Decision Making on Behalf of Another: Principals, Agents, and Advance Directives

Rutgers University New Brunswick, New Brunswick NJ

Investigators

Abstract

Many decisions are made on behalf of someone else. For example, family members must sometimes make medical decisions on behalf of an incapacitated loved one. The family member making the decisions (the agent) has to select the options she thinks the patient (the principal) would make if the principal could decide for himself. Economists have described this relationship in abstract terms as the principal-agent problem, where the agent is the person making decisions and the principal is the beneficiary of those decisions. In many situations, the principal has the opportunity to communicate his preferences and objectives to the agent. In surrogate health care decision making, for example, this communication often comes in the form of an advance directive for health care. Despite the recent popularity of advance directives, there is little evidence that they improve the agent's accuracy in predicting what the principal would have wanted. Such failures could result because (a) the principal may incompletely specify his preferences, and (b) the agent may have limited competence to interpret and apply the principal's objectives. The prediction made in the current research is that when such conditions apply, the agent will use one of several heuristics or short cut rules in order to make surrogate decisions on the principal's behalf. Four such heuristics are explored in the proposed studies. A question of major interest is whether use of these heuristics increases or decreases the agreement between the principal's true preferences and the surrogate decisions made by the agent. Seven experiments are proposed. Experiments 1 and 2 will examine principal competence, agent, and when advance directives increase agreement between the agent's surrogate decisions and the decision the principal would make on his own behalf. Experiments 3 - 6 examine four heuristics or strategies hypothesized to be used by agents when they are uncertain as to the principal's preferences. In the projection heuristic, the agent uses her own preferences as a guide to the principal's preferences, sometimes resulting in surrogate decisions that are more similar to the agent's own preferences than to the principal's preferences. In the fiduciary heuristic, the agent is less willing to take risks and more willing to wait for benefits when making surrogate decisions than she would be in making decisions on his own behalf (or than the surrogate would be in making decisions on his own behalf). In the intervention heuristic, the agent role elicits a stronger preference for active or aggressive intervention-like options than does the principal role (under the assumption that principals appoint agents to "do something," rather then to do nothing). In the status quo heuristic, the agent role is associated with a strong preference to stick with the status quo. Finally, unlike Experiments 1 - 6, which will use convenience samples of lay people, Experiment 7 will use elderly medical patients and their designated family member surrogates as the principals and agents in the study. The proposed research brings together basic research on the psychology of decision making and applied health research. It has the potential to illuminate which heuristics help and which ones hinder agents in representing the principal's preferences accurately. The findings could improve the practice of writing advance directives and promote patient autonomy by indicating how to make surrogate judgments more accurate.