By: J.S. Blumenthal-Barby

In his book, Self-Deception Unmasked, philosopher Ale Mele writes about two types of self-deception. There is the straight-forward kind, where a person falsely believes—in the face of strong evidence to the contrary—things that she would like to be true. And then there is the “twisted” kind, where a person falsely believes what she would not like to be true. Mele gives the example of a spouse who [falsely] believes that his wife is cheating on him despite evidence to the contrary and despite not actually wanting it to be the case that she is cheating on him.

While self-deception certainly occurs in medicine all of the time, what about twisted self-deception? A patient with twisted self-deception would be one who believes that she is sick or has some disease despite evidence that she does not (or at least no evidence that she does), and despite not wanting to actually have the disease in question. A patient who is malingering would not count since she does not actually believe she is sick, but a patient with hypochondriasis would since she falsely believes she is sick even though she does not want to be sick. But we need not invoke pathologies such as hypochondriasis to find instances of twisted self-deception. We can imagine a patient who “prepares for the worst” and convinces herself that she is ill (e.g., that she has cancer), or, if she is ill, that her odds of associated mortality or morbidity are much higher than they are (e.g., that she will die from her cancer even though this is unlikely). Or, imagine a patient who is having a procedure to fix some problem such as an ailing knee or difficulty conceiving. She may believe that these procedures will not work despite evidence that there is a high likelihood that they will in her case. These would all be instances of twisted self-deception.

What causes or explains cases of twisted self-deception? In ordinary self-deception cases, it is typically thought that it is the person’s desire for the desired outcome that in some way causes the self-deception. The desire causes us to discount data that should count against the desired outcome, seeing data as supporting the desired outcome when it really does not, selective focusing on evidence that is supportive of the desired outcome, and selective evidence gathering. In the case of twisted self-deception, however, something different is going on. What is causing the person to falsely believe in the unfavorable outcome? It is certainly not the desire for the unfavorable outcome per se, since they do not desire the unfavorable outcome. Mele hypothesizes that it is various emotions that cause twisted self-deception. For example, in the case of the husband who is [twisted] self-deceived about his wife cheating on him, it is the emotion of jealousy that, say, causes him to selectively focus on evidence that his wife is cheating on him even though the overwhelming amount of evidence points in the opposite direction. I would wager that in medical cases, it is the emotion of fear that plays a role in causing a person to believe that she has some disease or that a negative outcome will occur. That fear is managed by preparing for, or steeling oneself for the absolute worst, which is done by convincing oneself that the worst will happen.

This type of twisted self-deception can in a way be rational and constructive, but only if the twisted self-deception actually serves to stabilize or steel oneself against fear of the bad outcome. If the twisted self-deception is accompanied by extreme anxiety, panic, or stress, then it makes less practical and normative sense. Like cases of ordinary self deception, however, cases of twisted self-deception can be harmful in other ways as well. The similarity is that both cases involve a failure to face and prepare for what is most likely to happen. Now, in the case of ordinary self-deception this is bad since the thing that is most likely to happen is bad and then one is left having to unexpectedly deal with a bad thing (e.g., death of oneself or a loved one). Whereas, in the case of twisted self-deception, the unexpected outcome would be good—and it is presumably easy to have to deal with good but unexpected outcomes. So perhaps twisted self-deception makes a good deal of sense and is actually a fairly reasonable (dare I say rational) response to uncertainty (which is always present in medicine).

Another way to think about it: according to Mele, whether or not self-deception (twisted or regular) makes sense (is normatively desirable) depends on the “cost” of being wrong about what one believes. Compare the cost of falsely believing that p vs. ~p (assume p is something desirable such as that one’s spouse is faithful or one does not have cancer). This would translate into believing your spouse is faithful when they actually cheating vs. believing your spouse is unfaithful when they are actually faithful. Or, believing you don’t have cancer when you actually do vs. believing you have cancer when you actually don’t. It is not unimaginable that someone might find the former situations (believing spouse is faithful and being wrong, believing they have cancer and being wrong) to be the more costly epistemic states, thus ending in cases of twisted self-deception (believing the spouse to be unfaithful or that they have cancer, despite both being unlikely).

Some food for thought for the next time we encounter an unduly pessimistic patient or relative—or perhaps, when we ourselves encounter a threatening medical situation.