Advance Medical Decision-Making Differs Across First- and Third-Person Perspectives

James Toomey, Jonathan Lewis, Ivar Hannikainen, Brian D. Earp

Research output: Contribution to journalArticlepeer-review


Background: Advance healthcare decision-making presumes that a prior treatment preference expressed with sufficient mental capacity (“T1 preference”) should trump a contrary preference expressed after significant cognitive decline (“T2 preference”). This assumption is much debated in normative bioethics, but little is known about lay judgments in this domain. This study investigated participants’ judgments about which preference should be followed, and whether these judgments differed depending on a first-person (deciding for one’s future self) versus third-person (deciding for a friend or stranger) perspective.

Methods: A vignette-based survey was conducted (N = 1445 US Americans; gender-balanced sample), in a 3 (relationship: self, best friend, stranger) × 2 (T1 preference: treat, do not treat) × 2 (T2 contrary preference: ambiguous, unambiguous) design.

Results: Participants were more likely to defer to the incapacitated T2 preference of a third-party, while being more likely to insist on following their own T1 capacitated preference. Further, participants were more likely to conclude that others with substantial cognitive decline were still their “true selves,” which correlated with increased deference to their T2 preferences.

Conclusions: These findings add to the growing evidence that lay intuitions concerning the ethical entitlement to have decisions respected are not only a function of cognition, as would be expected under many traditional bioethical accounts, but also depend on the relationship of the decision to the decisionmaker’s true self.
Original languageEnglish
Pages (from-to)1-9
JournalAJOB Empirical Bioethics
Publication statusPublished - 30 Apr 2024


  • Medical decision-making
  • advance directives
  • experimental bioethics
  • self/other
  • true self


Dive into the research topics of 'Advance Medical Decision-Making Differs Across First- and Third-Person Perspectives'. Together they form a unique fingerprint.

Cite this