• Ethics
• Public Policy

In his featured article, Makins suggests that healthcare professionals ought to defer to patients’ higher-order attitudes towards their risk attitudes when making medical decisions under uncertainty.1 He contends that this deferential approach is consistent with widely held antipaternalistic views about medicine. While Makins offers novel, insightful and provocative perspectives, we illustrate in this commentary that the theory suffers from some weaknesses and shortcomings that limit its persuasiveness and applicability and professionals should take a cautious approach when applying it to their healthcare practice.

While Makins does not provide a clear and consistent definition of higher-order risk attitudes, in mathematics, higher-order attitudes should be defined by the sign and shape of the derivatives of the utility or value function beyond the second order. Prudence is defined by a positive third derivative (convex marginal utility), while temperance is defined by a negative fourth derivative (concave second derivative).2 It is worth noting that higher-order attitudes are domain-specific, context-dependent and situation-sensitive. They vary depending on the framing, wording, format or presentation of the choice problem, …