes associated with different treatment options should drive decision-making and not physicians’ attitudes towards these health outcomes. Although this deference principle is widely agreed on, it is less obvious which role patients’ risk attitudes should play. Makins takes patients’ attitudes towards health outcomes to be sufficiently analogous to patients’ risk attitudes in order to extend his deference principle. His extended deference principle states that patients’ attitudes towards the (...) health outcomes and risks associated with different treatment options should drive decision-making and not physicians’ attitudes towards these health outcomes and risks. This extension is not only taken to be ethically preferable, but also practically realisable as one can reliably trace patients’ (risk) attitudes. Problematic situations arise when patients exhibit risk attitudes they do not reflexively endorse. For instance, patients might systematically make more risky choices than they think they should make. In response to these kinds of situations, Makins proposes to revise his deference …. (shrink)

In his paper, ‘Patients, doctors and risk attitudes’, Makins argues that doctors, when choosing a treatment for their patient, need to follow their risk profile.1 He presents a pair of fictitious diseases facing a patient who either has ‘exemplitis’, which requires no treatment or ‘caseopathy’, which is severe and disabling and for which there is a treatment with unpleasant side effects. The doctor needs to decide whether the patient should pursue the unpleasant treatment, just in case he has caseopathy. Makins (...) believes that rational-choice theory is a productive way to approach this problem. This theory frames all decisions as gambles. Each possible gamble (eg, not to pursue treatment) leads, probabilistically, to a set of outcomes (life with no disease and no side effects, but also, possibly, life with a disabling disease, since no treatment is taken). Utilities of these outcomes and probabilities that they will happen are combined to yield a number—expected utility. One is supposed to gamble—to make a choice—in a way that maximises this expected utility. Makins takes this framework for granted and is focused on an additional complication, the patient’s risk preference. He believes that, in his hypothetical example, even if expected utility were exactly the same, withholding treatment …. (shrink)