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Epistemic burdens and the incentives of surrogate decision-makers

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Abstract

We aim to establish the following claim: other factors held constant, the relative weights of the epistemic burdens of competing treatment options serve to determine the options that patient surrogates pursue. Simply put, surrogates confront an incentive, ceteris paribus, to pursue treatment options with respect to which their knowledge is most adequate to the requirements of the case. Regardless of what the patient would choose, options that require more knowledge than the surrogate possesses (or is likely to learn) will either be neglected altogether or deeply discounted in the surrogate’s incentive structure. We establish this claim by arguing that the relation between epistemic burdens and incentives in decision-making is a general feature of surrogate decision-making. After establishing the claim, we draw out some of the implications for surrogate decision-making in medicine and offer philosophical and psychological explanations of the phenomenon.

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Notes

  1. The substituted judgment standard is widely accepted in medical ethics as the primary standard of surrogate decision-making. Some may prefer instead the best interests standard, whereby the surrogate makes decisions according to what she thinks the patient’s interests are. These standards have been thoroughly adjudicated throughout the medical ethics literature. But readers will notice that whether the appropriate standard is substituted judgment or best interest has little bearing on whether our argument is sound.

  2. We mean ‘knowledge’ to refer to both knowledge-that and knowledge-how. Lacking either of these types of knowledge implies that one is ignorant of that proposition or of that skill—ignorance is not limited to ignorance of propositions.

  3. Our use of ‘determine’ is compatible with any of the popular theories of causation. The truth of our claim does not hinge on any particular theory of causation. Also, the word ‘incentive’ is used in the paper in its well-understood sense, especially as commonly used in economics and the social sciences. That incentives play a causal role in decision-making is common currency across the social sciences.

  4. Kibbe and Ford’s (2016) concluding qualification approaches our point, but nevertheless stops well short.

  5. The argument is not materially affected even if the knowledge required to realize O1 is a subset of the knowledge required to realize O2, such that overcoming the epistemic burden of the latter requires overcoming the epistemic burden of the former. If our argument is sound, it remains the case that the relative epistemic burdens of the two options will affect how attractive they are to the subject and, thus, their placement in the subject’s initial incentive structure.

  6. The main thesis does not ultimately hinge on acceptance of this principle, which is not without controversy. One might think that a relation weaker than logical implication holds between ought and can, and still accept that ignorance shapes our incentive structures. The ought-implies-can principle merely illustrates the point in an especially stark way.

  7. That the significance of “can” in “ought implies can” must be something like “deliberately can” follows also from the fact that any other meaning seemingly trivializes the claim. That is, if the meaning of “can” in “ought implies can” is something like “possibly can” or “can, with luck,” then the principle prohibits no possible (in some undefined sense) course of action. We assume that the principle is not trivial.

  8. If one prefers the language of know-how and know-that, the physician is more likely to lack knowledge that the patient’s preferences are X, rather than to lack knowledge of how to achieve a particular medical goal.

  9. Decisions follow the path of least epistemic resistance in the case of personal decisions, also. Suppose that a physician gives you two treatment options, but you are uncertain which option best serves your own interests. Our claim is that, other things being equal, the option you pursue will be the one that imposes the lowest epistemic burden—the option about which your ignorance is most easily repaired.

  10. An option judged to be impossible is ipso facto judged to be epistemically impossible, i.e., to bear an infinitely heavy epistemic burden.

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Correspondence to Parker Crutchfield.

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Crutchfield, P., Scheall, S. Epistemic burdens and the incentives of surrogate decision-makers. Med Health Care and Philos 22, 613–621 (2019). https://doi.org/10.1007/s11019-019-09899-2

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