Springer

Consent and the Problem of Framing Effects

Author(s): Jason Hanna
Source: Ethical Theory and Moral Practice, Vol. 14, No. 5 (November 2011), pp. 517-531
Published by: Springer
Stable URL: http://www.jstor.org/stable/41472621
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Moral
Ethic
Prac(2011)14:517-531
Theory
DOI 10.1007/s
10677-0
11-9266-y

Consent

and the Problem

of Framing

Effects

JasonHanna

1 February
2011/Published
online:
18February
2011
Accepted:
MediaB.V.2011
Science+Business
Springer
AbstractOurdecision-making
is oftensubjectto framing
effects:
alternative
butequally
of
the
elicit
informative
same
different
choices.
When
a decisionoptions
descriptions
makeris vulnerable
to framing,
she mayconsentunderone description
of theact,which
suggeststhatshe has waivedher right,yetbe disposedto dissentunderan equally
thatshehasnotwaivedherright.
informative
oftheact,whichsuggests
I argue
description
thatinsucha case thedecision-maker's
consent
is simply
irrelevant
tothepermissibility
of
I thenconsider
twoalternative
views.According
tothefirst,
proceeding.
peoplesusceptible
to framing
areable to givevalidconsentso longas theyare sufficiently
informed.
This
I
maintains
an
narrow
focus
on
mere
of
information
to
suggestion,argue,
overly
quantity
the exclusionof otherchoice-affecting
factors.A secondresponse,whichappealsto
is likewiseof littleuse in resolving
themoralproblemposedby
consent,
hypothetical
I concludethatif susceptibility
effects.
to framing
undermines
thevalidityof
framing
we mayhavegoodreasonto reconsider
whether
consenthas therights-waiving
consent,
to it.
function
attributed
commonly
Informed
Rights
Waiver
Framing
Biases
consent
effects
KeywordsConsent
is oftensubjectto framing
Ourdecision-making
effects:
alternative
butequallyinformative
the
elicit
different
of
same
choices.
someofthe
Indeed,
options
impacts
descriptions
framing
mostimportant
decisionswe make.To illustrate,
consider
one classicstudy,
whichasked
toindicate
their
abouttwotreatments
forlungcancer
respondents
hypothetical
preferences
andradiation.
wereprovided
withthefollowing
Somerespondents
ofthe
surgery
description
outcomes
foreachtreatment:
"Of 100peoplehavingsurgery
10willdieduring
32
treatment,
willhavediedby 1 yearand66 willhavediedby5 years.Of 100peoplehavingradiation
nonewilldie during
23 willdie by 1 yearand78 willdie by 5 years"
treatment,
therapy,
et
al.
this
"the
ratedescription."
Otherrespondents
Call
1982,
(McNeil
p. 1260).
mortality
withthesurvival
inwhichthesameoutcomes
wereprovided
ratedescription,
wereexpressed
J.Hanna
(El)
IL 60115,
ofPhilosophy,
Northern
Illinois
Zulauf
USA
915,DeKalb,
Department
University,
e-mail:
jhanna@niu.edu
) Springer

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J.Hanna

518

90 willsurvive
thetreatment
as thelikelihood
of survival
("Of 100peoplehavingsurgery,
hada significant
influence
on therespondents'
andso on).Thepresentation
format
period,"
of thosewhoreceived
the
Whileradiation
was preferred
by forty-four
preferences.
percent
itwas favored
ofthosewhoreceived
the
ratedescription,
byjusteighteen
percent
mortality
ratedescription
et
al.
this
effect
was
survival
1982,p. 1261).Perhaps
(McNeil
surprisingly,
thatit was nota product
of
mostpronounced
respondents,
amongphysician
suggesting
death
"looms
for
it
seems
that
the
risk
of
treatment
Instead,
larger"
misunderstanding.1
during
thanforpeoplegiventhesurvival
ratedescription
ratedescription
peoplegiventhemortality
andKahneman
1981,p.
(McNeilet al. 1982,p. 1262;Shafiret al. 2000,p. 338; Tversky
treatment
is themajordisadvantage
ofsurgery
riskofdeathduring
456). Sincetheincreased
relative
toradiation,
underthemortality
ratedescription.
This
surgery
appearslessattractive
is hardly
seemstoinfluence
decisions
aboutwhether
sortofeffect
rare.Forexample,
framing
to take therapeutic
healthscreening
drugs(Halvorsenet al. 2007), seek preventative
and
et
al.
and
continue
lifesupport
for
Williams-Piehota
2001; Salovey
2004),
(Schneider
infants
et
al.
(Haward
2008).
premature
in psychology
and economics.Its
Framinghas receiveda greatdeal of attention
In thispaper,I
has beenunderappreciated
however.2
by moralphilosophers,
significance
I arguethatwhena personis susceptible
topartly
thisphilosophical
attempt
rectify
neglect.
Ifso,theprevalence
toframing,
herconsent
is simply
irrelevant
tohowshemaybe treated.
of framing
and antieffects
anti-consequentialist
maypose a problemfortheprevailing
viewof consent.
willbe as follows.In Section1, I describetwo
paternalist
My strategy
I thenarguein Section2 that,
viewsofconsentandindicate
whichI shallbe discussing.
to
a
that
this
there
is
case
decision-makers
vulnerable
toframing
are
view,
according
strong
to this
unableto givevalidconsent.In Sections3 and4, I consider
andrejectresponses
Ifnoneof
thatappealto informed
andautonomy.
consent,
consent,
argument
hypothetical
intheway
theseresponses
succeeds,I concludein Section5, consent
maynotbe relevant
thatmostethicists
suppose.
I shallfocuson examplesfrom
fortworeasons:it
thediscussion,
medicine,
Throughout
is a context
inwhichconsent
andinwhichframing
effects
have
seemsespecially
important
been well documented.
I offer,
in
The arguments
to
case
which
however,apply any
I leaveopenthepossibility
consent
is generally
towaiverights.
informed
necessary
thought
thatthefollowing
do
not
to
contexts
there
are any)in whichvalid
(if
arguments
apply
consent
neednotbe (very)informed.3
1 The Proprietary
Gate Model
- or at leastinformed,
Mostmoralphilosophers
believethatconsent
free,andcompetent
- functions
consent
as a "proprietary
which
the
moral
boundaries
ofpersonal
gate"
opens
1Asnoted
therespondents
their
were
notactually
wereasked
about
above,
preferences;
they
hypothetical
ona course
oftreatment
tobeadministered
Butthis
toundermine
theforce
tothem.
doesnotseem
deciding
oftheexample,
a goodchoice:
since
arise
even
when
aresignificant
incentives
tomake
there
effects
framing
intheeconomic
that
that
areprevalent
in
"Studies
andpsychological
literature
errors
haveshown
reported
tohypothetical
eveninthepresence
ofsignificant
responses
monetary
(Tversky
questions
persist
payoffs"
andKahneman
2000,p.221).
Mostofthediscussion
hascentered
of"libertarian
onthepossibility
among
philosophers
paternalism,"
- andthe
under
which
choices
arestructured
so as to encourage
Thisview
prudent
decision-making.
- areduetoSunstein
"libertarian
label
andThaler
(2006)and(2003).
paternalist"
Forexample,
some
holdthat
should
beenforced
evenifoneoftheparties
docsnot
certain
contracts
people
havea robust
ofthecontract's
Fordiscussion,
seeBix(2010).
terms.
understanding
Springer

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Consent
andtheProblem
ofFraming
Effects

519

action(Kleinig2010,p. 4). According

to permit
another's
to thisproprietary
sovereignty
to A's performing
someact showsthat has
, thefactthat consents
gate (PG) model
thatact.(Assume,
waivedhermoralright
A'sperforming
unlessotherwise
that
noted,
against
and
As
Judith
Jarvis
Thomson
theconsentis informed,
"The
free,
competent.)
putsit,
has acquireda privilege,
is thattheconsent-receiver
andthusthatthe
outcomeof consent
if consents
hasceasedtohavea claim"(1990,p. 348). Forexample,
toA's
consent-giver
withher, hasgivenA a permission
orhavingsexualrelations
to
givingheran uglytattoo
be a violation
ofB's right
tobodilyintegrity.4
To be sure,
anactthatwouldotherwise
perform
orunkind,
or
evenif consents,
A's actmaybe wrongforotherreasons;itmaybe greedy,
be wrong
B's rights,
and canthushave
Buttheactcannot
becauseitinfringes
exploitative.5
abouthertreatment
no validgrounds
forcomplaint
1986,pp. 177-178).
(Feinberg
withtheevidentiary
model
towhichconsent
ThePG modelcanbe contrasted
, according
it
insofar
as
evidence
the
is morally
relevant
provides
only
regarding presenceof some
in
set
of
virtue
of
which
the
act is rightor wrong.The
further
feature
features)
(or
be
favored
model
of
consent
would
Consent
obviously
by consequentialists.
evidentiary
itprovides
evidenceabouttheeffects
ofan
on thisview,insofar
matter,
(defeasible)
might
notalways)thefactthata subject
acton thesubject'swell-being:
typically
(though
perhaps
thattheactfurthers
herinterests,
whilethefactthat
somereasontothink
consents
provides
thatitdoesnot.Of course,a defender
of
a subjectdissents
providessomereasonto think
is theonlyintrinsic
modelneednotclaimthatwell-being
theevidentiary
value;perhaps
in relationto theseother
relevant
thereare others,and perhapsconsentis evidentially
it
be
to obtainconsentin
as
well.
sometimes
values,
Further,might
important
practically
in a jointundertaking,
suchas a regimen
of
orderto securethesubject'scooperation
thatrequires
to theevidentiary
activepatientparticipation.
medicaltreatment
According
model
consent
model,however,
possessesno moralforceofitsown.Boththeevidentiary
viewsaboutthemoral,rather
thanthelegal,importance
of
and thePG modelrepresent
A defender
oftheevidentiary
modelcan withperfect
holdthatsome
consent.
consistency
acts shouldbe legallypermitted
onlywiththe subject'sconsenton the grounds,for
that
alternative
policywoulddo moreharmthangood.
example, any
salient
between
thePG modelandtheevidentiary
modelareespecially
Thedifferences
ofthePG modelwouldgenerally
claimthatit
in theirtreatment
ofpaternalism.
Defenders
inB's self-regarding
without
B's consent,
evenif
forA tointervene
is impermissible
affairs,
B. Mostdefenders
ofthePG modelwouldalso holdthatso
benefit
doingso wouldgreatly
even
consents
toA's act,third
areprohibited
frominterfering,
parties
longas voluntarily
ifA's actwillseriously
harm (Feinberg
1986,pp.98-101).If,on theotherhand,consent
is relevant
(or othervalues),thenthe
onlyas evidenceaboutthesubject'swell-being
that
confident
absenceof consentshouldnotstandin ourway whenwe arejustifiably
thesubject(without
other
relevant
intervention
wouldbenefit
values).
compromising
attention
on thePG
of thispaper,I shallfocusmycritical
Fortheremainder
primarily
model.As we shallsoonsee,itis theviewthatseemstofacethemostsignificant
challenge
offraming
effects.
fromtheprevalence
4Thisiswhat
andO'Neill
toasconsent's
"moral
SeealsoManson
HeidiHurd
(2007,
(1996)refers
magic."
he
Kamm
that
consent
tobeharmed
likewise
claims
(when
"[i]nordinary
morality,
bytheperson
pp.72-77).
beimpermissible"
iscompetent
togiveconsent)
canoften
actsthat
would
otherwise
(2007,p.219).
justify
no
ThePGmodel
alsoseems
tobepresupposed
Volenti
non
("Toonewhoconsents
fitinjuria
bythemaxim
Foranendorsement
ofthismaxim,
seeFeinberg
isdone").
(1984,
115-117).
pp.
wrong
5Thomson
that
with
his
a boyisgiven
a boxofchocolates
herefuses
toshare
considers
anexample
inwhich
tothechocolates,
theolder
brother
brother.
theyounger
brother
hasnoright
maybe
younger
Although
- butnotunjust"
callous
(1971,p.60).
"greedy,
stingy,
Springer

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520

J.Hanna

2 The ProblemofFramingEffects
To see whyframing
effects
forthePG model,consider
a decision-maker
pose a problem
vulnerable
to theframing
effect
described
at thebeginning
ofthispaper:
Consent:Patienthas lungcancer.Doctorexplainsthetreatment
Framing-Induced
ofthesurvival
ratedescription,
andPatient
consents
tosurgery.
Had
optionsinterms
Patientbeen giventhemortality
ratedescription,
she
would
not
have
however,
consented
to surgery.
Call cases such as this,in whichthe subject'schoice is affectedby framing,
cases."Of course,we oftendo notknowwhether
a particular
decision-maker
"framing
is vulnerable
to framing,
butletus assumethatwe do in Framing-Induced
Consent.(I
in Section5.) We can now ask
considertheconsequences
of dropping
thisassumption
whether
a subject'sconsentis validwhenshe is subjectto framing.6
I
As is standard,
shallsaythata subject'sconsentis validjustin case itis sufficient
to waivetherelevant
model,consentis nevervalid in thisway,since
right.Accordingto the evidentiary
towaiverights.
consentdoesnotfunction
Forthisreason,framing
effects
do not
directly
seemto pose an especiallygreattheoretical
model.Whena
challengeto theevidentiary
decision-maker
is vulnerableto framing,
her consent(dissent)presumably
does not
evidence
that
would(not)promote
herwell-being
orother
provideverygood
proceeding
relevant
values.Theevidentiary
modelwillthenpermit
us toproceed(ornot)directly
on
thebasisofthesevalues.7Butitmayinitially
be unclearhowthePG modelwoulddeal
withFraming-Induced
Consent.
A defender
ofthePG modelmaybe tempted
tooffer
thefollowing
resolution
ofthiscase:
sincePatient
consents
tosurgery,
itispermissible
toproceed.
onthisview,
actually
Conversely,
ifPatient
hadactually
dissented
becauseshehadbeengiventhemortality
ratedescription,
then
itwouldhavebeenimpermissible
to proceedwithsurgery.
In short,
theproposal
holdsthat
treatment
ofPatient
is morally
holdsthat
governed
byheractualchoice.(A related
proposal
Patient's
actualchoiceis decisiveonlyonceshehasbeenprovided
withbothdescriptions.
I
criticize
thisproposal
further
I
after
out
the
shall
be
below, setting
problem
discussing.)
Framing
effects
becauseitis difficult
tobelievethatthepermissibility
ofanact
mayseemproblematic
coulddependonsomething
as trivial
as howthequestion
is asked.Butifwe arecommitted
to
themoralimportance
ofconsent,
weshouldsimply
whichaffects
perhaps
acceptthatanyfactor
thesubject's
choicetoconsent
alsoaffects
thepermissibility
oftheact.
thereby
Toseewhyframing
inthisway,wemustfirst
casescannot
beresolved
that
consent
recognize
isa dedictopropositional
attitude
some
overt
behavior
that
suchan
(or,alternatively,
expresses
an
One
consents
to
act
under
a
certain
one
and
consent
attitude).8 always
description,
might
6
I shallgenerally
interms
ofthevalidity
ofconsent
with
below
alsoapply,
, thearguments
Although
speak
todissent.
that
Most
believe
likeconsent,
canbeinvalid.
modification,
dissent,
Consider,
slight
philosophers
a caseinwhich
for
anill-informed
orintoxicated
toa beneficial
dissents
medical
example,
patient
procedure,
there
isnotime
toremedy
herdeliberative
andthere
isgoodreason
tobelieve
that
shewould
consent
defect,
ifshewereinformed
andunimpaired.
7Ofcourse,
there
that
makeitdifficult
todetermine
which
ofaction
course
maybe epistemic
problems
would
benefit
Patient.
Butthese
that
donotgiverisetoa paradox
ofthesort
I argue
thePG
problems
plagues
model.
itis irrelevant
Formypurposes,
whether
consent
is a "subjective
suchas an intention,
ora
state,"
Thesubjective
state
viewisadopted
andAlexander
"performative."
(1996,
byHurd
pp.124-126)
(1996,
p.
viewisadopted
andKleinig
165).Theperformative
byWertheimer
(2003,
(2010,
pp.144-152)
pp.9-11).
ofhowthis
issettled,
anactdescription,
debate
consent
isalways
under
asisdemonstrated
Regardless
given
below.
bytheexamples
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andtheProblem
Effects
Consent
ofFraming

521

under
oneactdescription
butnotanother
2004,
(MansonandO'Neill2007,pp. 12-13;Westen
thefollowing
case:
pp.40-42;Hurd1996,p. 127;O'Neill1985,p. 156).Consider
HIVPositive
: agreestohavesexualintercourse
with. is unaware
thatA is HIV
andifsheknewthisshewouldnotconsent.
positive,
withA") butnotunder
consents
underone description
of theact (say,"intercourse
with
HIV
another
someone
who
is
Eventhough
both
("intercourse
description
positive").
are
we
cannot
infer
the
fact
that

consents
under
the
from
first
that
accurate,
descriptions
underthesecond.9Considera secondexample:
sheconsents
BloodTransfusion
: Doctorinforms
Jehovah's
Witness
JWwillsoondieunless
(JW)that
he receivesa "standard
livertransplant."
SinceJWis unawarethata "standard
liver
a
involves
a
blood
he
form
to
the
transfusion,
signs
consenting procedure,
transplant"
heis strongly
eventhough
onreligious
grounds.
opposedtobloodtransfusions
of theact butis nonetheless
Again,JWconsentsunderone description
disposedto
dissent
undera morereadilyunderstandable
description.
Ifconsentis alwaysgivenunderan actdescription,
thenwe mustdetermine
whichact
matter
forthepurposesof determining
whether
thesubjecthas waivedher
descriptions
I shallsaythatanactdescription
ina givencaseifand
is morally
relevant
Forbrevity,
right.
In Blood
underthatdescription
has givenvalidconsent.10
onlyifa subjectwhoconsents
all defenders
of thePG modelwouldagreethat"standard
liver
, virtually
Transfusion
is nota morally
relevant
actdescription
thatJWdoesnotknowthata
transplant"
(assuming
standard
livertransplant
includesa bloodtransfusion).
JWconsents
underthis
Although
11
he
has
not
waived
his
description,
right
againstsurgery.
Consent
andconsider
thefollowing
which
ofthe
Return
nowtoFraming-Induced
question:
- is morally
- thesurvival
act descriptions
ratedescription
or themortality
ratedescription
itmay
relevant?
Therearejustthree
twoofwhichcanbe quickly
dismissed.
First,
possibilities,
is morally
relevant.
Ifso,thencontrary
to theproposal
be thatneither
oftheactdescriptions
actualchoiceis invalid.
under
Patient's
Second,itmaybe that
consideration,
justoneoftheact
withthe proposal
is morallyrelevant.
This possibility
is also inconsistent
descriptions
theother
wouldthen
above,sincethechoicesofthosewhodecideunder
description
suggested
rate
and
be invalid.
that
the
survival
rate
are
Further,
given
description mortality description
there
no
basis
for
that
one
is
is
non-arbitrary
claiming just
morally
equallyinformative,
relevant.12
9Cf.Westen
a mansnuck
NewYork
v.Hough
into
thebedof
, a caseinwhich
(2004,
p.41),whodiscusses
with
him.
twin
inorder
todeceive
thebrother's
tohaveintercourse
hisidentical
brother
girlfriend
10Ifsome
inthe
willbecasesinwhich
noactdescription
is morally
areinalienable,
there
relevant,
rights
of
inwhich
I amusing
this
Onecannot
validconsent
toanactifheisincapable
sense
terminology.
provide
hisright
it.
waiving
against
11What
ofhisHIV
HIVPositivei
ofsexual
assault
ifhefailed
toinform
should
wesayabout
IsA guilty
willdepend
webelieve
a person
must
beinorder
status?
Ouranswer
tothisquestion
onhowinformed
tosexual
that
onemight
holdthat
hasnotgiven
hermorally
toconsent
relations.
Notice,
further,
validly
valid
A should
notbesubject
tolegalsanction.
Forrelevant
seeWertheimer
even
consent,
discussion,
though
I willfocus
intheremainder
inwhich
itis
ofthepaper
oncontexts
(2003,
Chapter
9).AsI haveindicated,
that
validconsent
must
meet
informational
generally
agreed
fairly
demanding
requirements.
12Tobesure,
or
there
onewayofpresenting
information
ismore
confusing
maybesomecasesinwhich
statistical
more
difficult
forrecipients
toregister.
Forexample,
abletoanswer
many
peoplearebetter
when
datais presented
ina frequency
format
havea certain
(jcoutofevery
problem)
problems
people
than
a probability
havea certain
SeeGigerenzer
rather
format
ofpeople
(2000,
Chapter
(z percent
problem).
inourexample,
inwhich
therisks
concerns
donotseemtoarise
theonly
difference
iswhether
4).Butthese
arepresented
as mortality
orsurvival
rates.
Springer

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J.Hanna

522

aremorally
relevant.
thatbothactdescriptions
Nowby
Wearethusledtotheconclusion
abouttheclaimthattwo(ormore)actdescriptions
there
is nothing
itself,
especially
puzzling
in a givencase. For example,a doctorcoulddescribea particular
are morally
relevant
thatposessuch-and-such
or
a
kneesurgery
to
risks,"
as, say,"arthroscopic
procedure patient
the
room
number
in
which
inthiswaybefore
thedoctor
coulddescribe
theprocedure
adding
- theone thatprovides
theroom
willtakeplace.Bothof theseactdescriptions
thesurgery
to
sincea patient
canvalidly
consent
number
andtheonethatdoesnot- aremorally
relevant,
In cases suchas
withtheroomnumber.13
she is provided
of whether
regardless
surgery
actdescriptions
Consent
theclaimthatbothdifferently-framed
, however,
Framing-Induced
intractable
conflict.
On theone hand,if Patient
are morally
relevant
yieldsan apparently
thePG modelseemstoimply
that
relevant
actdescription,
consents
undera morally
actually
Patient
haswaivedherright
andthatitis permissible
forDoctortoproceedwiththesurgery.
toproceedwhena personis disposed
to
seemsimpermissible
On theother
hand,itgenerally
ifprovided
witha morally
InBloodTransfusion
dissent
relevant
actdescription.
, forexample,
todissent
underthemoreinformative
seemstoexplainwhyitis
JW'sdisposition
description
thatifFramingIt is also important
to recognize
to perform
theoperation.
impermissible
is likeother
casesinwhichframing
effects
havebeenobserved,
Patient
InducedConsent
may
totheprocedure.
Kahneman
toframing
evenaftershegivesherinitial
consent
be vulnerable
effects
are"noteliminated
evenwhenthesame
andTversky
notethatinmanycasesframing
within
a fewminutes";
answerboth[differently-framed]
questions
respondents
respondents
withtherespective
eventhough
standbyeachchoicewhenconfronted
formats,
presentation
theinconsistency
andwishtoavoidit(2000,p. 5).14
theyrecognize
Itthusappears
ofproceeding
that
Patient's
actualchoicedoesnotdetermine
thepermissibility
thatPatient
inFraming-Induced
Consent.
Therearestrong
forclaiming,
paradoxically,
grounds
haswaivedherright
under
a morally
relevant
actdescription)
andthat
(sinceshehasconsented
relevant
actdescription).
sheretains
herright
todissent
under
a morally
(sincesheis disposed
thedefender
ofthePGmodel
Callthis"theproblem
offraming
effects."
Toresolve
theproblem,
above.15
needstofindsomeprincipled
judgments
waytoavoidoneoftheconflicting
itwillbe usefulto forestall
one tempting
to thisproblem.
Beforeproceeding,
response
RuthFadenandTomBeauchamp,
the
few
moral
toaddress
explicitly
among
philosophers
it
that
be
handled
as
follows:
can
framing,
suggest
13I amindebted
toEricChwang
forthisexample.
andTversky
a study
inwhich
tochoose
twopublic
Kahneman
discuss
wereasked
between
participants
forcombating
a disease.
different
on
programs
Manyoftheparticipants
programs
depending
preferred
with
whether
theoutcomes
wereframed
as "livessaved"
or"liveslost":"Respondents
confronted
their
still
toberisk
aretypically
Evenafter
theproblems,
wish
averse
answers
they
puzzled.
rereading
conflicting
inthe'livessaved'
inthe'liveslost'version;
andthey
alsowish
toobey
wish
toberisk
version;
they
seeking
inthetwoversions"
andTversky
invariance
andgiveconsistent
answers
2000,p.5).
(Kahneman
inthefollowing
Theargument
I haveoffered
tohaveanunfortunate
case.Suppose
seem
may
implication
itwillnotharm
that
that
A chooses
toperform
some
there
isa ninety
chance
actafter
heistoldthat
percent
ifhehad
this
other
that
Awould
nothavechosen
toperform
/er,
act,how
(non-consenting)
people.
Suppose
Itseems
that
ifA'sactdocs
that
itwillharm
clear
beentold
isa tenpercent
chance
that
another
there
person.
harm
aninnocent
himtopay
himoratleastrequiring
wemayholdA responsible
bystander,
bypunishing
Itseems
thiscaseandFraming-Induced
tomethat
there
isanimportant
difference
between
compensation.
Aswehaveseen,
that
at
Consent.
most
defenders
ofthePGmodel
believe
consent
treatment,
(tomedical
that
isvalidonlyifitis informed
believe
anagent
must
meet
these
andunimpaired.
Butfewpeople
least)
Forexample,
hecanbeheldliable
for
hehascaused
toothers.
standards
before
topaycompensation
injuries
most
a person
tosurgery
while
while
most
would
that
cannot
consent
intoxicated,
philosophers
agree
validly
that
harms
others.
AsI havealready
that
a person
for
drunken
behavior
alsobelieve
beheldresponsible
may
that
validconsent
must
be
I amdealing
inwhich
itis generally
believed
contexts
indicated,
onlywith
tomyattention
wasbrought
informed
and(relatively)
Theoriginal
byDavidBoonin.
unimpaired.
objection
Springer

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Consent
andtheProblem
ofFraming
Effects

523

offraming
effects
aredifficult
in
toascertain
[B]ecausethepowerandprecisenature
concrete
courseforprofessionals
informed
consent
is to
cases,theprudent
seeking...
- thehalf-full
withbothsidesofthestory
and[research]
and
provide
patients
subjects
thehalf-empty
the
and
the
survival
in
frames
the
presentations, mortality
hopesof
the
in
that
effects
avoiding gaps understanding framing
mayproduce(1986,p. 321).
This responseholdsthatwe can avoid anyframing-related
complications
simplyby
all alternative
or"bothsidesofthestory."
In somecases,thissuggestion
frames,
providing
Itmaybe overlydemanding
torequire
medicalpractitioners
toprovide
maybe impractical.
it
if
all alternative
and
tax
our
and
attention
we
had
to
listen
to an
frames,
may
patience
of
a
risks
and
moments
listen
to
another
then,
later,
explanation procedure's
explanation
in whichtherisksareframed
therearetwomore
Nonetheless,
(andanother?)
differently.
forFadenandBeauchamp's
substantial
problems
suggestion.
all frames
is simply
another
thechoiceandhasno claim
First,
wayofframing
providing
After
to superiority
overothers.
ratedescription
arenot
all,peoplegivenonlythesurvival
adultknowsthata ninety
of mortality
chanceof
rates;anycompetent
ignorant
percent
survival
entailsa tenpercent
riskofdeath.So we cannotarguein favorofproviding
both
on
that
the
so
renders
the
better
or
informed
fills
descriptions
grounds doing
subject
"gaps"
in her"understanding."
And if providing
bothdescriptions
does notrenderthesubject
itis unclear
better
toconfront
thesubjectwitha
informed,
whydoingso shouldbe thought
"neutral"
frame
orpresentation
format.
offraming
effects
is precisely
Indeed,theproblem
thatthereis no neutral
thealternatives.
wayto present
andjustas importantly,
evenifit is concededthatwe oughtto provide"both
Further,
thesubject'schoicemaystillbe affected
sidesofthestory,"
oftheframe,
byotherfeatures
et al. 1993,p. 74).
suchas the"sequencein whichoptionsare presented"
(Redelmeier
underthe survivalrate
Suppose,forexample,thatafterPatientconsentsto surgery
her
with
Doctor
the
rate
Thereare nowtwo
description,
provides
mortality description.
with
in whichcase
Patient
dissent
when
this
new
possibilities.
may
provided
description,
inherchoicesmerely
theconflict
leadsus backtotheoriginal
now
problem.
Alternatively,
thatshehasactually
shemayreaffirm
herconsent
whengiventhemortality
rate
consented,
Butgivenheroriginal
to framing,
suchconsentmayonlybe an
description.
vulnerability
artifact
ofherhavingbeengiventhesurvival
ratedescription
first.
Andsurelythereis no
orderin whichto present
thedescriptions.
neutral
temporal
3 Informed
Consentand theDisposition
to Consent
Therearetwomorepromising
ofthePG modelmight
to
waysinwhichdefenders
respond
theproblem
offraming
effects.
to showthat,on closerinspection,
First,theymayattempt
is valid.Second,theymayattempt
to
Patient's
consent
toresolvetheproblem
byappealing
I consider
ofhypothetical
thefirst
ofthesestrategies
in thissection,
somevariety
consent.
andthesecondin thefollowing
section.
A defender
hasmoralforce,
themere
ofthePG modelmight
arguethatwhileactualconsent
toconsent
doesnot(see Thomson
1990,pp. 187-188;Brudney
1991,
(ordissent)
disposition
16
I claimedthatPatient's
effects,
pp. 236-240). In settingup theproblemof framing
to dissentundera morally
relevant
act description
disposition
suggeststhatshe has not
16Both
I shalllater
ofthese
authors
as
consent.
consent,
against
hypothetical
argue
hypothetical
distinguish
intheliterature,
invoked
from
thedisposition
toconsent
that
isatissuehere.
Butthearguments
commonly
advanced
andBrudney
toboth
ofthese
notions.
byThomson
mayapply
Springer

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J.Hanna

524

Butifthedisposition
todissent
doesnotmakea moraldifference,
thisclaim
waivedherright.
intheinconsistent
is mistaken,
andwe canthusavoidoneofthejudgments
pairthatgaverise
somecasesin whicha subject's
to theproblem
offraming
effects.
Now therearecertainly
to
seems
to
make
a
moral
in Blood Transfusion
dissent
, JW's
difference;
disposition
to
under
a
act
seems
to
account
for
the
dissent
more
informative
description
disposition
that
he
has
not
waived
his
But
defenders
of
the
PG
model
common
right. perhaps
judgment
inBloodTransfusion
ofproceeding
is explained
notby
wouldclaimthattheimpermissibility
todissent,
is ill-informed.
JW'sdisposition
butinstead
bythefactthathisactualconsent
By
thatPatient
inFraming-Induced
we havebeenassuming
Consent
is fullyinformed
contrast,
In
interms
towhichsheconsents.
abouttherisks(expressed
ofsurvival
rates)ofthesurgery
tothereplywe arenowconsidering,
whatmatters
is notwhether
thesubject
short,
according
is disposedtchoosedifferently
undersomealternative
frame
oractdescription,
butinstead
whether
heractualchoiceis sufficiently
informed.
whenthecriticattempts
to explainhowwe can
Thislineof argument
runsintotrouble
that
informed
from
consent
that
is
not.
Oneobviously
cannot
consent
is
distinguish
sufficiently
informed
information
consent
is sufficiently
onlywhenshehascomplete
arguethata person's
to attain(Mansonand
abouttherelevant
wouldbe impossible
act,sincesucha standard
it
O'Neill2007,p. 28; FadenandBeauchamp
1986,p. 302). In orderto givevalidconsent,
thatis relevant
to thechoice.A patient
can give
seemsthatone needsonlyinformation
informed
consent
toa medicalprocedure
without
thenumber
oftheroominwhich
knowing
theprocedure
willtakeplace,sincesuchknowledge
is notrelevant
toherdecision-making.
Butshecannot
consent
unlesssheknowstheprognosis
ofhercondition
under
giveinformed
will likelybe thebasis forher
alternative
treatment
sincesuch information
scenarios,
Information
is relevant
to a choiceif knowledge
of it wouldaffect
how the
decision.17
ifsuchknowledge
decision-maker
chooses(orperhaps
wouldbe sufficiently
likelyto affect
how the decision-maker
the following
consent
chooses).This view supports
informed
ifhe is disposedtodissent
: a subject's
consent
toan actis insufficiently
informed
principle
act
(or it is sufficiently
likelythathe is disposedto dissent)undera moreinformative
This
description.18 principle
obviouslyexplainswhyJW'sconsentis invalidin Blood
Noticethatiftheinformed
is correct,
consent
thedisposition
todissent
Transfusion.
principle
doesmatter,
insofar
as itshowsthatthesubject's
actualconsent
is insufficiently
informed.
In orderto bothacceptthe informed
thatPatient's
consentprincipleand maintain
consent
is validinFraming-Induced
Consent
, onewouldneedto drawa sharpdistinction
to dissentunderan actdescription
that
betweenthefollowing:
(a) a subject'sdisposition
a greater
includes
ofinformation,
and(b) a subject'sdisposition
todissent
underan
quantity
actdescription
thatincludes
else- say,a frame
orwayofpresenting
information
something
thatis notincluded
inthedescription
whichsheconsents.
Inparticular,
itwouldneedto
under
beshownthat
theformer
invalidates
whilethelatter
doesnot.Butitdoesnotseemthat
consent,
thedistinction
in thisway.To thinkotherwise
between(a) and (b) is morally
relevant
fetishizes
sheerquantity
ofinformation
ina waythatappearsindefensible.
17A similar
viewofrelevance
is defended
inChwang
ofrelevance
alsohaslegal
(2010).Thisaccount
AsFaden
andBeauchamp
lawhinges
almost
onwhether
about
disclosures
out,
support.
"[c]ase
entirely
point
undesirable
orrisks
under
outcomes
havebeenmade,
whether
tolerable
outcomes
and,ifnot,
they
represent
thecircumstances
orwhether
thepatients
intentions
would
havealtered
orbehavior"
ofthem
knowledge
(1986,
p.247,emphasis
added).
Notice
that
this
a sufficient
itdoesnot
condition
ofone'sbeing
informed;
insufficiently
principle
provides
andsufficient
I thusleaveopenthepossibility
thatother
informational
conditions.
provide
necessaiy
itmust
limitations
thevalidity
I alsoleaveitopen
bethat
some
ofconsent.
may
compromise
justhowlikely
mind
that
information
becomes
relevant.
would
thesubject's
before
pieceofinformation
change
Springer

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Effects
ofFraming
andtheProblem
Consent

525

consent
theviewthat(a) butnot(b) invalidates
Thisis so forat leasttworeasons.First,
the
Consider
would
that
(actual)example.A
following
reject.
mayyieldimplications many
knownas
morecommonly
aciddiethylamide,
a studyon lysergic
is conducting
researcher
full
chemical
the
uses
researcher
the
thestudyto potential
'LSD." In explaining
subjects,
refers
if
she
will
enroll
fewer
that
assume
us
she
believes
since
people
correctly)
(let
name,
thattheresearcher
to thedrugby itsmorecommonname.Supposefurther
providesthe
andthenatureof the
aboutthedrug'seffects
information
subjectswithall otherrelevant
that
ofthePG modelwouldclaim theresearch
thatmanydefenders
I suspect
subjects
study.
since(we areassuming)
validconsent,
havenotgiventheir
theywouldnothaveconsented
toas "LSD" (see FadenandBeauchamp
1986,p. 183;Manson
ifthedrughadbeenreferred
the
which
in
a
and O'Neill 2007,p. 13). Nonetheless,description
drugis calledby its
thanan equally
information
of
namedoesnotseemto providea greater
common
quantity
usesa
in whichitis calledby itschemicalname;eachdescription
merely
fulldescription
it
abouttheLSD case maydiffer,
Sinceintuitions
nameforthesamesubstance.19
different
relevant
a
is
there
that
view
the
to
a
decisive
not
morally
counter-example
provide
may
between(a) and(b). Buttheexampledoesseemtojeopardizethatviewto the
distinction
behavior.
in theresearcher's
thatwe findsomething
extent
objectionable
of
is
consentprinciple intuitively
theinformed
proponents
plausible,
Second,although
is
such
it.
to
defend
need
will
however,
defense,
likelyto
thePG model
Any
eventually
to
the
also
undermined
is
of
consent
the
that
disposition dissent
by (b),
validity
suggest
ofinformed
thattheimportance
forexample,
be argued,
Itmight
frame.
underanalternative
thisclaimis oftenmade,thenotionof
consentis explainedby autonomy.
Although
discussappealsto
I further
on whichit reliesis farless oftenexplained.20
autonomy
thata
itmaybe plausibletothink
at theendofSection4. Forpresent
purposes,
autonomy
and
values
settled
his
whenit does notreflect
subject'schoicefailsto be autonomous
to
a
If
(Savulescu1994; Scoccia 1990). so, however, subject'ssusceptibility
preferences
in
fails
to
choice
his
that
show
wouldalso sometimes
expressautonomy; framing
framing
thesubject's
choicesequallyreflect
to believethatbothconflicting
cases,it is difficult
information
about
not
care
do
we
valuesandpreferences
settled
Further,
(Schwab2006).
it
influences
the
extent
to
and
matters
Information
sake.
that,
own
its
for
because,
simply
ofoptionsalso
The framing
ofthesituation.
thesubject'schoiceoraltersherappreciation
features
choiceand altersappreciation,
influences
(suchas thechanceof
makingcertain
ortheriskofimmediate
survival
death)moreorless salient.It appearsthatany
long-term
19One
not
atleastonepieceofinformation
name
thecommon
outthat
provides
description
point
might
called"LSD."
is commonly
inquestion
thatthesubstance
namedescription:
inthechemical
included
theLSDcase.Forbythesame
from
I draw
theconclusion
itdoesnotchallenge
betrue,
this
may
Although
name
inthecommon
notincluded
information
description:
name
thechemical
provides
description
token,
eachdescription
aciddiethylamide."
is"lysergic
name
ofthedrug
mayprovide
that
thechemical
Although
Itis
than
theother.
information
more
neither
ofthesubstance,
thename
about
information
provides
different
thecommon
under
consent
that
onecangivevalid
havefor
wecould
what
reason
only
thus
unclear
claiming
onehas
when
consent
informed
that
onecangivetruly
itwillbesuggested
only
name
(Perhaps
description.
rather
seems
anditatanyrate
ofproposal,
this
sort
ButI havealready
names.
both
beengiven
against
argued
to
inorder
name
with
thechemical
toprovide
arerequired
that
theresearchers
tobelieve
difficult
participants
decisioninfluences
"LSD"likely
theuseofthename
andmost
validconsent.)
obtain
Further,
importantly,
thewaythey
andBeauchamp
emotions
1986,
onthesubjects'
p. 183)orchanging
(Faden
byplaying
making
inthe
toaffect
seems
andO'Neill
decision-making
"think
of'thetest
2007,p. 13).Framing
(Manson
drug
casesI
theframing
theLSDcasefrom
tobenobasisfor
There
thus
same
distinguishing
sharply
appears
way.
onthispoint.
forfeedback
this
from
toa reviewer
I amindebted
havebeendiscussing.
journal
isintormea,
autonomous
seeDworkin
consentyi/si
Foranexception,
7).Onsomeviews,
Chapter
(1988,
toexplain
invoke
cannot
consent
autonomy
andcompetent
seemingly
2010).Suchviews
(Beauchamp
free,
consent.
ofinformed
theimportance
Springer

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526

J.Hanna

reasonwe couldhaveforthinking
thatinformation
to thevalidity
ofconsent
is
is relevant
also a reasonforthinking
thatframing
format
is relevant
orpresentation
to thevalidity
of
consent.To claimthatthepresentation
format
does notmatter
simplybecauseit is not
fiat.
seems
to
resolve
the
information merely
problem
by
In short,
themoralconsiderations
thatsupport
consentprinciple
theinformed
suggest
thata subject'sconsentis invalidwhenshe is disposedto choosedifferently
underan
alternative
frame.Of course,we can rectify
defectsin the
(and equallyinformative)
toprovide
all relevant
information.
Butas I havealready
subject's
knowledge
byattempting
we cannotprovidethesubjectwithall frames;
to do so wouldmerely
argued,
anyattempt
oneparticular
thechoice.
represent
wayofframing
Beforewe turn
toa further
setofproposed
solutions
totheproblem
offraming
it
effects,
is worth
that
"libertarian
have
become
briefly
discussing
paternalist"
approaches
recently
institutions
popular(Sunsteinand Thaler2006, 2003).21Underlibertarian
paternalism,
harness
thepowerofframing
in
effects
andother
biases
order
to
individual
cognitive
improve
the
of
without
use
coercion
"libertarian"
(the
(the
decision-making "paternalist"
component)
Libertarian
wouldargue,forexample,thatDoctorshouldsimply
component).
paternalists
withwhichever
ina choiceconducive
Patient
frame
is mostlikely
toresult
toPatient's
provide
I shallnotargueagainst
ownwell-being.
thisview.Theimportant
pointis thatitseemslargely
irrelevant
totheissuethatI havebeendiscussing.
I havebeenconsidering
whether
peoplecan
issuevalidconsent
whentheyarevulnerable
to framing
effects.
The libertarian
paternalist
itseemstopresuppose
thatPatient
doesnotaddress
thisquestion.
is ableto
Instead,
proposal
valid
since
there
is
little
to
be
alternatives
so that
consent,
give
morally
gainedbyframing
Patient
consents
to
that
the
act
best
serves
her
interests.
invalidly
At thispoint,philosophers
to libertarian
sympathetic
paternalism
mayarguethatitdoes
a wayoutoftheproblem
offraming
after
all.Itmight
thatwhentwo
effects
beclaimed
suggest
actdescriptions
wouldelicitdifferent
thatwouldelicitthebetter
choices,onlythedescription
choiceis morally
relevant.
On thisview,ifPatient
is better
offreceiving
andthe
surgery,
survival
ratedescription
is morelikelyto leadherto choosesurgery,
thenthesurvival
rate
is
while
the
rate
not.
This
is
seems
relevant,
descriptionmorally
mortality description
proposal
however.
Theonlyreasongivenforfavoring
thesurvival
ratedescription
is thatit
arbitrary,
induces
that
But
would
this
show
Patient's
is
invalid
decision
prudent
decision-making. why
if she choosesundertheequallyinformative
rate
(and notmerelyimprudent)
mortality
I see no satisfactory
consistent
withthePG model.
description?
waytoanswerthisquestion
Themostobviousansweris thata subjectcangivevalidconsent
onlywhensheis choosing
ButthisproposalabandonsthePG model,downplays
themoralimportance
of
prudently.
andseemsto support
thatcanhardly
be described
as libertarian.
consent,
paternalism
4 Hypothetical
Consentand Autonomy
If I have been correctso far,peopleare unableto give valid consentwhentheyare
vulnerable
to framing.
havearguedthatwhena personis incapableof
Manyphilosophers
we shouldlookinsteadto hypothetical
anddefenders
consent,
givingvalidactualconsent,
of thePG modelmight
be willingto arguethatundercertain
circumstances
hypothetical
consentcan waiverights.
Arthur
forexample,arguesthatappealsto hypothetical
Kuflik,
consent
canextend
forsomeone'sright
todecidewhatwillhappeninandtohisor
"respect
21Trout
a verysimilar
I believe)
itas
buthe(wisely,
refrains
from
view,
(2005)develops
describing
"libertarian."
Springer

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ofFraming
Effects
Consent
andtheProblem

527

consent
herownbody"(2010,p. 140).Initially,
toresolve
hypothetical
mayappearunlikely
of framing
afterall, whether
a personwouldconsentto an act may
theproblem
effects;
Yetmostappealstohypothetical
consent
us
dependon howtheoptionsareframed.
require
ifshewerefullyinformed
to consider
whether
thesubjectwouldconsent
andable to give
valid consent(Kuflik2010; VanDeVeer1986,pp. 75-81). For example,we mayask
toa certain
a temporarily
intoxicated
intervention
ifshewere
whether
personwouldconsent
toframing
a subjectfrom
thenperhaps
sober.Ifsusceptibility
prevents
givingvalidconsent,
thesubjectwouldconsent
ifshewerefullyinformed
whether
we shouldlikewiseconsider
and immuneto framing.J.D. Trout,forexample,offersthe following"warrant
for
in imprudent,
choices:"[I]ftherewerea debiasingoption
intervention"
framing-affected
thedecision-maker's
to framing],
orifthedecisionsusceptibility
[viz.,a waytoeliminate
makerwerefullyinformed,
theywouldnothavemadethedecisiontheydid" (2005,p.
of the libertarian
430). To be sure,Troutseemsto have in mindonly"intervention"
his
sort.
But
someone
to
more
that
sympathetic suggestion
might
paternalist
argue
generally
in
consent
determines
the
of
on
this
cases;
hypothetical
permissibilityproceeding framing
in Framing-Induced
to perform
thesurgery
Consentso longas
view,it is permissible
andimmune
Patient
to framing.
wouldconsentifshewerefullyinformed,
competent,
has moralforce,it does not
Evenifwe supposethathypothetical
consentsometimes
effects.
Thisis so fortworeasons.First,
offraming
helpto resolvetheproblem
giventhat
and predictably
vulnerable
to framing,
thereis no way to
manypeopleare consistently
whattheywouldchooseiftheywereimmune
to framing.
To be clear,thepoint
determine
in practiceto determine
difficult
howa
hereis nottheobviousone thatit is sometimes
under
some
set
of
counterfactual
conditions.
the
is
would
choose
Instead,
subject
problem
thatthereis oftensimplyno basison whichto claimthata personwould(or wouldnot)
consentif she wereunaffected
consenttestseems
Second,thehypothetical
by framing.
thesubjectwouldconsentif she had hernormal
insofar
as it asks whether
compelling
vulnerable
to
capacities(VanDeVeer1986,p. 75). But whena personis consistently
ifshe
theviewwe areconsidering
wouldhaveus askwhether
shewouldconsent
framing,
had something
to see how thisformof
otherthanhernormalcapacities.It is difficult
be
relevant.
consent
could
morally
hypothetical
of hypothetical
consentarguethatit
An analogywillbe helpful
here.Manydefenders
or
suchas youngchildren
cannotbe appliedto thosewhohavealwaysbeenincompetent,
Thisis partly
andseverecognitive
disabilities.
because,echoingthe
peoplewithpermanent
thatan always-incompetent
first
personwould
pointabove,thereis no basisforclaiming
to someactifhe werecompetent
(Kuflik2010).22Further,
(orwouldnot)consent
echoing
one'streatment
ofa childby
thesecondpointabove,itwouldbe oddifoneweretodefend
thatthechildhas "as goodas consented"
sincehe wouldconsentifhe werean
claiming
thatthechildwouldconsentifhe werean
adult.Evenifwe couldsomehowbe confident
ifa personhas
oftheact.23Likewise,
tothepermissibility
adult,thispointseemsirrelevant
22Kuflik
thecourt
a "substituted
standard"
toa man
discusses
theSaikewicz
case,inwhich
applied
judgment
that
with
a "mental
2 years
and8 months"
the"best
(2010,p. 143).Kuflik
argues
ageofapproximately
andthat
thisis a fundamentally
different
should
thetreatment
ofsuchpatients,
interests
standard"
guide
than
that
tohypothetical
consent
provided
bytheappeal
(p. 144).
justification
hassuggested
that
towards
children
bejustified
Gerald
Dworkin
may
"[p]arental
paternalism"
by"futurewhen
heisolder
oriented
to"welcome"
theinterference
orthechild's
consent,"
(1971,
p.119).There
coming
that
insofar
as Dworkin
totheclaim
the
aretwopoints
worth
about
thissuggestion.
First,
making
appeals
willconsent
hisargument
doesnotappeal
to
child
orcometowelcome
theparents'
intervention,
actually
ofcriticisms,
tosubsequent
havebeensubjected
toa barrage
consent.
consent
Second,
hypothetical
appeals
those
raised
(1986,pp.66-70)andHusak
(1981,pp.33-35).
byVanDeVeer
including
) Springer

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528

J.Hanna

toa certain
itis difficult
tosee howwe couldjustify
effect,
alwaysbeenvulnerable
framing
ofherbyclaiming
thatshewouldconsent
ifshewerenowina psychological
ourtreatment
herimmune
condition
to framing)
thatshehas neveractually
beenin.
(onerendering
Arethere
other
in
which
defenders
of
the
PG
model
to
any
ways
might
respond theproblem
offraming
A finalproposal
effects?
to
the
value
of
is,after
all,
appeals
autonomy.
Autonomy
the
moral
to
of
consent.
Of
have
course,
commonly
thought explain
importance
philosophers
offered
ofautonomy,
andI obviously
cannot
consider
all ofthem
manydifferent
conceptions
here(seeChristman
1988foranoverview).
Someconceptions
ofautonomy
seemirrelevant
for
ourpurposes,
however.
tooneview,autonomy
is a right
of"personal
According
sovereignty"
thatprohibits
ina decision-maker's
intervention
for
choices;respect
voluntary
self-regarding
inthissenserequires
thatwe securethevalidconsent
ofautonomous
adultsbefore
autonomy
themincertain
1986;Christman
1988,p. 110).Thisproposalis not
treating
ways(Feinberg
if
I
have
been
correct
that
consent
is
in
invalid
cases.
helpful
framing
be
relevant
to
our
at
for
least
tworeasons,however.
Autonomy
may thought
problem
ithasbeensuggested
thatpeoplelack"effective
when
First,
autonomy" theyaresubjectto
effects
and othercognitive
biases:"Effective
is fostered
whenbiases
framing
autonomy
from
boundedcognition
areidentified
as risksinthedecisionprocesses
ofpeople
resulting
andthisis followedby 'appropriate
debiasing'"(Schwab2006,p. 578).24Theideahere
seemsto be thatrespectforautonomy
thatthepersonseekinginformed
consent
requires
eliminate
thecognitive
biasesoftheperson
itmaybeniceifwewere
consent.
giving
Although
able to eliminate
others'susceptibility
to framing,
thisis nota reasonable
As the
strategy.
on
literature
heuristics
and
biases
now
effects
are
and
attests,
psychological
framing
"pervasive
robust"
andcannot
beeasilyeliminated
and
even
the
2000,
Further,
(Kahneman Tversky
p. 5).
"mosteffective"
"areonlya qualified
success"(Trout2005,p. 418). In
debiasing
strategies
lightofthis,we needa waytodealwithpeopleas theflawedchoosers
theyare.Onecannot
totheproblem
offraming
effects
outthatitwouldnotarise
successfully
respond
bypointing
ifpeoplewereimmune
to framing.
to theextentthathe
Second,manyphilosophers
arguethata personis autonomous
his
own
life.
This
actuallyshapes
mayrequirethathe havethecapacityto endorsehis
desiresafter
critical
reflection
(Dworkin1988;Frankfurt
1971),orthathe forma life-plan
orconception
ofthegoodthatguideshischoices(see Savulescu1994;Young1986,p. 8).
To be sure,somephilosophers,
is a "global"
Dworkin,hold thatautonomy
including
a wholeliferather
thana particular
or episode(1988,
conceptthat"evaluates"
preference
havebeenconcerned
withtheautonomy
ofpreferences
orchoices
pp. 15-16).Butothers
2010; Savulescu1994;Elster1982),andonemight
(see Beauchamp
arguethatwe respect
thathavebeenreflectively
endorsed
or
autonomy
byhelpingagentsto satisfy
preferences
formed.
This
that
view
Doctor
appropriately
suggests
mayproceedin Framing-Induced
Consent
so longas doingso servesPatient's
autonomous
aims.I willnotargueagainstthis
it
to
is
that
seems
to coherewiththeevidentiary
proposal.The important
point recognize
modelofconsent
better
thanitcohereswiththePG model.A defender
oftheevidentiary
to claimthatconsentmatters
as it provides
model,afterall, is well-placed
onlyinsofar
evidencethattherelevant
actservesthesubject'sgoalsorreflectively-endorsed
desires;on
thisview,theact's relationto thesubject'sdesires,rather
thanhis consent,
ultimately
determines
its permissibility.
It is unclear,however,whythe secondautonomy-based
ofthePG model.Thefactthata certain
actservesthe
proposalwouldappealtodefenders
aimswouldnotappeartoshowthatthesubjecthassomehow
losthis
subject'sautonomous
24Tobesure,
Schwab
that
wecanalways
ridpeople
oftheir
toframing,
(2006)doesnotclaim
susceptibility
anditisunclear
howhebelieves
weought
toproceed
when
wecannot
doso.
Springer

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ofFraming
Effects
Consent
andtheProblem

529

thatthesatisfaction
ofthesubject'sreflectivelyright
againsttheact.Indeed,to theextent
desiresis goodforhim,thesecondautonomy-based
endorsed
proposalmaynotbe much
towhichwe mayproceedwhendoingso benefits
thesubject.
oneaccording
different
from
5 The PG ModelRevisited
I haveoffered
aresound,theyshowonlythatconsent,
whether
Evenifall ofthearguments
ofproceeding
inframing
doesnotdetermine
thepermissibility
cases.
actualorhypothetical,
fortworeasons.First,one mightarguethat
Thisconclusion
modest,
mayseemrelatively
inthewaydescribed
is invalid
consent
bythePG model,evenifconsent
usuallyfunctions
in framing
offraming
effects
stillrequires
a solution,
cases.Ifso, thenwhiletheproblem
perhapsit does notpose muchof a challengeto thePG model.Second,in practicethe
itouttobe,since
offraming
effects
mayseemlessacutethanI havebeenmaking
problem
is vulnerable
to framing.
knowthata particular
decision-maker
we rarely
both the theoretical
and practical
I believe thatthese responsesunderestimate
are "ubiquitous"
of theproblem.Framingeffects
(Tverskyand Kahneman
significance
- suchas medicine
- in which
2000,p. 220). Justas importantly,
theyoperatein contexts
Defenders
ofthePG modelgenerally
is supposedtobe ofparamount
consent
importance.
forvalidconsent
mustnotbe setso highthatwe oftenfailtomeet
agreethatthestandards
them(Beauchamp
however,
2010,p. 62; MansonandO'Neill2007,p. 25). IfI amcorrect,
areoftenunableto
evengenerally
informed,
calm,andsoberdecision-makers
competent,
therewas
In thestudycitedatthebeginning
ofthispaper,forexample,
givevalidconsent.
interms
insubjects'preferences
on
whether
risks
were
framed
a substantial
shift
depending
fordefenders
ofthePG model
ofmortality
rateorsurvival
rate.Itmaynotbe inconsistent
of generally
adultsareunablevalidlyto
to admitthata substantial
competent
percentage
forlungcancer.Butsuchan admission
consent(or dissent)to surgicaltreatment
maybe
sincethemajorsellingpointofthePG modelis thatit
nonetheless,
devastating
especially
validconsent
Thelessattainable
ouractualchoicesabouthowwe aretobe treated.
respects
from
the
model.
will
the
PG
model
the
less
is,
evidentiary
separate
beeasily
offraming
effects
cannot
tothesecondpointmentioned
above,theproblem
Turning
to
thata particular
decision-maker
is vulnerable
brushed
asidewhenwe areabletodetermine
that
doctors
not
be
all
uncommon.
For
could
and
such
cases
actually
example,
framing,
may
in orderto gaugetheir
withalternatively-framed
act descriptions
theirpatients
confront
the
Ifa patient's
arefound
tovarywiththeactdescription,
toframing.
preferences
susceptibility
thatsheis incapable
ofgiving
validconsent
I haveoffered
wouldimply
(ordissent).25
argument
to framing
before
to testpeoplefortheirsusceptibility
Indeed,it maynotbe unreasonable
them.
acts
to
harm
them
to
consent
to
benefit)
(orsignificantly
likely
give(orwithhold)
allowing
a particular
decision-maker
is
todetermine
whether
Evenwhenwe areunableconclusively
effects
toframing,
theproblem
offraming
vulnerable
importance.
Many
maystillbeofpractical
choicesmustmeetmorestringent
believethatmoreharmful
self-regarding
philosophers
iftheyaretobe protected
fromintervention
standards
1986,pp.
(DeMarco2002; Feinberg
- suchas therefusal
ofa lifeOn thisview,veryharmftil
choices
117-124).26
self-regarding
25Wecannot
inwhich
inthisway;as I noted
theorder
toframing
testforsusceptibility
earlier,
always
canbepresented
first.
andonly
onealternative
arepresented
canaffect
decision-making,
preferences
harmful
hebelieves
that
more
Itisnotentirely
discussion
whether
clearfrom
self-regarding
Feinberg's
that
wemust
be
a higher
standard
orwhether
hebelieves
must
meet
ofvoluntariness,
choices
merely
actually
that
a fixed
more
suchchoices
meet
standard.
SeeFeinberg
(1986,
pp.117and120).
confident
Springer

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530

J.Hanna

- aremorally
from
intervention
savingamputation
protected
onlyifwe canbe veryconfident
thattheymeetthestandards
forvalidconsent.Whena decision-maker
is choosingin a
inwhichframing
context
effects
areknownto operate,
thereis a non-trivial
that
probability
she is vulnerable
to framing.
For instance,
if one-fifth
of otherwise
adults
are
competent
unablevalidlytochooseamongalternative
treatments
fora particular
medicalcondition,
we
shouldbe lessconfident
that
further
in
such
(absent
evidence) anyparticular
personchoosing
circumstances
has madea validchoice.In somecases,particularly
whena greatdeal is at
stakeforthedecision-maker
andthere
thatsheis vulnerable
is a verysignificant
likelihood
to
we maybejustified
inproceeding
heractualconsent.
evenwithout
I
Thearguments
framing,
haveoffered
unwelcome
todefenders
ofthePG model.
maythushavepractical
upshots
Sinceframing
effects
are commonand unavoidable,
theplausibility
of thePG model
in
itcan be shownthatthosewhoarevulnerable
be
unless
to framing
can
may
jeopardy
valid
consent.
It
not
does
that
such
an
is
In
Section
3, 1
give
appear
argumentforthcoming.
that
if
we
a
of
informed
we
must
either
conclude
consent,
argued
accept plausibleprinciple
thatchoicessusceptible
to framing
are invalidor else maintain
a narrowand fetishistic
focuson merequantity
ofinformation.
Whena subjectis temporarily
unabletogivevalid
of him shouldbe guidedby
consent,manyphilosophers
arguethatour treatment
consent.
As I arguedin Section4, however,
consent
hypothetical
appealsto hypothetical
do notresolvetheproblem
of framing
effects.
Of course,theremaybe further
responses
availableto defenders
of thePG model,though
difficult
to anticipate
theyare somewhat
the
scant
attention
that
moral
have
to
effects.
ButifI am
given
philosophers paid framing
correct
thatconsent
inframing
is irrelevant
should
we
the
cases,perhaps
accept evidentiary
model.To be sure,a fulldefenseof theevidentiary
modellies outsidethescopeof this
The problemof
paper,and it has been rejectedby mostcontemporary
philosophers.27
effects
leadus to re-examine
themoralstatusofconsent.28
should,however,
framing
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I gratefully
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University
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Ethics
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Effects
Consent
andtheProblem

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