Richard Armitage is a GP and Honorary Assistant Professor at the University of Nottingham’s Academic Unit of Population and Lifespan Sciences. He is on twitter: @drricharmitage
All our patients – actually, all humans full-stop – make numerous decisions in their lives that are deeply challenging. Should I get a divorce? Should I become a parent? Should I take that new job and relocate my family? Should I have a risky operation with a small chance of success? Should I take preventative measures against my dangerous BRCA genes? These ‘Wild problems’ – forks in the road of life where the right path is not obvious, but whichever path we choose defines both who we are and who we might become1 – defy the standard rational decision-making strategy of pro-versus-con lists (how do you quantify the pro of seeing your child take his first steps?). And yet, these decisions can cause sufficient anxiety to lead the patient deliberating them directly to our doors. So, how can we best help them? The answer may lie in re-framing these difficult choices. Rather than seeing them as engineering problems with correct and incorrect answers, we should instead help our patients to regard these decisions through a philosophical lens – as ‘transformational experiences.’
For Paul, ‘transformative experience’ is the concept of experiences that are so fundamentally life-altering to those that undergo them that they change the very fabric of the individual’s identity and their perspective.
Lori A. Paul – often cited as LA Paul – is the Millstone Family Professor of Philosophy and Professor of Cognitive Science at Yale University. Her work spans various fundamental questions about the nature of the self, causation, and time, time’s arrow, and temporal experience. One of her seminal works is Transformational Experience,2 which encapsulates metaphysics, cognitive science, and decision theory in a deep philosophical enquiry, tackles the complexities of life’s most profound decisions – those of wild problems.
For Paul, ‘transformative experience’ is the concept of experiences that are so fundamentally life-altering to those that undergo them that they change the very fabric of the individual’s identity and their perspective. This kind if experience is defined by two central characteristics: firstly, they are epistemically transformative, meaning they provide knowledge and understanding to the individual undergoing the change that was utterly inaccessible to them prior to the change. This means that certain experiences, regardless of how vividly they can be foreseen through imagination, simulation, or description by others, cannot be truly comprehended by an individual unless lived through by that individual. A classic example is the ‘Alice’s Room’ scenario: Alice is the world’s leading expert on colour vision, yet has lived her entire life in a black and white room totally devoid of colour. While she has a complete scientific understanding (i.e. physical information) of colour vision – wavelengths of light, retinal photoreceptors, optic nerves and visual cortices, etc – does she learn anything new when she experiences, for the first time, the colour red (an example of the philosophical concept of qualia)?;3 secondly, transformative experience is personally transformative, meaning it reshapes the core values, perspectives, preferences, and identity of the individual undergoing the experience. Following such a change, an individual’s worldview, priorities, and desires are substantially different to those prior to the change.
Paul’s primary example of transformative experience is the decision to become a parent. For Paul, no amount of reading parenting blogs, listening to parental anecdotes, or shopping for baby paraphernalia can truly convey the essence of parenthood – only becoming a parent can do so (making it epistemically transformative). In addition, once someone has become a parent, their worldview, priorities and values are likely to undergo a profound shift (making it personally transformative).
According to Paul, transformative experiences present a substantial – and ultimately insurmountable – challenge to the classical approach to decision-making. Typically, when presented with a choice, humans use their current knowledge, past experiences, and the products of their research to calculate the expected value of each possible course of action. They then choose the option that they foresee will generate the greatest value in terms of their preferences. For example, when choosing between Rome and Crete as a holiday destination, I weigh up the expected value of each option according to my partialities for historical buildings, exquisite gelato, and sand-free environments, and choose the option that maximally satisfies these preferences. However, given that transformative experiences are inherently unknowable in advance, and can change the experiencer’s preferences post-factum, the same rational decision-making model of expected value becomes entirely inadequate – and even rather laughable – when deployed against transformative decisions.
For example, consider a patient with a debilitating neurological condition. He is offered a high-risk experimental neurosurgical intervention that has a 25% chance of curing his condition, a 50% chance of having no impact whatsoever, and a 25% of making his condition substantially worse. For this patient, the post-surgery life – in both the worse-case and best-case scenarios – could be so qualitatively different from his present that it is impossible to truly predict how he will feel in either situation (it is epistemically transformative). In addition, if he finds himself in either of these conditions, he may begin to view the world through a profoundly altered lens of values, preferences and identity to his pre-surgical state (it is personally transformative). Accordingly, deploying the rational expected value calculation strategy to this decision – and similar decisions that cause transformative experiences – is unlikely to be useful.
So, how can GPs help their patients in facing transformative decisions? The advice offered by Paul, which I think could be helpful to all individuals presented with these choices, is to reframe the decision-making process with which we approach them. Rather than attempting to predict the outcomes based on current knowledge and preferences – how we decide on holiday destinations – the decision-making process should also encompass considerations about the kind of person the individual wishes to become. For Paul, this is not just a predictive but also a creative endeavour.
According to Paul, transformative experiences present a substantial – and ultimately insurmountable – challenge to the classical approach to decision-making.
For example, consider a young lady with a family history of breast cancer who is known to have risky BRCA genes. She is considering preventative mastectomies but is aware that the genes do not guarantee that she will develop breast cancer and so she might have her breasts removed, “For nothing.” This choice is not solely about her current preferences – the certainty of no breast cancer versus the desire to keep her breasts. It is also about her potential transformation into, for example, a person who voluntarily made an empowered and decisive choice about her body, health and identity (in whichever option she chooses). For the patient considering the neurosurgical intervention, his choice is not only about cure versus deterioration, but also about the kind of person he could become, such as an adaptable, resilient, insightful person with a severe disability (in the worse-case scenario) who could work to make positive changes in the world through his unique viewpoint on his culture and society. Rather than being founded on expected value theory, this alternative decision-making approach is rooted in self-discovery and self-creation. Crucially, Paul acknowledges that this strategy might not always generate clear-cut answers, since there is rarely an objectively ‘right choice’ to be discovered. Instead, transformative experiences are about willingly, and even gleefully, embracing the uncertainty and unpredictability of life. Moreover, it is about recognising that these transformative decisions, while undoubtedly challenging, can be pathways to profound personal growth.
While there is rarely the time or appetite for academic philosophy in our consulting rooms, Paul’s account of transformative experiences offers not only a deeply intuitive, but an immediately deployable strategy for guiding our patients with applied philosophy. I, for one, have also found this to be an invaluable tool in my decision-making outside general practice.
- R Roberts. Wild Problems. Portfolio, 2022.
- LA Paul. Transformational Experience. Oxford University Press, 2014.
- M Nida-Rümelin and DO Conaill. Qualia: The Knowledge Argument in Stanford Encyclopedia of Philosophy (EN Zalta and U Nodelman, eds.) 2019. https://plato.stanford.edu/entries/qualia-knowledge/#BasiIdea [accessed 07 August 2023]