Fuzzy trace theory and adolescent medical decisions

fttimagesThis post is based on the paper, “Fuzzy Trace Theory and Medical Decisions by Minors:  Differences in Reasoning between Adolescents and Adults,” by Evan Wilhelms and Valerie Reyna that appeared in the June 2013, Journal of Medical Philosophy. This is an application of Fuzzy Trace Theory to the medical decision setting. The concept is more generally addressed in the first of three posts: FTT Meaning, Memory, and Development.

The mature minor exception allows adolescents under the age of 18 to make medical decisions and consent to procedures with equivalent authority of an adult. Although this was originally conceived to be applied in emergency situations in which parents are not available, it now according to Wilhelms and Reyna represents a blanket exception for those over the age of 14, so long as the benefits outweigh the risks and the adolescent is not otherwise deemed intellectually incapable. This expansion of rights has been used for easier access to abortion and contraceptives without parental consent, as well as the access to treatment for sexually transmitted infections, addictions, mental health problems and prenatal care. On occasion, this expanded legal standing of minors has been used to justify treatment refusal.

Parents’ concerns are more likely to include long-term considerations than are adolescents’, such as infertility. That is, planning for future health and well-being are generally not as salient in the mind of the adolescent patient. Treatment decisions that entail immediately unpleasant consequences, including pain, nausea, and hair loss, are likely to be unduly weighted relative to long-term consequences. One important question, then, is can adolescents fully appreciate the tradeoffs between short-term unpleasant or socially embarrassing side effects as opposed to long-term health consequences and quality of life.

According to Fuzzy Trace Theory, adolescents are not just more emotional and impulsive than adults; their understanding of the gist of such decisions is not mature. More specifically, adult decisions more heavily rely on intuitive, bottom-line gist representations. Prior to the acquisition of such insight, adolescent processing of risky decision making resembles solving a mathematics problem. An adolescent chemotherapy patient might decide to consume alcohol despite the accurate perception that it would reduce the effectiveness of the treatment. One might argue that she was merely trading off the relative risks and rewards: the pleasure of fitting in socially by drinking compared to the reduction in treatment effectiveness. In contrast, according to Fuzzy Trace Theory, mature understanding of the gist of this situation would be a rejection of the standard model of trading off (e.g., trading off social benefits against survival); such compensatory reasoning would indicate a fundamental failure of insight (despite full knowledge of the facts) that survival trumps everything.

Gist representations preserve meaning, i.e., patterns, inferences, and themes. Numerical representations, in particular, are critical to the understanding of how adults and adolescents process risk and make decisions. For example, an individual might be required to choose between two treatment options, which carry with them a 6% and 18% chance of severe side-effects, respectively. The information can be encoded with an exact verbatim representation (i.e., the exact values of 6% and 18% associated with each treatment), with an ordinal gist representation (i.e., “the second treatment is riskier”), or with a categorical representation (i.e., “both treatments carry some risk”).

Crucially, for decision making, note that the gist of information is an interpretation that extracts the important nub of information, such as whether a medication is safe or risky or whether the risk is low or high. Gist, because it reflects meaning, depends on content and context. For example, an 18% risk of a heart attack is pretty high, whereas an 18% risk of catching a cold is pretty low. Adults have a fuzzy processing preference, meaning that they use the simplest gist they can to make decisions. Adolescents, in contrast, are more likely to focus on more precise representations toward the verbatim end of the gist-verbatim continuum. Thus, adults and adolescents reason in qualitatively different ways, which implies that minors will not base their “consent” on the same processes as adults.

Emotion increases one’s level of arousal, which interferes more with verbatim processing than with gist processing according to Fuzzy Trace Theory. Many treatment decisions are accompanied by a high level of arousal—such as being informed that you have cancer. Therefore, Fuzzy Trace Theory predicts that arousal that accompanies medical decisions will be more impairing for adolescents than adults, because of the nature of their information processing. If an adolescent is generally less likely to be using stored gist representations, the revelation of a grim diagnosis is more likely to result in confusion of the verbatim information they receive regarding details about treatment options, risks, and prognoses.

Ironically, adolescents may seem more rational and logical than adults, but that mode of thought signals immature judgment in situations in which tradeoffs are unhealthy (e.g., risking HIV because the probability of transmission is low).

One of the other major differences between Fuzzy Trace Theory and the standard model of adolescent reasoning is that reliance on gist processing can have a protective effect, and that the deliberative analysis that is the ideal of the standard dual-process models can backfire.
However, in order for this protective effect to exist, an individual must first encode an
advanced gist that reflects an accurate and healthy understanding of the situation, and
subsequently the individual must retrieve and process that gist at the moment of deciding.
The accurate encoding of advanced gists, especially in medical or health-related domains, is
not without challenges.

Similarly, during the process of informed consent; patients may read the document they must sign that grants consent and acknowledges risks, but without the additional context, such as pertinent medical knowledge that is not included in the consent document, they retain or understand very little of it. Without this understanding of the procedure the patient is consenting to—the gist of the procedure and risks—then consent to the procedure is not informed, according to Fuzzy Trace Theory. The successful encoding of gist is also a critical element of informed consent in medical practice in that the gist representations of numbers also represent an essential element of understanding the risks involved in consenting to medical procedures. As informed consent requires patients to have an understanding of risks, questions such as whether the patient has an appropriate interpretation of risk magnitude are of critical import. Consider the example of consenting to a surgical procedure for which there is a 2% chance of serious complications. A patient who recalled a risk of 0% would reflect closer verbatim accuracy than a patient who recalled a risk of 10%, although the former’s report of the procedure entailing objectively no risk represents a fundamental misunderstanding compared to the latter patient.  Because of developmental differences in gist processing, adults would be more likely to clearly appreciate the significance of this categorical contrast in safety versus risk, compared to adolescents.

Wilhelms and Reyna suggest that it could be said that some adolescents know “the price of everything but the value of nothing”. They further conclude that given the necessity of the advanced cognitive reasoning that comes with adulthood—i.e., a reliance on gist processing—and its role in both the risky choices necessary in medical decision making and in informed consent, the mature minor exception should remain an exception. If the exception is necessary for an emergency situation, the physician or medical experts involved should emphasize the bottom-line gist of risks involved during the process of consent or deciding on treatment options.  Even in this case, however, these conclusions regarding the potential protective effect of gist understanding and its critical role in informed consent are still warranted, as many who make these decisions in unfamiliar medical contexts are novices, both adults and adolescents.

Wilhelms, E A., Reyna V. F.,(2013). “Fuzzy Trace Theory and Medical Decisions by Minors:
Differences in Reasoning between Adolescents and Adults.” J Med Philos. 2013 June ; 38(3): 268–282.

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