Fuzzy trace theory and medical decisions by minors: differences in reasoning between adolescents and adults

State Authority, Parental Authority, and the Rights of Mature Minors

When mature minors face a decision with important consequences, such as whether to undergo a risky but potentially life-saving medical procedure, who should decide? Relying on liberal political theory's account of the importance of decisional autonomy for adults, and given the scalar nature of the capacities needed to exercise decisional autonomy, I argue that mature minors with the requisite capacities and commitments have a right to decisional autonomy though they are not yet 18. I argue for this right using a 'balancing of interest' account of rights: the interest mature minors have in decisional autonomy outweighs their parents' interest in shaping their children as a means of 'creative self-extension'. But I propose two limitations on this right: requests for waivers of the rule that one must be at least 18 to decide cannot be so numerous as to make adjudication impractical; and though a competent adult's voluntary decision to refuse medical treatment should generally be respected, the state may reject a mature minor's decision upon review by an indifferent judge of the minor's capacities and reasons. The judge reviews not the substantive merits or prudence of the decision, but whether the decision promotes the interest in decisional autonomy, by asking among other things whether the decision is the minor's own, is tethered to core commitments rather than based on arbitrary preferences, and could be regarded as reasonable to the minor's 'future self'.

Top Ten Tips Palliative Care Clinicians Should Know About Medical Decision-Making Capacity Assessment

Palliative care (PC) clinicians treat seriously ill patients who are at increased risk for compromised decision-making capacity (DMC). These patients face profound and complex questions about which treatments to accept and which to decline. PC clinicians, therefore, have the especially difficult task of performing thorough, fair, and accurate DMC assessments in the face of the complex effects of terminal illness, which may be complicated by fluctuating acute medical conditions, mental illness, or cognitive dysfunction. This study, written by a team of clinicians with expertise in PC, ethics, psychiatry, pediatrics, and geriatrics, aims to provide expert guidance to PC clinicians on best practice for complex DMC assessment.

Young adult consumers’ involvement in branded smartphone based service apps

Purpose

The purpose of this paper is to investigate various factors that shape young adult consumers’ smartphone-based service app involvement and their subsequent development of brand loyalty for the app.

Design/methodology/approach

A survey was conducted to test the hypothesized relationships. The survey data were analyzed using SPSS-based PROCESS macro (Hayes, 2013).

Findings

The study results show that consumer can perceive an app to be largely hedonic or utilitarian, and the perceived app design (hedonic vs utilitarian) impacts consumers’ involvement with a particular service app category. Further, the findings elucidate that the impact of app hedonism on app category involvement is moderated by consumer’s surfing task orientation and the extent to which app arouses their imagination. On the other hand, the impact of app utilitarianism on app involvement is moderated by consumer’s information-seeking task orientation and perceived relevance of the information. Finally, app category involvement predicts loyalty toward a particular brand in the service app category. The effect of app involvement on brand loyalty is moderated by hot and cold brand relationship quality in cases of hedonic and utilitarian apps, respectively.

Originality/value

The value of this research lies in identifying relevant managerially actionable moderators that shape the relationships between perceived dominant app design (hedonic vs utilitarian), app category involvement and app brand loyalty.

Family-Based Consent to Organ Transplantation: A Cross-Cultural Exploration

This special thematic issue of The Journal of Medicine and Philosophy brings together a cross-cultural set of scholars from Asia, Europe, and North America critically to explore foundational questions of familial authority and the implications of such findings for organ procurement policies designed to increase access to transplantation. The substantial disparity between the available supply of human organs and demand for organ transplantation creates significant pressure to manipulate public policy to increase organ procurement. As the articles in this issue explore, however, even if well intentioned, the desire to maximize organ procurement does not justify undermining foundational elements of human flourishing, such as the family. While defending at times quite different understandings of autonomy, informed consent, and familial authority, each author makes clear that a principled appreciation of the family is necessary. Otherwise, health care practice will treat the family in a cynical and instrumental fashion unlikely to support social or individual good.

Adolescents, neurosciences et prise de décisions médicales : devrions-nous revoir certaines dispositions du Code civil du Québec?

Au Québec, le mineur de 14 ans et plus peut consentir seul aux soins médicaux requis par son état de santé, sauf exception. Or, les données provenant des neurosciences indiquent que : 1) l’acquisition de la « maturité cérébrale » est un processus continu, pouvant durer jusqu’à la mi-vingtaine, et que 2) certaines habiletés décisionnelles de l’adolescent, comme l’évaluation des risques et bénéfices à court et à long terme, seraient différentes de celles des adultes, surtout dans les situations émotivement chargées. Nous soumettons que, dans une perspective de protection de l’intérêt supérieur de l’enfant, la réalité neurophysiologique de l’adolescent devrait être prise en compte en contexte de soins de santé. Ainsi, nous questionnons le caractère adéquat de la présomption de capacité d’exercer un jugement de façon autonome dès l’âge de 14 ans et soulignons l’aspect paradoxal de la possibilité d’une intervention judiciaire en cas de refus de traitement. Nous questionnons également la pertinence de considérations d’âge dans le cadre de la relation entre le médecin et son patient, dès lors que la détermination de la capacité décisionnelle est une composante essentielle de l’obtention d’un consentement libre et éclairé. Enfin, nous questionnons l’exclusion des parents du processus décisionnel, à la fois en regard de leur responsabilité parentale et des bénéfices que peuvent représenter leurs conseils pour l’adolescent. Par conséquent, nous soumettons qu’une évaluation du bien-fondé de l’octroi d’un pouvoir décisionnel à l’adolescent de 14 ans et plus serait souhaitable et qu’un régime uniformisé tout au long de la minorité, avec de possibles exceptions, reflèterait mieux les connaissances scientifiques actuelles.

Illness-Specific Risk-Taking in Adolescence: A Missing Piece of the Nonadherence Puzzle for Youth With Type 1 Diabetes?

Risky behavior is often at its lifetime peak in adolescence. Chronic illness creates additional opportunities for risk because nonadherence behaviors can jeopardize adolescents' health. Adolescents with type 1 diabetes could engage in risky behavior around insulin administration that would put them in danger of severe health consequences. It is possible that some nonadherence behaviors observed in adolescents with type 1 diabetes may result from youth taking risks with their medical treatment. Illness-specific risk-taking behaviors are not captured in most assessments of adherence, which primarily focus on frequency of adherence behaviors. This article reviews current models of general risk-taking and their implications for diabetes management. The authors argue that illness-specific risk-taking may be an important, understudied aspect of illness management that can inform future studies and treatment of nonadherence in adolescents with type 1 diabetes.

Understanding Genetic Breast Cancer Risk: Processing Loci of the BRCA Gist Intelligent Tutoring System

The BRCA Gist Intelligent Tutoring System helps women understand and make decisions about genetic testing for breast cancer risk. BRCA Gist is guided by Fuzzy-Trace Theory, (FTT) and built using AutoTutor Lite. It responds differently to participants depending on what they say. Seven tutorial dialogues requiring explanation and argumentation are guided by three FTT concepts: forming gist explanations in one's own words, emphasizing decision-relevant information, and deliberating the consequences of decision alternatives. Participants were randomly assigned to BRCA Gist, a control, or impoverished BRCA Gist conditions removing gist explanation dialogues, argumentation dialogues, or FTT images. All BRCA Gist conditions performed significantly better than controls on knowledge, comprehension, and risk assessment. Significant differences in knowledge, comprehension, and fine-grained dialogue analyses demonstrate the efficacy of gist explanation dialogues. FTT images significantly increased knowledge. Providing more elements in arguments against testing correlated with increased knowledge and comprehension.

Gist Representations and Communication of Risks about HIV-AIDS: A Fuzzy-Trace Theory Approach

As predicted by fuzzy-trace theory, people with a range of training—from untrained adolescents to expert physicians—are susceptible to biases and errors in judgment and perception of HIV-AIDS risk. To explain why this occurs, we introduce fuzzy-trace theory as a theoretical perspective that describes these errors to be a function of knowledge deficits, gist-based representation of risk categories, retrieval failure for risk knowledge, and processing interference (e.g., base-rate neglect) in combining risk estimates. These principles explain how people perceive HIV-AIDS risk and why they take risks with potentially lethal outcomes, often despite rote (verbatim) knowledge.For example, people inappropriately generalize the wrong gist about condoms' effectiveness against fluid-borne disease to diseases that are transferred skin-to-skin, such as HPV. We also describe how variation in processing in adolescence (e.g., more verbatim processing compared to adults) can be a route to risk-taking that explains key aspects of why many people are infected with HIV in youth, as well as how interventions that emphasize bottom-line gists communicate risks effectively.

Child euthanasia: should we just not talk about it?

Belgium has recently extended its euthanasia legislation to minors, making it the first legislation in the world that does not specify any age limit. I consider two strands in the opposition to this legislation. First, I identify five arguments in the public debate to the effect that euthanasia for minors is somehow worse than euthanasia for adults--viz, arguments from weightiness, capability of discernment, pressure, sensitivity and sufficient palliative care--and show that these arguments are wanting. Second, there is another position in the public debate that wishes to keep the current age restriction on the books and have ethics boards exercise discretion in euthanasia decisions for minors. I interpret this position on the background of Velleman's 'Against the Right to Die' and show that, although costs remain substantial, it actually can provide some qualified support against extending euthanasia legislation to minors.

Decision making and cancer

We review decision making along the cancer continuum in the contemporary context of informed and shared decision making in which patients are encouraged to take a more active role in their health care. We discuss challenges to achieving informed and shared decision making, including cognitive limitations and emotional factors, but argue that understanding the mechanisms of decision making offers hope for improving decision support. Theoretical approaches to decision making that explain cognition, emotion, and their interaction are described, including classical psychophysical approaches, dual-process approaches that focus on conflicts between emotion versus cognition (or reason), and modern integrative approaches such as fuzzy-trace theory. In contrast to the earlier emphasis on rote use of numerical detail, modern approaches emphasize understanding the bottom-line gist of options (which encompasses emotion and other influences on meaning) and retrieving relevant social and moral values to apply to those gist representations. Finally, research on interventions to support better decision making in clinical settings is reviewed, drawing out implications for future research on decision making and cancer.

Ethics of pharmacological research involving adolescents

Pharmacological research in the adolescent population is not meeting adolescents' needs. Medication is still frequently prescribed off label, and studies especially in sensitive areas of adolescent health care are underrepresented. Adolescents did not benefit from the new knowledge gained in cancer research, and their outcome has essentially not improved during the last two decades in comparison to younger children and adults. There are many obstacles that make it challenging to enroll adolescents in pharmacological research. Access can be difficult. Confidentiality plays an essential role for minors and may be a hindrance, notably to studying sexual and mental health matters. Pharmaceutical companies may exclude the adolescent patient because of a lack of profit and in fear of a complex study design. Research concepts should be explained to the adolescent in a comprehensive manner, and assent and consent forms should be clear and understandable. New laws and incentives have been developed to encourage pharmaceutical companies to engage adolescents in their research projects. Centralization and collaboration of all parties involved may make the whole approach to adolescent research more efficient and uniform. The mature minor doctrine has facilitated the enrollment process. Parental consent may be waived for low-risk medical trials to promote recruitment. Ethics committees therefore play a major role in protecting the adolescent from harm from participating in research. In conclusion, pharmacological research in adolescents has to be encouraged. This will increase the safety of current medical treatment regimens and will allow this population to benefit from therapeutic advancements.

An Overview of Judgment and Decision Making Research Through the Lens of Fuzzy Trace Theory

We present the basic tenets of fuzzy trace theory, a comprehensive theory of memory, judgment, and decision making that is grounded in research on how information is stored as knowledge, mentally represented, retrieved from storage, and processed. In doing so, we highlight how it is distinguished from traditional models of decision making in that gist reasoning plays a central role. The theory also distinguishes advanced intuition from primitive impulsivity. It predicts that different sorts of errors occur with respect to each component of judgment and decision making: background knowledge, representation, retrieval, and processing. Classic errors in the judgment and decision making literature, such as risky-choice framing and the conjunction fallacy, are accounted for by fuzzy trace theory and new results generated by the theory contradict traditional approaches. We also describe how developmental changes in brain and behavior offer crucial insight into adult cognitive processing. Research investigating brain and behavior in developing and special populations supports fuzzy trace theory's predictions about reliance on gist processing.

Communicating Numerical Risk: Human Factors That Aid Understanding in Health Care

In this chapter, we review evidence from the human factors literature that verbal and visual formats can help increase the understanding of numerical risk information in health care. These visual representations of risk are grounded in empirically supported theory. As background, we first review research showing that people often have difficulty understanding numerical risks and benefits in health information. In particular, we discuss how understanding the meanings of numbers results in healthier decisions. Then, we discuss the processes that determine how communication of numerical risks can enhance (or degrade) health judgments and decisions. Specifically, we examine two different approaches to risk communication: a traditional approach and fuzzy-trace theory. Applying research on the complications of understanding and communicating risks, we then highlight how different visual representations are best suited to communicating different risk messages (i.e., their gist). In particular, we review verbal and visual messages that highlight gist representations that can better communicate health information and improve informed decision making. This discussion is informed by human factors theories and methods, which involve the study of how to maximize the interaction between humans and the tools they use. Finally, we present implications and recommendations for future research on human factors in health care.