Counterfactual Thinking and the Identity Problem: The Casus of Communication about Genetic Risks

Lavrentyeva Sof'ya Vsevolodovna ORCID: 0000-0002-3082-2975 Junior Researcher of the Humanitarian Expertise and Bioethics Sector of the Institute of Philosophy of the Russian Academy of Sciences 109240, Russia, Moscow, Goncharnaya str., 12, p. 1, office 312 sonnig89@gmail.com

IntroductionThroughout our lives, reflecting on the past, present or future, we often ask the question – "what would have happened if ...?" - referring both to our own life and to global, historical events.

This kind of questioning helps us to see different ways in building our own destiny and the idea of our future, allows us to form an attitude to what has already happened and outline the boundaries of what is possible in the world in principle.

Thinking in this way, we rely on judgments that are called counterfactual. The term "counterfactual", currently used in logic, philosophy of language, formal semantics and cognitive science, was first used by N. Goodman in 1946 in an article on the problem of counterfactuals as part of implication in classical logic ^[1]. The origins of understanding the interaction of the components of a counterfactual statement: antecedent (basis) and consequent (consequence) have already been laid down in the reflections of the philosopher David Hume. "[P]richina is that object followed by another object, where all objects similar to the first are followed by objects similar to the second.  <...> Or, in other words, where in the absence of the first object, the second would never have existed" ^[2]. This theory became the basis for the counterfactual theory of causality ^[3].

Thus, "counterfactual thinking" means that we refer to events that have already occurred in the subjunctive mood by making our own changes (that is, we are talking about something that contradicts the facts) using a grammatical structure of the form: if there were A, then there would be B ^[4]. At the same time, building a counterfactual, we must understand which cause will lead to which effect. We do not consider the statement "if I had worn a red jacket in the morning, it would not have rained in the afternoon" counterfactual, because the relationship between the antecedent and the consequent is not clear to us.

In addition to the fact that counterfactual thinking itself is an important component of our everyday life, the problem of counterfactuals is relevant and in demand in various kinds of scientific research. So, for example, psychology turns to counterfactual thinking within the framework of the formulation of the attributes of free will and identity, cognitive sciences in their research associate rational thinking with the ability to operate with counterfactuals, and in physics, counterfactual thinking is a tool for constructing thought experiments aimed, for example, at finding out how natural science laws would work in different from the usual ones for us Counterfactual thinking is one of the central concepts in philosophical reflections on the nature of modality, problems of consciousness and theories of multiple worlds. Actually, the analysis of the role of counterfactual thinking in genetic counseling presented below was largely inspired by the article by the philosopher A.S. Karpenko devoted to modal metaphysics ("Superrealism", published in two parts). In it, A.S. Karpenko deals with a wide range of problems (philosophy of consciousness, problems of possible worlds, modal epistemology, counterfactual thinking) and, based on Chalmers' zombie concept and Lovejoy's principle of completeness, indicates how the transition from counterfactual thinkability to metaphysical possibility becomes possible, which in turn gives him the right to assert: "everything the conceivable is realized" ^{[5] [6]}. At the same time, one of the central conclusions in his conclusions about the nature of modality and counterfactual thinking is the concept of "possibility", which I will also address in this article.

The purpose of this article is to analyze counterfactual thinking as a tool in communication between a geneticist and a patient in conditions of uncertainty, based on the theory of narrative identity. At the same time, I would also like to add to the piggy bank of examples illustrating the potential of counterfactual thinking, showing how it is implemented in the framework of communication between a geneticist and patients with a chronic genetic disease. From this perspective, we can consider both counterfactuals that help to rebuild routine everyday life and counterfactuals that guide in making decisions that we believe are fateful. 

Why is counterfactual thinking important for genetic counseling?As mentioned above, counterfactuals are familiar to each of us, being part of our everyday.

When making plans for tomorrow, we will look back at the elections we made earlier in order to assess the alternative development of events. Turning in this way to the past in counterfactual thinking, we overestimate it and instead of simply regretting the mistakes that have already been made, we hope, by considering alternative scenarios and relying on the acquired experience, to avoid rash and incorrect decisions. But one can imagine situations when a person cannot build a counterfactual narrative about himself without the help of a competent specialist.

For example, in the course of communication with a doctor about his illness, a patient can build a counterfactual narrative of the relative past and future self only thanks to the information that the doctor gave him. Therefore, counterfactual thinking is, in principle, an important component in the communication of a doctor and a patient – not only within the framework of clinical genetics. Counterfactuals help the doctor, when discussing the diagnosis, to identify possible medical risks and outline a plan on how to avoid them. The patient himself will also use counterfactual statements, asking the doctor about his possible mistakes – in the future or in the past. Therefore, it should not be surprising that medical plots often become the basis for constructing thought experiments concerning the moral consequences of decisions, and that they also often contain elements of counterfactual thinking.

But the genetic mutations and hereditary diseases revealed during DNA tests cannot be compared with acute diseases that require urgent intervention or immediate solutions, when most of the responsibility falls rather on the doctor, and success depends, if not entirely, but more on the abilities and experience of the doctor than on the patient's consciousness. Genetic diseases often require increased attention of patients themselves - to themselves and their health. For example, it may be necessary to adhere to a special diet, lead a healthy lifestyle or constantly attend physical therapy to avoid possible complications. Therefore, the doctor's recommendations in the case of a chronic genetic disease will be aimed at the long-term supervision of the patient, when there will be possible changes in treatment regimens due to failure or the appearance of new information about the disease, etc. In this case, the counterfactual narrative becomes a necessary tool to provide patients with an idea of what the course of the disease will be in case of making (sometimes everyday) certain decisions. At the same time, however, it is worth noting that also often in the course of genetic counseling, a counterfactual narrative in the course of communication between a doctor and a patient can be built on the basis of uncertainty. This is due to the fact that a geneticist may not always have sufficient knowledge about how a particular genetic mutation will affect the patient's health, and therefore can only warn about the likely risks and various alternative scenarios associated with them. And since genetic counseling addresses the problem of future decisions of patients, on which the quality of his/her life may depend, it is important to build a joint understanding of the values of patients and their desired future during diagnosis and counseling.

But how exactly should a conversation about a possible, not yet available and uncertain future be built in order to provide patients who are faced with difficult knowledge about a chronic disease with an adequate and appropriate scenario for their intentions? In the following sections, I would like to reveal the role of counterfactuals as the main tool in building such a conversation, and I suggest starting by analyzing the general conditions from which it begins. 

The main features of communication about the future and the possible in the framework of genetic counselingFirst of all, we must keep in mind that the knowledge of the diagnosis of a chronic genetic disease in itself will significantly affect a person's understanding of his fate – after all, the diagnosis indicates to the patient the life perspective that he can no longer change, as if he were in the plot in which the main character lives the prophecy given to him.

Calculated hereditary risks are perceived as an invasion of human life by the game of blind or malicious external forces. Here there is a danger of a kind of trap that shackles any actions of the "fatal prediction" - when the patient appears to be in a situation already predicted by the oracle of fate, which he cannot change in any way and he can only wait for the predicted to occur. This state echoes the situations described by A.F. Losev in the study of Homer's work "the tragedy of fate" (and the tragic canon, in general). Like a character in an ancient tragedy, a patient who is faced with the knowledge of a hereditary disease seems to be at the mercy of blind fate and the inevitable ("natural") actions of "impersonal" forces ^[7].

An important role in the development of such a view of the future is played by the fact that hereditary diseases enter a person into the bonds of blood kinship (often we are talking about a genetic consultation not only about a specific patient, but also about his relatives), which also deepens deindividualization. Often in such a situation, kinship ties begin to be highlighted in a new way and relations / relationships with a particular line of pedigree are articulated in a new way. At the same time, often such articulation may not coincide with the scientific approach to genetic inheritance. An excellent example of such a discrepancy is given in the study by anthropologist A.S. Kurlenkova and sociologist A.A. Shirokov of ideas about kinship between patients and geneticists. In a joint article, they describe a situation when, during an appointment, a patient, based on her "everyday" idea of the biology of inheritance, assumes that the mutation identified in her passed to her from her father, arguing that their external similarity ("[I] am all, in structure, all, into this, dad's, breed"), while the doctor (for whom, during the reception, it is important to identify possible relatives who may also have this mutation and point them out to the patient) explains: the genes responsible for appearance and the genes responsible for a particular disease are not related to each other in any way ^[8]. Thus, the analysis of the pedigree to identify other potential carriers of the mutation on the part of the patient can often be evaluated not just as scientifically sound evidence of possible risks for relatives, this procedure is layered on already established relationships and ideas about blood ties and affects deeper ideas about the genus and fate.

In the confrontation of this logic of finality of fate and predestination, one of the central messages of Karpenko's article concerning the concept of possibility is important. According to him, the rejection of the attitudes of the absence of the subjunctive mood can be contrasted with the transition described from the conceivable to the possible in the representation of L. Wittgenstein ("what is conceivable is also possible") and D. Chalmers ("the connection between representativeness and possibility lies in the rational roots of our modal concepts") ^[5]. At the same time, Chalmers notes the importance of the counterfactual narrative when considering the situation of the possible. Karpenko develops this line based on the principle of abundance by A. Lovejoy ("[N]and what genuine potency of being cannot remain unfulfilled" ^[9]). I will not touch on the question of the ontological status of the possible, but I will note the heuristic value of the possibility mentioned by Karpenko, which makes it possible to overcome the rigid limitations of thinking about the future ^[5], in particular the ideas described above that constrain a person's personal choice about the genus and fate as determining factors of a person's life path.

Another important feature of genomic medicine, which we must identify in the context of thinking about the expected future, is the shift from the suffering, present body to the potential risks that may arise in the future. The principle of possibility and counterfactual thinking in this perspective can unexpectedly intertwine with ideas about blood ties and fate. These features, as well as, in principle, the influence of genomic technologies on modern medicine (within the framework of preventive and predictive medicine), are well illustrated by the case of Angelina Jolie.

The famous actress, having learned that she is a carrier of the BRCA1 gene mutation and has high cancer risks (doctors talked about an 87 percent risk of breast cancer and a 50 percent risk of ovarian cancer), resorted to preventive double mastectomy and bilateral ovarian laparoscopy. At the same time, if we do not take into account the very possibility of the disease (Jolie had no corresponding diagnosis at the time of the operations), then even after a genetic analysis revealed a high probability of cancer risks, she, however, should have been considered a healthy person ^[10]. The actress, talking about her choice, also referred to the stories of her mother, aunt and grandmother, whom cancer "took away" from her.

This incident, it would seem, is a reference illustration of how, thanks to predictive medicine, an individual approach is implemented to patients who, based on scientific data, get the opportunity to make an informed choice.

However, Angelina Doli's decision cannot be completely alienated from the actress' everyday thoughts about her family history. At the same time, the identified risks become a decisive factor in order to highlight only one branch of counterfactual reasoning: if Angelina had not agreed to the operation, she would have died early, as well as her mother/grandmother/aunt). As we can see, there is also the influence of ideas about the hereditary and generic as something supra-individual, fatal and unavoidable.

If we rely on the principle of completeness as a methodological basis for the formulation of possible forecasts, then the possibility that the disease will not manifest itself (despite the identified mutations) cannot be completely excluded by us. In another potential scenario, Jolie, having accepted all the risks, and relying on the knowledge of existing genetic mutations, could detect diseases at an early stage and start treatment on time. The absence of this principle in doctor-patient communication threatens the creation of similar scenarios for patient decision-making in conditions of uncertainty (and in Jolie's case, her decision-making model could be perceived by the general public as an example, due to the popularity of the actress).

Thus, the principle of possibility, perceived as a guideline for a doctor's conversation with a patient within the framework of discussing possible solutions and probable scenarios, can become an excellent tool for calibrating the tools of predictive medicine, making the use of the latter more accurate and truly personalized.

But applying this principle, it is also important to take into account how the patient builds a picture of himself of the future and which reference points in his questions and doubts should be paid attention to. And in order to reveal the mechanism of constructing the future self with the help of counterfactuals, I will turn to two thought experiments. The first one will highlight for us the problem of identity within the framework of a counterfactual narrative. The second one will show how this problem is revealed in the conditions of an uncertain future.

Vilma's Choice: Non-identity and Moral Responsibility As indicated above, communication and counterfactual thinking in biomedicine are closely related.

Using this connection as an example, we can highlight the generally significant philosophical aspects concerning ethical issues and the problem of identity. In cases when it comes to making decisions about the future of a patient with a genetic disease and his possible offspring, the question of identity can be revealed by the example of the concept of non-identity, as formulated by Derek Parfit. Addressing the issues related to the so-called "ethics of the population", Parfit outlined a problematic point concerning identity and the issue of responsibility to future generations. As an example, Parfit cites an incident – a 14-year-old girl decides to have a child, realizing, however, that due to her youth, inexperience, etc., she is likely to give him a bad start (she will not be able to provide enough attention, a decent college, etc.). If the child is already born, we cannot use quality his life as an argument against this decision, since the child is alive (which is a blessing), and in the case of another, "responsible" decision of the girl, he would not have been born ^[11].

Starting from Parfit's reflections, philosopher David Bunin reveals the problems of non-identity with the help of a thought experiment describing the possible consequences of refusing to follow the doctor's recommendations.

He offers readers the following plot: patient Vilma goes to a doctor's consultation to find out how she can conceive a healthy child. The doctor warns her that in order to give birth to a healthy baby, she needs to take special pills for two months before conception. Otherwise (without taking pills), the child will have serious health problems (will be blind). Bunin then presents the following alternative scenarios for the development of the current situation: imagine that Vilma, after a consultation, throws out the pills prescribed by her doctor and becomes pregnant a few days later. As a result, nine months later, her blind daughter Pebbles is born. Another variant of the development of this situation is that Vilma takes pills for two months and eleven months after the consultation, her healthy son Rox is born ^[12].

Based on the presented plot, Bunin poses the following questions: can we assume that Vilma acted unethically towards her born blind daughter? Is she hurting her? Is Vilma morally responsible for her daughter's condition?

Bunin thinks not. In his justification, he repeats Parfit's conclusions: Wilma's act did not harm her sick daughter in any way - after all, if she had taken pills, Pebbles would not have been born.

Considering this thought experiment on the topic of non-identity, we can see in it two possible angles of consideration of the presented plots. And the moral assessment of the consequences of Vilma's choice will depend on the choice of the angle. On the one hand, we can evaluate Wilma's choice by focusing on the moment when, after consulting with a doctor, she decides not to take pills, knowing that the child will be born sick in case of refusal. In this case, of course, we will most likely condemn her (knowing that she chooses the birth of a sick child instead of a healthy one). On the other hand, we can evaluate Wilma's choice in terms of the final consequences of her decisions, having knowledge of the entire sequence of events caused by Wilma's decision (a blind daughter was born). This is exactly what D. Bunin does.

 To better clarify the structure of this experiment, we will be helped by the juxtaposition of two types of personality identity: qualitative and numerical. The numerical identity denotes which object is in question, and the qualitative identity denotes the properties of the object (which may change) ^[13]. Assessing Wilma's act, Bunin is a numerical identity – which implies a specific child. But what kind of identity are we talking about for a patient who is in the same situation as Vilma? When consulting with a doctor, two characteristics of the unborn child will be important for her – this is her child, and he is healthy. That is, we are talking about a qualitative identity, not a numerical one (whether it will be a son or daughter and what their names will be – such a question is not raised for consultation).

Based on the characteristics set by the patient for himself or for the future child, the doctor will build his counterfactual narrative.  He needs to highlight in the patient's narrative what we can designate within the term "necessary properties". This term was formulated by Rudolf Carnap, but in this article it is used in the sense in which it is used by Umberto Eco to denote how the central qualities of objects or characters in the narrative stand out, which allow them to be recognized throughout the story ^[14]. Highlighting the "necessary properties" will be the element of communication through which the doctor will be able to complement the patient's autobiographical narrative – which will be discussed in more detail in the sixth section of the article.

The theory of the double and the uncertainty of the futureIn the first thought experiment, we are not dealing with the usual uncertainty associated with our lack of knowledge about the world or the possible development of events.

Bunin, as part of a thought experiment, gives a clear definition of alternatives: taking pills will definitely lead to the birth of a healthy child. In the case of Vilma, the problem only lies in the identity of her unborn child.

 However, in the case of a medical-genetic consultation, the doctor will rather talk about probabilities, rather than about exact scenarios of the future.

The thought experiment presented below will show us a more typical example of a counterfactual narrative that can arise during the communication of a geneticist and a patient. We can consider it a simple example of counterfactual thinking as a tool for decision-making. 

In an article devoted to the peculiarities of counterfactual thinking and its limitations, the American philosopher of science Chris Dorst presents a thought experiment in which he reveals the problematic points of counterfactual thinking about non-deterministic and unpredictable events.

In the scenario presented by him, there are two participants and both are quite rich. The first participant offers the second one a bet: he will flip a coin, and if the second one bets on which side the coin will fall out - heads or tails and does not make a mistake, then the second one will receive a million dollars. In case of a mistake, he has to give a million dollars. The person who was offered the bet refuses. The coin is still tossed and it falls like an eagle. The second participant can build the following counterfactual statement: if I had bet on the eagle, and not refused, I would have become richer by one million dollars ^[15]. Such a conclusion seems to be quite accurate and consistent with the rules of counterfactual thinking, but we understand that the fall of a coin is a rather difficult-to-predict process, and even a change of decision can lead to the fact that the coin, being tossed later, will fall on the other side. And therefore we cannot consider this lesson a lesson for the future – this is the counterintuitive essence of this thought experiment. At first glance, it seems that the essence lies in the non-deterministic behavior of the coin, but in fact, the essence of the thought experiment is that we are faced with the question of identity. It can be formulated as follows: is a person with knowledge of the future in the past (that is, knowing that the coin will be an eagle) the same person who made the decision? This question can be answered negatively – after all, we see that there is a difference in at least one characteristic (knowing / not knowing the future), and therefore we cannot talk about a qualitative identity by constructing such a counterfactual statement.

But if such a narrative of the relative self of the future as the self of the past was built up before the coin fell, then it would only set a space of uncertainty. And it is precisely this type of counterfactual statement that a geneticist will build in the case of a diagnosis in which it is not known for sure whether a genetic mutation will affect the patient's health over time and whether it will be transmitted to the patient's future children.

The construction of a counterfactual narrative in conditions of uncertainty comes into contact with the problem of doubles, which is also related to the understanding of counterfactual thinking. According to the concept of multiple worlds by D. Lewis, we can talk about the possibility of the existence of all worlds that we are able to conceive ^[16]. Among them, there may be worlds similar to our Earth, inhabited by our counterparts. Therefore, a counterfactual narrative can be perceived by us as realized in another possible world in which our double is present and for which circumstances have developed differently.

It is important for the doctor and the patient to jointly build an understanding of who exactly is being discussed in the counterfactual - that is, what characteristics the double in the counterfactual statement should have and which of them will be most important for the patient. This will be the main subject of the conversation. In his book "Aboutness", Yablo, within the framework of reasoning about subject matter, cites S. Kripke's thought about the theory of a double: if we are faced with unfortunate consequences for us, we care little that in another possible world everything ended successfully for our double ^[17].

For a doctor who outlines all possible scenarios (including relying on the stories of mutations or unsuccessful curation of the disease already known to him), it is important to create the very possible world in which a particular patient will make the right decision and will not become the one who regrets the consequences of his choice. But the approach to making forecasts in conditions of uncertainty cannot be based on the success or failure of already implemented scenarios in the past (depending on how the coin was laid).

Thus, a counterfactual statement, on the one hand, should contain those elements that will be aimed at reducing the risk to the patient (that is, they will convince him to follow medical prescriptions) and at adapting him to difficulties in the event that a genetic mutation manifests itself in him or in his future children. On the other hand, in conditions of a lack of knowledge about the possible development of the disease, it makes no sense to focus on the examples of other patients to create some standard of a successful solution. In this case, the guiding thread in should be the wishes and properties of the person making a decision about his future.

Narrative identityAll of the above points to the importance of constructing a counterfactual narrative in accordance with the interests of the patient and the tasks that the doctor faces.

It seems to me that the narrative approach to identity, as interpreted by D. Dennett, will be the most successful tool for the implementation of such tasks. Dennett believes that numerical identity is much less suitable for the implementation of practical tasks than qualitative, and it is on the identity of a person of certain properties that his concept of narrative identity is built ^[18]. According to his interpretation, an ever-changing story about oneself is the way in which a person defines himself and establishes his identity.

If we transfer the above into the context of communication between the geneticist and the patient, we can assume that the patient will build a new narrative about himself in the future based on the knowledge received from the doctor and from changing personal circumstances. There may be a problem associated with the constant change of narrative identity that the patient will undergo.

Analytical philosopher Galen Strawson criticizes the concept of narrative identity, suggesting that in real life there are also episodic personalities who will not identify the past self with the present self and the future self and will not build a consistent narrative about themselves ^[19]. Philosopher Dmitry Volkov objects to G. Strawson, relying on the so-called "pragmatic thesis", according to which moral responsibility, as well as concern for survival, etc., are based precisely on narrative identity ^[20]. Thanks to this approach, we can build a holistic autobiographical narrative.

This conclusion is significant for us when we turn to counterfactual thinking within the framework of communication between a geneticist and a patient. What the patient asks about in a counterfactual statement will be an auxiliary tool for highlighting important identity characteristics related to the future, past and pressing problems of the patient (his "necessary properties" according to the formulation of U. Eco). Focusing on the ideas of the patient's personality, the doctor, in turn, clarifies his goals and designates the means to achieve it. Thus, thanks to counterfactual thinking, the doctor can complete the patient's autobiographical narrative, make it complete. At the same time, under conditions of uncertainty, he will focus on the qualitative identity of the patient in the future.

Counterfactuality at the same time allows you to emphasize the hypothetical nature of the statement. The hypothetical nature of the statement in this case will proceed not only from the characteristics of the genetic disease itself (the doctor may not always know exactly how this or that genetic mutation will manifest itself), but also from the assumption that the very knowledge about the disease or the patient's values may change during treatment.

ConclusionWhen we talk about making decisions in conditions of uncertainty, one of the obstacles is the limitations of thinking that can arise if no attempt is made to consider more than one likely scenario.

Although the "everything is possible" setting itself (perhaps seeming excessive) is not a universal tool for answering questions about the uncertain future, it can still be a good methodological guideline to avoid abuse of one preferred, simple scenario for solving problems related to the disease, and opens up the prospect for building more complex and multi-component scenarios both on the part of the doctor and the patient.

The example of communication between a doctor and a patient in the framework of a genetic consultation also allows us to formulate a specific understanding of what type of identity is being discussed in counterfactual statements in the framework of decisions concerning our own future.

Both thought experiments given in the article show that in the counterfactual narrative, which concerns the future hero of the narrative, we cannot speak from the standpoint of already accomplished events. Numerical identity cannot be thrown back into the past in counterfactual thinking – as we see in the first thought experiment with Vilma. As it was shown by the example of the experiment with a coin, we cannot talk about the qualitative identity of the self who regrets the events that have already happened and the self of the past. But it should be added that qualitative identity gives us more space to create a counterfactual narrative about the future in conditions of uncertainty. Applying this to medical-genetic counseling, we see that the "necessary properties" that the patient attributes to himself, building a counterfactual statement, help the doctor to determine which scenario is desirable for the patient and clarify his long-term goals.  This, in turn, allows the doctor to outline the possible world in which the patient will not regret the consequences of his choice. 

Counterfactuals allow the doctor to present information to the patient in a form convenient for the patient, emphasizing the hypothetical nature of his statements and not giving a final assessment of events, and to form several narrative directions that are more convenient than simple imperative recommendations. Counterfactual thinking focused on the qualitative identity of the patient, allows us to take into account that the patient may change value orientations, assessment of the development of risks and events. As a result, the doctor and the patient can jointly build a holistic autobiographical narrative about the patient's future.

In addition, in the context of communication about genetic risks, counterfactual thinking and the related problems of narrative identity highlight for us one of the significant properties of the narrative: the narrative constructs reality, and not just describes it.

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