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Home , Affective forecasting, Suffering

Responses and Dialogue Reconsidering the Impact of

NADA GLIGOROV

A response to ‘‘Affective Forecasting and Its Implication for Medical ’’ by Rosamond Rhodes and James J. Strain (CQ 17(1))

In the article ‘‘Affective Forecasting and forecasting is as all-encompassing as the Its Implications for ,’’ authors claim. In the next section, I Rhodes and Strain1 present current re- consider the effects of in affec- search documenting a psychological tive forecasting on policymakers. I as- that affects our ability to correctly sert that, although the research on the predict future emotional states. The reveals misconceptions bias they discuss is the wrongful esti- about what is needed for , it mation of the emotional impact of does not provide guidelines for en- significant events. Research on affec- dorsing policies. In the third section, I tive forecasting by T.D. Wilson and consider how the bias affects doctors D.T. Gilbert2 indicates that people tend and patients differently. I argue that to overestimate both the positive and doctors are not affected by the bias in negative impact of events. Rhodes and the same way as patients. In the fourth Strain correctly note that the conclu- section, I argue against Rhodes and sions derived from the research—that Strain and claim that affective forecast- bad events do not seem to us as ing does not diminish decisional ca- much as previously assumed—has appli- pacity. I argue further that because cations for . In a field where the bias is incorrigible, paternalism doctors are often faced with delivering will not help in restoring patient bad news and offering treatments that . will significantly alter the lives of their patients, that bad events Values and the Impact Bias are not as deleterious as once thought is news. Wilson and Gilbert’s research purports I argue in agreement with the authors to capture a universal psychological that the research on the impact bias could mechanism. As such, the bias affects support an change in terms of all people who make predictions based how doctors approach and communicate on future emotional states. Rhodes and with their patients. It can contribute, also, Strain claim that ‘‘once we recognize to a change in attitude when doctors are that affective forecasting is part of faced with the grim task of telling patients normal , we are that they have a chronic illness or that alerted to consider just who in the they are faced with making difficult deci- medical environment is susceptible to sions about their . its effects. Patients are. The families of I disagree, however, that the pre- patients are. Clinicians are. And poli- dicted impact of the biases in emotional cymakers are.’’3

Cambridge Quarterly of Healthcare Ethics (2009), 18, 166–173. Printed in the USA. Copyright Ó 2009 Cambridge University Press 0963-1801/09 $20.00 166 doi:10.1017/S0963180109090276 Responses and Dialogue

Let us first consider the influence ness. Doctors, policymakers, and pa- of this psychological bias on policy- tients share this predicament, but I makers. The research on the impact do not take that to indicate that par- bias cannot offer any help when it ticular policies are the result of the comes to policy issues because the impact bias. Rhodes and Strain’s claim results of the research are explanatory is that affective forecasting biases in- and not predictive. The research shows fluence policymaker’s decisions. Con- that we are not good predictors of our sider policies regarding promotion of future emotional states but it does not health.Wecanconcludebasedonthe allow for predictions about what will new information about the impact bias make us happy. Policies, however, are that not being healthy is not as devas- an attempt to promote or protect uni- tating emotionally as we once thought. versally held values. If the studies on Plenty of people can be happy even affective forecasting were to have an if they have lived through or are still impact on policymaking, they should living with illness. We may not need help in the selection values to be en- health for happiness. But does this dorsed. I claim that the affective fore- mean that policies promoting health casting research cannot be used to do that. are based on biased affective forecast- I take affective forecasting research to ing? I assume that most people would show that there is a disconnect between disagree with that conclusion. Even if some of our values, which are in we decide that health is no longer termsofwhatweexpectwillmakeus worth promoting, predictions about happy, and what actually makes us which values should be promoted can- happy. The findings indicate that there not be based on affective forecasting. is not a clear connection between what If emotional states do not trail or we and pursue—like health, em- depend on the events in one’s life, ployment, wealth, and prestige—and one can only conclude that what we happiness. In other words, the research thought were necessary ingredients for shows that there is a cleavage between happiness are not essential to it. Poli- some of our current commonly held cies are meant to endorse generally values and what we require for happi- accepted values that rest on ideas peo- ness. The disconnection between happi- ple have about what is good or worth ness and values was manifested in the promoting. If we do not require good following way: People tend to overesti- events, or the absence of bad events, mate their emotional reaction to nega- for happiness, one has no resources tive events, but also to positive ones.4 It left for making predictions about what is not just that losing a limb does not to promote. One can conclude that make somebody as unhappy as pre- the impact bias research indicates that dicted, but that positive events, such as illness might not devastate your life job promotions, are not likely to make but that research does not provide one as happy as predicted. Significant guidance in the selection of policies events do not seem to make a large, pertaining to healthcare. lasting difference on our emotional con- dition overall. Momentous events might The Impact Bias from Different cause a spike in positive or negative Perspectives , but one ultimately settles back toone’spreviousemotionalstate. Although research on the impact bias The impact bias exposes our deep supports the claim that forecasting ignorance about the nature of happi- biases are part of human psychology,

167 Responses and Dialogue the way in which such biases affect other words, it might be a problem for reasoning is different for patients and me but not for my doctor. At the very those deciding for the patients. least the problem is not of the same Affective forecasting is a first-person nature from the two perspectives. My phenomenon. The research on the bias doctor might know that I will do much supports the view that we tend to be better dealing with my illness than I wrong about our own reactions to expect. She might be able to reason free events. From the first-person point of from bias when it comes to my case. view the bias is incorrigible, because The research itself gives no indication a person who has gone through bad that people deciding for others are events is likely to continue wrongful susceptible to the influence of affective estimates about her future emotional forecasting. Studies only show that states. In fact, we tend to be wrong people are affected with this bias when about how we feel all the time. In they are trying to predict how this or a review of the literature on emotional that event will make them feel. Con- , Christiansen and Safer con- ceivably the doctor might reason by cluded that ‘‘there are apparently no adopting the patient’s perspective and published studies in which a group imagine what it would be like for her of subjects has accurately recalled the to be in the patient’s condition. If the intensity and or frequency of their pre- process of reasoning is simulating the viously recorded .’’5 This con- patient’s point of view, the effects of clusion can be explained in part by the impact bias could be transferred to appealing to the workings of the ‘‘psy- the doctor. It strikes one as much more chological-immune system,’’6 so termed likely that when a doctor is thinking by Gilbert and Wilson. A person recov- about future states of her patient, she is ers emotionally from a traumatic event probably doing so based on probabili- by making of it.7 The negative ties about what happens on average for event becomes normalized and its emo- a particular population. The doctor’s tional impact is less likely to be re- reasoning will be based on her experi- membered accurately. Past good or bad ence with past patients with similar events become less extraordinary be- conditions. Moreover, if the doctor cause of the ameliorating effect of the takes into account information about psychological immune system. Thus, the impact bias, she may reach a differ- the disconfirmation of the prediction entconclusionthanthepatient.Thedoc- remains unnoticed because our mem- tor’s forecast, then, will be free from ory of past emotional states is often error. inaccurate. If we cannot draw on past In contrast to the patient, the doctor experience to generalize for the future, whose reasoning might be influenced the impact bias continues to affect our by the impact bias is not in the same predictions about emotional states.8 predicament as the patient. There is no The brunt of this research indicates reason to argue that the bias is incorri- that, when we are forecasting our own gible from the third-person perspec- future emotional states, the prediction tive. Familiarizing the doctor with the is plagued by errors. The studies, how- bias is likely to influence her thinking ever, do not show that the errors occur about her past and future patients. If when we make prediction about other the doctor has not already concluded peoples’ future emotional states. from experience that people deal with ill- The impact bias may not persist ness better than expected, the affective from the third-person perspective. In forecasting literature should successfully

168 Responses and Dialogue alter the doctor’s point of view about Another source of error in affective delivering bad news and help improve forecasting is framing effects: People with the patient. The tend to focus on the difference between problems that plague emotional mem- two alternatives rather than on simi- ory from the first-person perspective larities. For example, the patient might do not apply to the doctor. Also, the focus on the difference between her life psychological mechanisms that, before and after being diagnosed with in part, cause the bad memory of emo- an illness rather than on the similari- tional events are specific to the first ties. So, the consequences of illness and person and have no consequences on treatment stand out, and the impact of people reasoning for others. the event is exaggerated. The patient Clinicians reasoning about patients’ fails to take into account that much future emotional states are less likely about her life is likely to remain un- to be affected by some of the sug- changed. gested causes of the bias. I number A doctor thinking about her patient some of the sources of the bias and might, however, be able to normalize then illustrate how they differ in their the negative event by reasoning based effects on reasoning of doctors and on previous experiences with her patients. One of the sources of error patients. Clinicians are able to track is undercorrection for the passage of the of their patients after the time. People forecasting their future initial diagnoses and notice improve- emotional states take into account only ment. The doctor, unburdened by the how they will feel right after a nega- first-person errors in emotional mem- tive event and fail to consider that first- ory, is able to holistically appraise the blush emotional reactions will change situation, take into account all the fac- after some time. A person reasoning tors that will contribute to the person’s about how she would feel after being future emotional states, and avoid the diagnosed with a chronic illness is framing affects. likely to make a false prediction be- A further source of the impact bias is cause she does not take into account the projection bias where people fail to that her unhappiness will abate over adjust their predictions to accommo- time. A doctor attempting to make a date for change. Life at the time when prediction for her patient is more likely the patient is faced with the decision to take into account the passage of time to accept a particular treatment could because the prediction is based on be different from life after the treat- different facts, such as her experiences ment. Positive events like the birth of with patients from similar a grandchild or a promotion and neg- conditions. The doctor knows that ative events like death in the family or her other patients’ negative emotional financial troubles could improve or ag- reaction abated after the initial diag- gravate our emotional states, respectively. nosis and can assume that the same All of those things seem to be ignored will happen in the case of the current when predictions about future emo- patient. The doctor’s reasoning is tional states are made. The projection much less likely to be biased by sub- bias, like the other sources of the jective factors that are endemic to per- impact bias, is made from the first- sonal decisions. When reasoning for person point of view. There are no others, people are more likely to make indications that doctors are affected decisions objectively and in accordance by those same errors when predicting with facts. their patient’s future emotional states.

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Similarly as with the framing affects, pass the Understand and Appreciate a doctor familiar with the progress of (U+A) criterion, but the decision to her past patients will be able to apply refuse treatment is deemed irrational that experience to her current and by most people. The definition of ca- future patients. pacity is task specific; so when a doctor The remaining issue is how to rec- is evaluating capacity, he or she is oncile reasoning from the first-person estimating the patient’s ability to make point of view with what we know a decision about a particular medical about the impact bias. Rhodes and treatment. Rational thought can be im- Strain note: ‘‘When affective forecast- paired by mood disorders like depres- ing persists it can have serious conse- sion or a phobia. Rhodes and Strain quences for the affected patient.... assert that affective forecasting is Some patients may avoid seeing a doc- comparable to a ‘‘psychological distor- tor, ... others may avoid disclosing tion’’11 that disables decisional capacity. problems or symptoms.’’9 In addition, I argue that the impact bias dos not the patient might refuse treatment be- impair capacity. As stated previously, cause he not being able to cope the only case in which we need to with the consequences. Inasmuch as about the damaging influences affective forecasting is largely to blame of the impact bias is when the person is for the listed avoidance , it is reasoning from the first-person per- important to consider how the doctor spective and making decisions for her- might communicate with the patient. self. In considering whether the patient deciding for or against a particular treatment is making her decision vol- Reasoning Free from Error untarily, we must first gauge whether Becoming aware of the impact bias and the patient understands and appreci- noting its potential effects on decision- ates the information at hand. Affective making in medicine raises issues of forecasting does not seem to interfere whether one should interfere in order with a person’s ability to understand the to prevent such distortions in judg- diagnosis, prognosis, and likelihood of ment. The impact bias might put a dent risks and benefits and treatment alter- in our regard for patient’s autonomy. natives. The patient should also be able Respect for autonomy calls for the to apply all that information to himself doctor to respect the patient’s decisions in order to appreciate the information in all cases in which the patient has presented about diagnosis and prog- decisional capacity. To have decisional nosis. Biased forecasting about future capacity10 patients must understand the emotional states seems irrelevant in information presented to them (e.g., the both of those steps necessary for de- severity of the diagnoses and possible cisional capacity, because I limit the treatment options), appreciate the in- U+A criterion to medical information formation given to them, and be able to about treatment alternatives. The im- apply the information to their own pact bias also seems not to interfere case. In addition, Gert et al. propose with a patient’s ability to make and that in estimating capacity the doctor communicate a decision that he has is also judging the of a pa- made. The last component of capacity tient’s decision, which is evidenced in pertaining to rationality rests on the the patient’s ability to articulate rea- patient being able to articulate the sons for refusal. This is supposed to reasons behind his decision to refuse cover cases where patients are able to treatment, for example. The reasons

170 Responses and Dialogue cited by the patient should be in accor- Before I continue with my argument dance with the patient’s values. At this I wish to note that if it is indeed true juncture problems with affective fore- that the impact bias is a universal psy- casting could arise. Each person has chological mechanism that affects all her idea of what constitutes a good life, in the same way, there are problems which rests on convictions about what with defining ‘‘reasoning free from er- is necessary for happiness. The person ror.’’ In case we all reason similarly deciding about undergoing medical in- about future emotional states, one would tervention will attempt to forecast her have to posit an idealized criterion for emotional states in accordance with the correct reasoning in order to qualify outcome of treatment. reasoning affected by this type of bias Based on the research about affective as erroneous or skewed. In most cases forecasting, any person reasoning in what is considered rational or nor- this way is likely to be wrong. The cause mal would be defined in terms of an of the problem is not, however, that the average, and in this case the average person has inconsistent reasons for her person’s reasoning is influenced by dissent; the patient is, in fact, reasoning the bias. in accordance with her values. The root According to Rhodes and Strain, of the problem is that what most of us paternalism is needed to restore auton- value turns out not to be what is required omy. Instances where attempts are for a happy life. I see this as the outcome made to restore autonomy to patients of the affective forecasting research. If are cases where the patients are in the my rendition of the problem is correct, grip of a temporary or treatable mental the patient making decisions under the ailment. The patient who is depressed influence of the impact bias has capacity. and refuses treatment will most likely The issue is not that the patient in make a different if her depres- question cannot relate her decision to sion is treated. Persons suffering from previously endorsed values; rather none bipolar disorder might think that they of us are able to correctly cite the values are impervious to illness when in needed for a good life. a manic phase. For patients in those Rhodes and Strain suggest that ‘‘some scenarios, there is a way of rectifying degree of paternalism may, therefore, the problem. Once the person is on be justified to prevent people from medication her reasoning will be free making decisions based on distorted from error and distortion. estimates of their future responses.’’12 The impact bias is not analogous to According to Gerald Dworkin, pater- those instances. The bias is incorrigible; nalism not justified by diminished ca- it is not a temporary ailment impeding pacity is ‘‘hard paternalism.’’13 Hard the reasoning of a patient. People do paternalism is not restricted to patient not reap the benefits of past emotional refusal only in cases where the patient recovery because they do not accurately is deemed not to have decisional ca- remember them. Consequently, even pacity. I do not, in this paper, argue people who have overcome grave cir- about whether such a form of pater- cumstances in the past will continue nalism is a good idea. Let us consider making the same errors in affective the claim that some degree of paternal- forecasting. In that sense, one cannot ism would be needed to restore the restore autonomy, because for most the autonomy of the patient and help her baseline is biased reasoning. In the case in making a decision free from error or of the depressed or the manic patient, distortion. the deviation from normal reasoning is

171 Responses and Dialogue more obvious. Further still, there is an nisms are implicit in the process of established way of treating the patient. recovery. When faced with illness, one Given that the impact bias is a more might not take comfort in the informa- ubiquitous and permanent feature of tion that things will get better with human psychology, it becomes more time or that one is more likely to feel difficult to identify it as a ‘‘psychological better than one expected. At the very distortion.’’ In conclusion, I assert that least, knowing about the literature on the impact bias is not a sign of abnormal the impact bias might not have such reasoning and thus not an indication a large effect, because some of us al- that a person does not have autonomy. ready knew that one can recover even from the worst things in life. The disparities between what we Conclusion know and how we reason are part of The discovery of affective forecasting what restricts the benefits of affective biases reveals something about human forecasting research. In medical ethics, psychology that some of us grasped the impact of the bias is not as extensive intuitively. People tend to be mis- as claimed by Rhodes and Strain. The guided about what constitutes a good information about the bias cannot be life and often find that what they used to draw conclusions about policy assumed they would need for a happy because it does not help identify any life they can do without. We realize— new values and to be promoted. mostly when thinking about other’s Furthermore, the impact bias influences lives—that people overestimate both doctors and patients in different ways, the importance of desirable goals, such which prevents the far-reaching conse- as jobs, attractive spouses, or wins in quences cited by the authors. More sports, and the devastation of negative generally, the biases do not affect people events, such as dissolution of mar- deciding for others as they do people riages or death of close relatives. For making decisions for themselves. Fi- others, we are often able to notice nally, the biases do not affect capacity errors in reasoning but still continue in a way that would justify paternalism making the same mistakes when think- because their ubiquity and permanence ing about our own future. seem to indicate that they are part of The interesting work by Gilbert and the baseline for human reasoning. Wilson points to a problem that one oftenencountersinthemedicalset- ting: People’s ideas about illness do not always approximate the of Notes living with a health condition. One 1. Rhodes R, Strain JJ. Affective forecasting and might even conclude that most people its implications for medical ethics. Cambridge cannot accurately predict what it will Quarterly of Healthcare Ethics 2008;17:56–67. be like for them to live with or face an 2. Gilbert DT, Pinel EC, Wilson TD, Blumberg SJ, Wheatley TP. Immune : A source of illness. This insight might help doc- durability bias in affective forecasting. tors differently than patients. It might Journal of Personality and help doctors deal with the onerous 1998;75(3):617–38; Gilbert DT, Driver-Linn psychological burden of having to tell E, Wilson TD. The trouble with Vronsky: the truth to their patients when the Impact bias in the forecasting of future affective states. In: Barrett LF, Salovey P, truth is not anything anybody would eds. The Wisdom in Feeling: Psychological wish to hear. For patients, the benefits Processes in . New York: of our psychological coping mecha- Guilford; 2002:114–43; Wilson TD, Gilbert DT.

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Affective forecasting. Advances in Experimental 5. Christianson SA, Safer MA. Emotional events Social Psychology 2003;35:345–411. and in autobiographical memory. In: 3. See note 1, Rhodes, Strain 2008:57. Rubin D, ed. Remembering Our Past: Studies in 4. It should be noted that the studies indicate, Autobiographical Memory. Cambridge, UK: in some instances, that there is a difference in Cambridge University Press; 1996:218–43 at happiness between people who have had p. 235. a positive event as opposed to others who 6. See note 2, Gilbert et al. 1998. did not. Gilbert et al. (1998) compared the 7. See note 2, Gilbert et al. 1998:637. levels of happiness for both ‘‘lovers’’ (people 8. A further obstacle to transferring benefits currently in romantic relationships) and from past emotional recovery is that the ‘‘loners’’ (people not currently involved in ‘‘psychological immune system’’ is an un- romantic relationships). The results of the conscious process. People rationalize an research was summarized: ‘‘In short, lovers event in order to cope with it, but the mech- were happier than loners, loners expected anism only works if the person is not aware that becoming involved in a close romantic of it. One could see a parallel in the ‘‘sour relationship would increase their happiness, grapes’’ phenomenon. If one does not get and loners correctly predicted that if they a desired outcome, one deals with it by were to become lovers, they would be just attempting to diminish the desirability of about as happy as old and young lovers that goal. Drawing to that process actually turned out to be’’ (see note 2, Gilbert by alerting the person that he or she has et al. 1998:621). The results seem to indicate a case of the ‘‘sour grapes,’’ will diminish the that positive events actually do contribute to effectiveness of the coping mechanism. levels of happiness. Conclusions drawn from 9. See note 1, Rhodes, Strain 2008:58. the research should not be that the of 10. Gert B, Culver C, Clouser KD. : A the event does not impact happiness level, Return to Fundamentals. New York: Oxford rather that our predictions about how strongly University Press; 1997. we will feel are not always correct. Bad news 11. See note 1, Rhodes, Strain 2008:61. can have a negative affect. One is happier if 12. See note 1, Rhodes, Strain 2008:61. healthy than sick, but getting sick is not as bad 13. Dworkin G. Paternalism. The Monist 1972; as predicted. 56:64–84.

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