Nearly 30% of all physicians in the United States (U.S.) are immigrants, working alongside millions of foreign-born nurses, technicians, and aids [
1]. Among U.S. residents, over 20% report speaking a language other than English at home, with the estimate growing closer to 50% in the bigger cities [
2]. Combined with the millions of multilinguals around the world who live their lives in a language other than their native tongue, it becomes clear that important decisions, such as those about our physical health, are routinely made while using a foreign language. How language impacts health outcomes has therefore garnered significant interest, with topics spanning the efficacy of interpreters and communication strategies ([
3,
4,
5], see also [
6] for review) to linguistic discrimination and perceptions of foreign accented doctors and patients ([
7,
8,
9], see also [
10] for review). One question that has received relatively less attention, however, is how evaluating health-related information in a foreign language impacts the clinical decision-making process.
According to decision theory [
26], individuals form preferences based on the expected utility of the available options—that is, the combination of how positive or negative a given outcome is perceived to be (i.e., the subjective value or utility) and how likely that outcome is perceived to be (i.e., the expected probability). Within this framework, an individual deciding whether to accept preventative treatment should consider how severe the consequences would be if a particular illness is contracted, as well as the probability of contracting the illness if no preventative measures are taken. These estimates could then be weighed against the perceived severity and probability of potential treatment complications to ultimately determine whether to accept preventative care. Considering the costs and benefits of multiple options, however, does not necessarily guarantee that the wisest decision will be made. In addition to the fact that we rarely have perfect knowledge of the stakes and probabilities associated with different outcomes, both subjective value and expected risk can be biased by emotional reactions and cognitive heuristics. Emotions can also affect the degree to which we account for expected utility when making decisions, resulting in substantial variability in people’s preferences and behaviors. In the following sections, we provide an overview of how medical judgements and decisions can be shaped by emotion, as well as how emotions, and subsequently preferences, can be shaped by language.
1.1. Evaluating Outcomes: How Bad Would It Be If Things Went Wrong?
The role of emotion in medical decision-making is perhaps most apparent when considering how individuals assign value to the available options. When deciding whether to get vaccinated for an illness, there are many different factors related to one’s health, finances, social and professional lives, and more that could be logically taken into account to estimate the value of each course of action. Sometimes, however, emotions are used as a substitute for reasoned evaluations, resulting in the relative value of one option over another becoming based on which one elicits a more positive or less negative feeling [
27,
28] (i.e., an “affect heuristic” [
29]).
When making decisions regarding preventative healthcare, emotions such as fear, anxiety, and anger have been shown to influence a wide range of behaviors, including genetic testing for disease susceptibility [
30], dietary habits [
31], safe-sex practices [
32], and willingness to accept preventative treatments that may introduce adverse effects of their own [
33]. Making decisions that involve tradeoffs between negative outcomes of a disease and its treatment can be especially difficult as individuals are often disproportionately sensitive to the latter (i.e., “side effect aversion” [
34,
35,
36,
37]). Indeed, when informed of the possibility of treatment side effects, individuals will often prefer to take no action and instead face more severe consequences associated with the illness (i.e., an “omission bias” [
38,
39]). Waters et al. [
36] observed that willingness to accept a preventative treatment declined with the “mere presence” of any negative side effect, but did not vary with the number of potential complications or with the likelihood of contracting the disease. It has also been found that ensuring comprehension of the treatment risks and benefits (e.g., through graphical displays) can reduce, but not eliminate side effect aversion [
35], indicating that suboptimal decisions cannot be fully explained by imperfect knowledge or understanding. Instead, these findings are consistent with the idea that potential outcomes are often evaluated based on affective reactions rather than reasoned considerations.
We propose that one factor that could attenuate the perceived severity of adverse effects is the use of a foreign language. Bilinguals often report feeling less emotional when using a non-native language [
40,
41]—a finding that has been corroborated with physiological [
42,
43] and neural [
44,
45,
46] evidence of attenuated emotional reactivity when processing foreign language stimuli. Bilinguals in psychotherapy settings reportedly switch to a non-native language to discuss traumatic or distressing topics [
47], and verbally induced fear conditioning is reduced when using a foreign language [
48]. Cross-linguistic differences may stem in part from language-dependent retrieval of memories [
49,
50,
51,
52] and the types of contexts in which native and foreign languages are acquired and used (see [
53,
54] for reviews). Marian and Kaushanskaya [
50] observed that bilinguals express more intense affect when describing autobiographical memories in the language in which the memory took place. Differences in how bilinguals respond to and evaluate situations when using a native vs. non-native language can subsequently lead to different preferences and behaviors. For instance, when faced with moral dilemmas, bilinguals using a foreign language often express greater willingness to take emotionally aversive actions such as sacrificing one person’s life to save a group relative to those using their native language. More closely related to the health domain, Geipel, Hadjichristidis, and Klesse [
22] found that innovative, but potentially aversive products (e.g., recycled water, insect-based food) were perceived as less disgusting in a foreign language, resulting in greater intended as well as actual consumption.
The effect of language on moral judgment may be partly attributable to a reduction in the vividness of mental imagery [
17], which could subsequently reduce the emotional impact of difficult decisions. It has also been argued that effects of language on moral judgments may stem from less automatic and intuitive processing, rather than dampened emotion per se (e.g., [
55,
56]). Replicating earlier findings, Geipel et al. [
15] observed that using a foreign language increased utilitarian responses to moral dilemmas and attenuated the perceived aversiveness of the decisions. Importantly, however, they found that the effect of language on moral judgment was not mediated by ratings of emotional distress. Furthermore, the authors observed that using a foreign language increased the perceived acceptability of violating social or moral norms, indicating that the influence of language on moral judgment may primarily stem from reduced activation of internalized norms (e.g., against causing harm to another person, even for the greater good).
Integrating the blunted norm-activation and attenuated emotion accounts, a recent study by Caldwell-Harris and Ayçiçeği-Dinn [
57] investigated how using a foreign language affected ratings of agreement with ethical vs. selfish actions while measuring participants’ skin conductance responses (SCRs). Similar to Geipel et al. [
15], the authors observed that participants using a foreign language expressed greater agreement with selfish actions than those using their native tongue. This finding lends support to the hypothesis that using a foreign language may reduce the salience of social and moral norms, which could contribute to foreign language users’ greater willingness to harm one individual to save a group (e.g., [
12,
13,
16]). Additionally, while selfish statements generally elicited a larger stress response (i.e., higher SCRs) than ethical statements, the difference in SCRs was reduced in a foreign language. Notably, using a foreign language also led to an overall increase in physiological arousal. The authors therefore suggest that the added cognitive load and stress of using a non-native language may “swamp” emotional signals (i.e., “somatic markers” [
58]), which would normally guide moral judgments. In other words, rather than merely dampening emotional responses, the anxiety and effort associated with using a less proficient language may mask the intuition-based gut feelings that enable quick and automatic judgments.
Such a mechanism could help reconcile the often-observed foreign language increase in utilitarian behavior with research suggesting that stress and cognitive load tend to elicit
less utilitarian behavior [
59,
60]. Youssef et al. [
59] found that when participants underwent a stress induction procedure, they tended to make fewer utilitarian decisions in response to high-conflict moral dilemmas (such as to sacrifice one person to save five) relative to controls. Likewise, Greene et al. [
60] observed that increasing cognitive load with a concurrent digit-search task selectively interfered with utilitarian judgments. In both cases, the authors interpret their findings within the framework of a dual-process theory [
61] of moral decision-making positing that judgments are made through a combination of relatively automatic, affective, and intuitive processes (i.e., System I) and more resource-dependent, deliberative, and analytical processes (i.e., System II). Based on the idea that stress and cognitive load should increase reliance on automatic processes, the consequent reduction in utilitarian choices has been taken as evidence that the “default” gut response when faced with sacrificial dilemmas is to abstain from taking the utility maximizing action—that is, to refuse to sacrifice one person to save a group. While at first glance, such an explanation seems to be at odds with the finding that the use of a more difficult foreign language
increases utilitarianism, the apparent inconsistency could be resolved by Caldwell-Harris and Ayçiçeği-Dinn’s [
57] proposal. For instance, while using a foreign language may indeed increase reliance on automatic or emotionally driven processes, any discomfort experienced when contemplating an aversive action may be attributed to the use of the foreign language rather than the choice itself, thereby minimizing its effectiveness as a cue.
The dual-process framework has also been invoked to suggest that the moral foreign language effect may stem, not from a reduction in emotion or intuition, but rather an increase in deliberative (System II) processing (see Hayakawa et al. [
62] for discussion). This “enhanced deliberation” account is predicated on the idea that increasing perceptual or cognitive disfluency may enhance deliberative processes by signaling the need for more careful consideration. For instance, Alter et al. [
63] found that participants completing the Cognitive Reflection Test (CRT [
64]) were less likely to produce an intuitive, but incorrect response to misleading word problems when the text was more difficult to read. To the extent that a foreign language is processed less automatically and fluently than one’s native tongue, it may be more likely to engage careful, deliberative modes of thinking. If so, the greater willingness to sacrifice one life to save a group may result from increased deliberation and cost-benefit analysis rather than a reduction in the aversiveness of the sacrificial action itself. Along similar lines, it has been proposed that the foreign language increase in utilitarianism may be the result of language switching rather than the use of a foreign language per se. Oganian et al. [
65] observed that bilinguals made more utilitarian moral judgments not only after switching from the native language to the foreign language, but also after switching from a foreign language to a native language (c.f. [
12]). Given that language switching has been shown to engage domain-general cognitive control processes [
66,
67], the cognitive control required to inhibit a previously active language while activating another may carry over to subsequent moral judgments, resulting in greater deliberation and utilitarian preferences.
In sum, while using a foreign language can influence moral judgments and decisions, the mechanisms underlying existing foreign language effects have yet to be conclusively established. The robust evidence indicating that language modulates affective responses, however, provides a compelling basis to generate predictions regarding how using a foreign language may influence judgments in the medical domain, including emotionally charged evaluations of severity and risk.
1.2. Estimating Risks: What Is the Likelihood That Things Will Go Wrong?
In addition to guiding evaluations of outcomes, emotions can influence medical judgment by inflating or otherwise distorting the perceived likelihood of the potential consequences. The subjective value and expected probability of outcomes are often assumed to be theoretically independent, and yet there is substantial evidence that the estimated likelihood of experiencing an event is often biased by how beneficial or harmful that event is perceived to be [
68]. For instance, the expected probability of catching a disease or experiencing treatment complications is often positively correlated with the perceived severity of the aversive outcome (e.g., [
69,
70]). Indeed, though risk is operationalized in the present study as the likelihood of experiencing adverse effects, the word “risk” itself is often associated with both the likelihood and severity of negative outcomes [
71] (further highlighting the close correspondence between the two constructs). The influence of “affect heuristics” [
29] can be observed even when individuals are explicitly provided with information regarding the prevalence of medical conditions (i.e., “population risks” [
72]).
To the extent that using a foreign language attenuates the perceived negativity of potential outcomes, it may subsequently reduce the perceived likelihood of aversive events relative to when judgments are made in a native language. Indeed, it has been found that individuals evaluating the risks and benefits of potential hazards (e.g., nuclear energy, nanotechnology) perceive less risk and greater benefit when using a foreign language compared to a native language [
73]. Such differences in risk perception may help account for a number of findings suggesting that using a foreign language can increase willingness to engage in novel and/or risky behaviors (e.g., [
18,
19,
20,
22,
74]).
The role of emotion in language-dependent risk taking has also been explored in a number of recent neuroimaging studies (e.g., [
75,
76]). In one functional Magnetic Resonance Imaging (fMRI) study, He et al. [
75] presented unbalanced bilinguals with a series of gambling decisions. Each gamble was followed by positively- or negatively-valenced written feedback signaling a monetary gain (e.g., “Wonderful! +
$10”) or loss (e.g., “Terrible! −
$3”) in either the native language (Chinese) or foreign language (English). Consistent with prior behavioral evidence indicating that judgments of risky events may be more positively biased in a non-native tongue [
73], the authors found that positive feedback elicited a greater tendency to gamble in the foreign language than in the native language, which was in turn associated with greater activation of the right hippocampus (implicated in both declarative memory [
77,
78] and emotion regulation [
79,
80]). Relative to neutral feedback, negative feedback elicited greater functional connectivity between the dorsolateral prefrontal cortex (dlPFC) and visual cortex in the foreign language, but not in the native language. Given the role of the dlPFC in cognitive control processes [
81,
82], as well as analytic reasoning [
83], the authors propose that using a foreign language may engage increased control processes to divert attention away from negative stimuli.
1.3. Weighing Costs and Benefits: Will You Rely on Intuition or Data?
In addition to directly modulating perceptions of risk, affective responses can influence the degree to which individuals are sensitive to actual or perceived probabilities when forming judgments and preferences. Colomé et al. [
69] found that decisions to recommend preventative treatments for highly negative medical conditions (e.g., cancer) were primarily guided by affective evaluations (severity, worry) rather than the likelihood of contracting the disease. Decisions regarding less severe and worrisome conditions (e.g., hypertension), on the other hand, were more impacted by estimates of risk. The greater tendency to neglect probabilistic information when making emotional decisions is consistent with the moderating effect of emotion on “scope insensitivity” [
84,
85,
86,
87]. As it pertains to health risks, scope insensitivity (or embedding) refers to how individuals are often insufficiently sensitive to the magnitude of risk reduction when determining the value of treatments, policies, consumer products, and so on [
88]. For instance, an individual may be willing to pay
$500 to reduce the risk of a disease from 20% to 10% (i.e., a 10% reduction), and yet may only be willing to spend
$600 to reduce the risk from 30% to 10% (i.e., a 20% reduction). In other words, twice the risk reduction would not be valued at twice the price. Rottenstreich and Hsee [
86] find that individuals are especially insensitive to magnitude when evaluating high-affect outcomes (such as a painful electric shock) relative to lower-affect outcomes (such as a monetary loss, i.e., an “affect gap”, see [
87]). The authors suggest that, for negative events, any deviation from impossibility to some possibility inspires fear, causing individuals to inflate the likelihood of small probabilities. At the other end, deviation from certainty to some possibility inspires hope, resulting in underestimations of high probabilities. Stronger emotional responses may thus flatten the probability-weighting function, resulting in reduced sensitivity to relative degrees of risk. Chang and Pham [
84] similarly observed a relationship between scope insensitivity and psychological distance, with greater psychological proximity to the situation (temporally, socially, or physically) resulting in greater insensitivity. To the extent that a foreign language induces a more psychologically or emotionally distant mindset, the prospect of aversive medical events may elicit less fear, making people more likely to account for relative magnitudes of outcome severity and risk. In other words, using a foreign language may increase sensitivity to expected utility when making difficult medical decisions.