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  • Obstacles in the Assessment of Intuitive Decision-Making Capacity
  • Wayne Martin (bio)

Suppose that three patients each independently confront the same high-stakes treatment decision. Perhaps it is an option to terminate a high-risk pregnancy, or to accept a blood transfusion after a catastrophic hemorrhage. Suppose further that the three patients approach their choice in radically different ways. The divergence lies not in the choice made (which may or may not differ), but in the pathway followed in arriving at it.

P1 is a classic analytical reasoner. She enumerates the potential costs and benefits of each option, reviews the probabilities, and makes a decision on the basis of her analysis.

P2 does none of that analytical work. She has a settled and robust prior conviction that settles the treatment question decisively. For her, the path she is asked to consider is ethically forbidden, and she refuses to be drawn into any weighing up of possible pros and cons. When pressed, she explains that even to engage in such analysis would be ethically and religiously problematic: It would be to countenance the possibility that she might engage in an abhorrent act, and it could have the ethically dangerous effect of weakening her resolve to do what she is sure is the right thing.

P3 approaches the decision in yet a different way. For her, the way forward is decisively shaped by her intuitive gut reactions to the two possible courses of action. Unlike P1, she finds it difficult and distressing to engage in an analytical “totting up” on this sensitive and intensely personal matter; unlike P2, she does not subscribe to a moral or religious position with rigidly fixed principles that settle the matter. But she trusts her instincts and follows them.

For most of us, most of the time, decision making about important matters involves some kind of hybrid of the approaches taken by these three patients. Like P1, we reflect on possible outcomes of different choices, but in doing so we also rely in some measure on something more instinctive—both in weighing up incommensurable goods against one another, and in feeling our way toward an overall path of action with which we can feel comfortable. Like P2, our deliberation is guided and constrained by ethical considerations, but typically not in a way that neatly prescribes one course of action. Moreover, our ethical principles themselves are characteristically rooted in some sense of the costs and benefits of adhering to them (analytical reasoning) and an emotional sense for the consequences of violating them (intuition). So we also share something with P3, insofar as our “gut reactions” to challenging decisions play a significant role in shaping our deliberative [End Page 329] response. But we typically are able to supplement our intuitive responses with the forms of reasoning in which P1 and P2 engage.

But if real decision making is typically the product of a mixed deliberative economy, there is risk that our standard techniques for assessing decision-making capacity (DMC) tend to focus predominately, if not exclusively, on the sort of deliberation upon which P1 relies. In a provocative analysis, Helena Hermann, Manuel Trachsel, and Nikola Biller-Andorno have argued that one particularly influential assessment instrument, the so-called MacCAT-T developed in the 1990s by Thomas Grisso and Paul Appelbaum, understands “reasoning” too narrowly in terms of analytical reasoning. Hermann et al. (2017) claim that the unduly narrow standard has two unwelcome consequences. If our assessment of DMC focuses too narrowly on analytical reasoning abilities, we may be blind to the incapacity of individuals whose deficits lie elsewhere. Call this the false-positive problem: A patient who can analytically tot up pros and cons, but is “neither emotionally involved nor appreciative of subjective factors in making the decision,” may be wrongly assessed as competent. On the other side there is a false-negative problem: A patient like P3 might have an advanced ability to process complex information intuitively, but could be deemed incompetent if she fails to engage in the forms of analytical consequential reasoning that the MacCAT-T is said to privilege.

Of the two concerns, the false-positive problem is the less troubling of the two...

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