Should Doctors Take More Risks When Treating Risk-Seeking Patients? An Argument for a Deferential Approach in Medical Decision-Making

By Sofia Weiss Goitiandia

Dr Nicholas Makins, an alumnus of the Philosophy & Medicine project, is a philosopher specialising in the intersections of ethics, decision theory—the study of how people make choices—and the philosophy of medicine. In one of his latest articles, published in the Journal of Medical Ethics, Dr Makins takes a lively debate from decision theory, which centres on understanding decision-makers’ risk attitudes, and examines it through the lens of choices in medicine. Dr Makins argues that, when it comes to medical decision-making, it’s the patient’s, not the doctor’s, risk attitudes that matter.

Medical decisions typically involve at least two parties: a patient and a doctor. Doctors play a pivotal role in providing patients with information about treatment options and their likely outcomes. Nevertheless, there is a general consensus that, in most cases, the patient’s assessment of the desirability of those outcomes ought to guide the course of action. This position, known as ‘the deference principle’ (Makins, 2023, p. 1), reflects the anti-paternalistic thought that has prevailed in medicine over the past century (see, e.g., Will, 2011). It is grounded in respecting patients as independent decision-makers who ought to be free to make informed choices whenever possible (the autonomy principle). It also reflects the idea that medicine ought to promote the well-being, or best interests, of patients (the beneficence principle).

In his article, ‘Patients, doctors and risk attitudes’ (2023), Dr Nicholas Makins argues that this position ought to be expanded. His thesis asserts that medical decision-making should consider not only patients’ preferences about treatment outcomes but also their attitudes to risk.

Evidence suggests that people have different risk preferences when making medical decisions (Makins, 2023, p. 2). Some people are cautious, while others are more willing to take risks. Philosophers increasingly argue that these varying risk attitudes are rational; when an outcome is uncertain, but the likelihoods of the different possibilities are known, individuals are free to choose in more or less risk-averse or risk-inclined ways (see, e.g., Thoma, 2023). For instance, risk-averse patients may prefer a treatment with a highly likely but slightly unpleasant outcome over one with a less probable but more severe outcome. Conversely, a risk-neutral or risk-seeking patient might find the second option more attractive.

Dr Makins contends that if medical decision-making endorses a deferential approach to patients’ preferences about possible outcomes, it should also extend this approach to their risk attitudes.  There are two reasons for this: first, respecting patient autonomy entails striving to make decisions that align with what a patient would choose for themselves, and evidence indicates that risk attitudes play a role in these decisions (see Makins, 2023, p. 2). Second, the fact that patients have preferences about the kinds of risks they would like to be exposed to makes it likely that aligning with their risk attitudes will be good for them, meeting the beneficence principle.

While one might think the case closed here, Dr Makins suggests that unresolved aspects can lead to tensions within the previous arguments. One concern is the ambiguity surrounding what risk attitudes exactly are. Dr Makins’s claims in favour of broadening the deference principle are based on the idea that risk attitudes mirror patients’ values or desires about their options. However, some philosophers, like Professor Lara Buchak (2013), deny that risk attitudes are similar to desires. Instead, they argue that risk attitudes are a way people approach achieving their goals, and therefore, are merely a means to an end.

To illustrate with an example, most of us know people who make decisions based on gut instinct, while others try to reason their way to an answer. These are features of how people make decisions, but they don’t reveal much about how the decision-maker values their options. It would seem strange to imagine doctors deferring to these kinds of features; say, penning a lengthy list of ‘pros’ and ‘cons’, just because this is how their patient usually makes decisions. On Buchak’s view, risk attitudes are akin to these decision-making features. If she is correct, her view would weaken the argument for including them in the deference principle.

Dr Makins isn’t sold on this position. He explains:

‘Maybe it’s because in medicine, versus other parts of life, people are presented with options that are particularly concrete and well-defined, but if patients have preferences towards options involving degrees of risk, then it seems like their risk attitudes have something to do with their desires about the different prospects they face.’

By Dr Makins’s lights, medical decision-making lends intuitive support to the view that risk attitudes capture something about people’s desires. In this way, norms and practices in everyday medicine seem to suggest an answer to a theoretical question in philosophy.

Nonetheless, in his article, Dr Makins shows that even if we embrace Buchak’s view of risk attitudes, we don’t have to abandon the deference principle; instead, it can be adjusted. This adjustment proves to be necessary because the current version of the deference principle is vulnerable to a second objection. To illustrate this critique, imagine a patient who consistently opts for the safer medical option, driven by extreme risk aversion. Despite preferring to play it safe, they secretly wish they didn’t. They recognise that their approach diminishes their chances of reaping some desirable benefits. In this case, it’s questionable whether the patient’s doctor ought to defer to their risk attitudes, which the patient admits are overly cautious.

Dr Makins suggests that the key to resolving this problem is the patient’s dissatisfaction with their risk attitude. Even though the patient makes decisions this way, they would prefer not to do so. In turn, they probably wouldn’t want others to make decisions for them in the same risk-averse manner either. Building on this insight, Dr Makins proposes a revised version of the deference principle: instead of straightforwardly following the patient’s risk attitude, medical decision-makers should consider ‘what [patients] want themselves to want’ (Makins, 2023, p. 3). This adjustment resolves the previous case by showing that when a patient desires a different risk attitude for themselves, their doctor should not adhere to their current attitude. It also evades Buchak’s critique, as even if risk attitudes aren’t desires, patients’ preferences about them are. Therefore, fully engaging with patient preferences seems to require considering patients’ desires about how they would ideally like risky choices to be made for them.

To seal his argument, Dr Makins shows how his modified deference principle upholds autonomy and beneficence. He highlights a widely shared philosophical view asserting that autonomy in moral decision-making hinges on the ability ‘to choose courses of action on the basis of those desires that one endorses’ (Makins, 2023, p. 4). On this view, when making medical decisions on behalf of patients, doctors aiming to respect autonomy ought to be guided by those attitudes, including risk attitudes, that patients endorse. Moreover, it seems probable that the desires patients endorse—i.e., those harmonising with what they would want for themselves—will offer an equally good, if not better, indication of what will maximise their well-being compared to their immediate desires. Take, for example, a person who wants to smoke now but, upon reflection, wishes to quit; following their deeper desire to quit is likely to be better for their well-being. Therefore, by prioritising the desires patients endorse, including those related to their risk attitudes, medical decision-makers can better adhere to the principle of beneficence.

Overall, Dr Makins skilfully constructs his case in favour of a deferential approach to patients’ risk attitudes—specifically, the risk attitudes they desire to have. His arguments connect abstract concepts in philosophy with the real-world philosophical challenges faced by medical decision-makers, leaving readers with an enriched understanding of both.

Link to Dr Makins’s article and citation:

https://jme.bmj.com/content/early/2023/03/09/jme-2022-108665#ref-12

Makins, Nicholas. ‘Patients, Doctors and Risk Attitudes’, Journal of Medical Ethics. Published Online First: 10 March 2023. https://doi.org/10.1136/jme-2022-108665.

Further references:

Buchak, Lara. 2013. Risk and Rationality. Oxford: Oxford University Press.

Thoma, Johanna. ‘Taking Risks on Behalf of Another’, Philosophy Compass 18, no. 3 (27 January 2023): e12898, https://doi.org/10.1111/phc3.12898.

Will, Jonathan F. ‘A Brief Historical and Theoretical Perspective on Patient Autonomy and Medical Decision Making: Part II: The Autonomy Model’, CHEST 139, no. 6 (1 June 2011): 1491–97, https://doi.org/10.1378/chest.11-0516.