The reality of life and death decisions
In their article in the December edition, Kitzinger and Wilkinson (‘A matter of life and death’, December 2015) argue that the use of advanced decisions rather than relying on surrogate decisions ensures that end-of-life care reflects our wishes and values. But painting surrogate decisions as errorful and advanced decisions as relatively error-free does not reflect the reality of human decision-making.
As Kitzinger and Wilkinson point out, surrogate decision-making by next of kin is often inaccurate. Systematic research reveals 69 per cent accuracy in predicting hypothetical medical scenarios (e.g. Shalowitz et al., 2006) and chance level for predicting a partner’s end-of-life choices (Suhl et al., 1994). Advance directives, however, are effective neither in improving this accuracy (Ditto et al., 2001) nor in ensuring that patient’s wishes are followed in their end-of-life care (Coppola et al., 2001).
Advance decisions or directives are a form of inter-temporal choice, in which we discount the consequences of outcomes in the remote future more than the immediate future. The rate at which we discount future consequences varies systematically across the lifespan, making it highly relevant to advance directives. Older adults discount future consequences much less than younger adults; therefore the earlier in life the directive is made the less likely it is to reflect the wishes of the older person. Perceived closeness to death affects impulsivity in discounting (Kelley & Schmeichel, 2015), but this mortality salience doesn’t affect everyone in the same way. Whereas wealthier people become more future-oriented and value time they have left more, less well-off people become more impulsive (Griskevicius et al., 2011). Discount rates are generally steeper in people who are less wealthy, educated or healthy (Reimers et al., 2009). The advance directives of some sections of society might therefore be even less likely to accurately reflect their wishes when the hypothetical becomes reality. Notably in the examples of successful advance directives cited by Kitzinger and Wilkinson, there was little time between the directive being made and its coming into effect; this short temporal frame is likely to be the most successful in making accurate predictions, but is still subject to distortions.
Whilst we intuitively feel an authority on our own values and preferences, research shows that we are not good at predicting our long-term preferences (Loewenstein, 2005b) and consequently, advance directives don’t always reflect what we would choose in the reality of the situation (Winter et al., 2010). For example, only 10 per cent of healthy people predict they would undergo chemotherapy as cancer treatment to gain a short increase in life expectancy, but that figure increases to 47 per cent in current cancer patients. This prospective empathy gap is caused when we try to predict our own future preferences in an affective state different from the one we are in; when in acute medical distress we are likely to experience intense fear, anxiety, pain and discomfort, but we make advance decisions about the situation whilst experiencing none of these affective states and are likely to underestimate the influence they will have on motivating any decision we make (Loewenstein, 2005a, 2005b).
Although not immediately apparent, advance decisions might be very similar to surrogate decisions and thus facing the same problems and inaccuracies. Our research into the cognitive processes that people use to make surrogate decisions suggests that people engage in a form of perspective-taking when making decisions on behalf of others (Tunney & Ziegler, 2015b). We tend to make more rational decisions for other people than we make for ourselves, and we discount future consequences less for other people (Ziegler & Tunney, 2012). Two principal reasons for this are the hot–cold empathy gaps (Loewenstein, 2005a, 2005b) and the construal or temporal distance between a decision made about an abstract hypothetical scenario and a concrete situation (Trope & Liberman, 2010).
We think that advance decisions should be treated with caution because the processes used to make an advance decision may be the same as those we use to make surrogate decisions. One of the most common errors in surrogate decision-making is the assumption that other people have preferences that are similar to our own (Marks & Arkes, 2008; Tunney & Ziegler, 2015a), and we are also likely to assume that our future selves are similar to our present self. This assumption is almost certainly wrong (Loewenstein, 2005b; Winter et al., 2010), and may be even more inaccurate than the decision made by our next of kin because our future identities often turn out to be quite different from our younger identity (Parfit, 1984). There are a number of reasons why the decisions that we make on behalf of our future selves might be inaccurate. Personal ethics and values are not fixed. People often become more conservative with age (Truett, 1993), and certainly become less impulsive (Reimers et al., 2009). More importantly those religious values that often are considered important in the refusal of medical treatment are not fixed (McCullough et al., 2005). Of course, religiosity is not the causal variable here and may result from qualitative changes over time in the attribution of personal trust and loyalty towards what Fowler (1991) calls Centres of Value that may include religion but may also include an entirely secular humanism (Fowler, 1991, 2001). Thus a decision to decline treatment that is informed by a religious or personal belief or at one point in time may not be relevant at another point in time as the person’s faith and commitment to those values waxes and wanes over the lifespan (McCullough et al., 2009).
The critical assumption of living wills and advance directives is that we can accurately predict our own long-term preferences, but evidence suggests that this is not the case.
Dr Fenja V. Ziegler
University of Lincoln
Dr Richard J. Tunney
University of Nottingham
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