Jennifer Blumenthal-Barby

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Welcoming the Concept of Alief to Medical Ethics

by J.S. Blumenthal-Barby, Ph.D.

Philosopher Tamar Gendler has introduced (circa 2008) a new concept in the philosophical literature that could be of interest to medical ethicists. The concept is that of ‘alief’ and it is meant to contrast with the concept of ‘belief.’ An example Gendler discusses to tease out the difference between the two concepts is the example of a woman who believes African American and Caucasian people to be of equal intelligence, yet in her behavioral responses it seems as if she believes differently (e.g., she is more surprised when an African American student of hers makes an intelligent comment than she is when a Caucasian student does, she more quickly associates intelligence with her Caucasian students, when grading exams she might grade the same quality exam differently if written by an African American student than a Caucasian student, etc.). In other words, if you ask her explicitly, she says she believes P (in this case, P is “all races are of equal intelligence”), and she says it sincerely. But, you might think from the outside that she believes ~P (in this case, “all races are not of equal intelligence”). You might be tempted to say that she does not really believe P. What Gendler wants to say is that this woman does believe P, but that she has an ‘alief’ that is in tension with her belief of P (she has a “belief discordant alief”). The content of this alief is a set of associations that get activated (usually from habit) and show themselves in behavioral responses. Another example Gendler discusses is a glass walkway over the Grand Canyon. When walking across, a person may believe that the walkway is completely safe, but alieve something very different. The content of the alief is: ““Really high up, long long way down. Not a safe place to be! Get off!!”” While beliefs change in response to evidence, aliefs might not (they change in response to habits or affective associations).

How might this concept be relevant to medical ethics? In several ways, I think. In my own work, we have found that many patients with advanced heart failure who are not transplant eligible (and have been told this in a formal letter) still believe themselves to “be on a transplant trajectory.” This has been puzzling to us. But it is a familiar sort of phenomenon, so empirical research is showing us. Many patients have something along the lines of an “optimism bias” some way or another—they believe themselves to be less likely than other patients to have something bad happen to them (such as a certain risk associated with a medical procedure), they believe themselves to be more likely than others to have something good happen to them (e.g., “the treatment will work for me”), they believe themselves to be able to “beat the odds” even when the odds are bad. And in research ethics, we know about the therapeutic misconception whereby patients believe that they will be in the intervention group and that the intervention will help them/cure them—almost no matter what we tell them. These cases raise deep questions about understanding and informed consent. Might the concept of alief help us analyze such cases from a new angle and with new depth? What if a patient believes that their chance of getting a heart is almost nil or that their risk of developing some negative side effect or condition is, say 70%, but nonetheless alieves as if they will get a heart (thinking about it, talking it about, participating in online transplant forums) or as if some negative side effect or condition will not happen to them (e.g., by not talking about it, preparing for it, etc.)? If this is the case, does the patient really understand the consequences of the intervention? In other words, is accurate belief-alief accordance a necessary condition for understanding? Current accounts of understanding seem focused on belief only. And if aliefs need to be adjusted to reach valid understanding and consent, how can this be done? It seems to me that there is rich conceptual and empirical work to be done on the concept of alief in medical ethics.

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