Key Takeaways

  1. Time inconsistency: How preferences change over time, splitting the self into young and old versions
  2. Living wills dilemma: Which self’s preferences should govern end-of-life decisions?
  3. Behavioral bioethics: Integrating psychology into ethical decision-making
  4. Justice within individuals: Internal negotiations between competing selves

The Internal Contradiction of the Self

The experience of addiction, whether to tobacco or gluttony, presents an acute moral paradox that begins not with society, but within the individual. Consider the smoker who “grinds his cigarettes down the disposal swearing that this time he means never again” to smoke, only to be found hours later “looking for a store that’s still open to buy cigarettes”. Similarly, the glutton eats a high-calorie lunch, regrets it instantly, resolves to compensate, yet repeats the high-calorie meal that evening, knowing and accepting the coming regret. These behaviors, often cyclical and autonomous to the habit itself, suggest a fundamental internal division. If an individual seems to act against their own long-term, articulated self-interest, who is truly in command of the person?

This internal conflict is central to the exploration of bioethics, particularly when decisions carry the ultimate stakes of life and death. Modern bioethics traditionally assumes the patient is a monolithic entity: clear-headed, far-sighted, informed, and consistently eager to make decisions—in short, “mentally competent”. However, this expectation works as poorly as a Procrustean bed, forcing complex psychological realities into a simplistic binary. Behavioral economics offers a more nuanced framework—a “behavioral bioethics”—by recognizing bounded rationality and the profound implications of time inconsistency. When a patient must decide how they wish to die, they encounter a question far more complex than simple choice; they confront the war between their multiple selves.

The Fracture of Rational Autonomy

The story of the time-inconsistent patient is less about a failure of will and more about a psychological reality; it reveals how the principles governing medical ethics operate under the constraints of human psychology, particularly the temporal split of the self. This behavioral bioethics, recognizing that people are not consistently rational across all phases of life, is believed to benefit both physicians and patients by bringing them closer together.

Time inconsistency, where one’s views and preferences change over time, becomes more pronounced with age, as the mind is better built for managing a short life (20 years) than a long one (90 or 100 years). The concept of the self splits into multiple selves, such as the young self and the old self. The young self, unconcerned with saving for old age or current health problems, often behaves as if the negative long-term consequences “will befall others only”.

This internal division creates a crisis for the central pillar of modern bioethics: the Principle of Autonomy. Autonomy dictates that the physician must respect the informed choice of the patient. This premise is immediately challenged by living wills (or advance directives), which are written by the younger, healthier self, anticipating a future state of incompetence. For instance, if the young Jones signed a no-resuscitation order, but years later the elderly, frail Jones wishes to rescind it, the core ethical dilemma becomes: which self is authentic?. The President’s Council on Bioethics has critiqued living wills using this very two-self model, arguing that the young self has no knowledge of what it is like to be the old self and, therefore, may “discriminate against an imaginary future self long before the true well-being of that future self is really imaginable”. This suggests that the young self, by minimizing the resources transferred to the old self, possesses the potential to exploit the older self.

The tension inherent in the principle of autonomy is starkly illustrated by hard cases, such as the Alzheimer’s patient with an operable malignant tumor. Though the patient’s living will, drafted while competent, explicitly rejects invasive treatments, the patient’s current cheerfulness and appearance of well-being leads the surrogate (daughter) to ignore the directive. This resistance to “extending autonomy” to the demented patient demonstrates the moral quagmire resulting from the assumption of consistent rationality throughout life.

The Cognitive Cost of Ethical Certainty

The Straitjacket of Nonmaleficence

The Principle of Nonmaleficence instructs the physician to avoid actions that cause harm. However, in a two-self world, harm is difficult to define. In the case of Natanson v. Kline, Dr. Kline administered radiation therapy to 35-year-old Irma Natanson for breast cancer without fully informing her of the risks, fearing she would reject the treatment and suffer greater harm—death—later. While the treatment extensively damaged the young Natanson, Dr. Kline believed he saved the life of the future Natanson. The two-self model does not immediately solve this dilemma, but it shifts the focus: the pressing question for Dr. Kline becomes what is the fair thing to do?.

Fidelity, Veracity, and the Divided Patient

The principles of Fidelity (loyalty and trust to the patient) and Veracity (telling the patient the truth) also fracture when the patient is time-inconsistent. Behavioral economics routinely deals with problems like moral hazard and strategic behavior, which bioethics tends to treat merely as anomalies.

In the case of Dr. Wordsworth and Mr. Sullivan, an obese smoker who refuses to quit, the conflict is clear. Fidelity demands Dr. Wordsworth act to preserve the patient’s future health; Veracity demands he report the chest X-ray is fine. Ultimately, Dr. Wordsworth lies, telling Sullivan that spots on his X-ray suggest precancerous development, successfully scaring him into quitting smoking. By lying to the present Sullivan (violating Veracity), Dr. Wordsworth remains loyal to the future Sullivan, who would otherwise suffer poor health. This scenario forces the physician to choose between being “a liar or a traitor”. Only by recognizing that the patient has two internal, competing selves can bioethics help the physician identify the appropriate ethical principle.

Justice Within the Individual

When the time-inconsistent patient requires decisions that extend or shorten life, questions of social justice arise, even when dealing with a single person. Extending the life of the old self via new technology, even if free, adversely affects the young self. The old self faces a lowered standard of living and calls upon the young self to transfer income, which leaves the young self feeling “dealt a bad hand”. The physician, before performing an intervention like a kidney transplant, must therefore seek to understand and mediate the internal negotiation between the young self and the old self. A bioethics that recognizes bounded rationality allows for the patient to need time to reach an internal compromise, requiring the physician to take time and listen to the patient’s two voices.

The Inescapable Internal Bargain

The ascendancy of complete patient autonomy, unsupported by the reality of the time-inconsistent self, may be a Pyrrhic victory. It places an impossible burden on the patient to be consistently rational over a lifespan that now extends far beyond the duration for which the human mind was built. The journey inward, toward the “selves,” reveals that health decisions are not singular, rational acts but ongoing, internal bargains that oscillate between the short-sighted impulse and the long-term plan.

If we view the individual not as a fortress of autonomous choice but as a complicated negotiation table, new insights emerge. Just as two nations might negotiate a treaty (or a division of goods via the Nash Solution), the young self and the old self are constantly negotiating the terms of survival and resource allocation. The internal injustice—the potential for the young self to exploit the old self, or the present self to harm the future self—is inherent in time inconsistency.

The lesson of behavioral bioethics is that when the patient’s mind gets old, it is prone to work in “odd ways,” and mental competency is not a stable, binary state. By acknowledging this cognitive fragility, the physician and the patient can move beyond the straitjacket of the “competent/incompetent” dichotomy toward a shared understanding of fairness. Recognizing the patient as a dynamic, conflicted entity allows the ethical response to shift from rigidly upholding a written rule (the living will) to actively seeking justice for the current self, even if that means violating the preferences of a past self. In the end, the most profound bioethical challenge is learning to manage the two warring architects of our own mortality.