A few months ago, I wrote a piece on imagining the social futures of patients, in an effort to think about what it takes to keep people healthy over time. My main point was to expose the “past bias” we have in medicine; for documenting past events meticulously at the expense of imagining future lives. Since then, I’ve come across two provocative thinkers that challenge my basic premise.

The first question is whether we are in fact biased towards the past, present or future. According to philosopher Derek Parfit we are biased towards the future. His argument is that we are narrative, future oriented creatures. As an example, we care less if we are told we endured pain in the past, than if we imagined enduring a similar pain in the future. The more precise question is “how much should we value our future selves?” This question is a gold-mine for a philosopher, as it opens up an infinity of hypothetical situations. Likewise for the behavioral economist, it is quite easy to measure how much we put away for retirement, or how happy we are considering that vacation next month. A more naturalistic way to look at this is through the lens of illness.

Dementia is the paradigmatic example of an illness that ruptures one’s current and future sense of self. As one slowly loses the common thread of time, it becomes more difficult to live day to day. In fact, to meet the criteria of dementia versus mild cognitive impairment involves interference in tasks of daily life. In a future-oriented culture, it is not surprising that we mourn the loss of future. In a recent NY Times article, one doctor describes Alzheimer’s dementia as “a fate worse than death.” The embarrassment of the physician here is on behalf of the patient. If only the patient could see himself, he would be ashamed. In other words, his former self would be embarrassed. David Hilfiker, a physician and writer recently diagnosed with dementia, astutely points out the ambiguity here: “I’d like to suggest that we feel shame because we are looking at our future self as if we had our full mental faculties and were still behaving that same way.” (1)

What is odd here is that people with Alzheimer’s feel far less shame than their caregivers. It may occur to them to mourn their future selves, but this, according to Hilfiker, is not common. I think Hilfiker’s point is deeper than the conventional wisdom that to age is to become more present-focused. His point seems more about the indeterminacy of the future; our capacity to accurately capture our future self. This could help explain modern medicine’s bias on the past. To describe a patient’s path up until this point is easy; to describe their future trajectory becomes highly complex.

The importance of defining what self we as caregivers heal is more than a philosophical exercise – it guides the boundaries of our responsibility. Why should we take a social history, or imagine the social future of our patients at all? Presumably, because we have a stake in advocating for socio-economic conditions that promote health.

There are two issues here. First, how we as humans value the past, present, and future as parts of our identities. Second, how ought medicine to respond to this? For Parfit and Hilfiker, our default state is to consider our future selves first, while conditions such as dementia may allow us to be more present oriented. As caregiver, and as a healthcare system, we have an ethical choice of which futures to prioritize. This comes down to the following questions. What do we owe our unborn patients? (I.e. creating social and economic justice that impacts health downstream). What do we owe our current patients? (I.e. promoting health, curing disease). Finally, what do we owe our future patients? (I.e. preparing a health system to take care of an increasing population with dementia). This last question takes the greatest act of imagination, as it involves confronting Hilfiker’s sticky problem of defining future selves. While medicine may still be biased towards the past, the future is open for definition, and change.

 

(1) http://davidhilfiker.blogspot.com/2014/05/a-fate-worse-than-death.html

 

Image courtesy of Flickr Commons.