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Reconsidering risk attitudes: why higher-order attitudes hinder medical decision-making
  1. Liam Francis Ryan1,
  2. Jennifer Blumenthal-Barby2
  1. 1 Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, Illinois, USA
  2. 2 Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
  1. Correspondence to Liam Francis Ryan, Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA, 60515; liam.ryan{at}

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In his paper, ‘Patients, doctors and risk attitudes,’ Nicholas Makins1 argues that healthcare professionals should defer to a patient’s higher-order risk attitudes (ie, the risk attitudes they desire to have or endorse within themselves upon reflection) when making medical decisions. We argue against Makins’ deference to higher-order risk attitudes on the basis that (1) there are significant practical concerns regarding our ability to easily and consistently access and verify the higher-order risk attitudes of patients, (2) there is a lack of a theoretical limit on higher-order risk attitudes (eg, second, third, fourth order), and (3) the consideration of higher-order risk attitudes is actually more paternalistic than Makins suggests because it narrows what counts as an autonomous preference to the limited occasions in which an individual actually reflects on his or her own risk attitude.

On the issue of practicality, we can reasonably expect that healthcare professionals would find difficulty eliciting the higher-order risk attitudes of their patients. Take for example the patient who has never expressed his higher-order desire to be more risk adverse and who is not willing nor comfortable expressing this desire. What is the healthcare professional expected to do in this situation? This is even more of a concern for the incapacitated patient, to which Makins seems to imply that …

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  • Contributors LFR made substantial contributions to the design, drafting and revision of the work. JB-B made substantial contributions to the design and revision of the work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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