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Psychology of Patient Sections
Author Bio
Introduction
Omission Bias
Discount Rates
Framing
Assessing Probabilities
Predicting Utility
Sequences
Role-based decisions
Currently selected section: Role of Emotions
Visceral Influences
Conclusion
Chapter 4: The Psychology of Patient Decision Making: The Role of Emotions in Patient Decision Making
        

For many of the participants in the study by Ritov and Baron (1995), the knowledge that they would know the fate of each child reduced the number of deaths they would tolerate from the vaccine.  Knowing which children they chose to vaccinate would have lived but for the vaccination induced regret in many people.  Among those participants for whom knowing the fate of the children influenced their decision, the vaccine was not given unless it caused no more than an average of 4.1 deaths.  On the other hand, when the deaths occurred to anonymous children, 6.5 deaths were tolerated. 

The role of regret has been demonstrated in actual patients contemplating real consequences.  For example, Smith (1996) analyzed the net benefit of adding a 52-week course of adjuvant chemotherapy to surgical resection of colonic carcinoma.  Five-year survival could be increased from 55% to 71% by adding the chemotherapy. However Smith found that in a patient sample of 8, both overall and for every individual patient, the addition of the chemotherapy resulted in a loss of QALYs (quality-adjusted life years).  Nevertheless, every patient chose to have the chemotherapy.

Choosing an option characterized by a loss of QALYs would seem to define not acting in one’s own best interests.  Why would patients do so?

Some theorists (Loomes and Sugden, 1982; Bell, 1982) have suggested that the value of any alternative depends on the value of the other alternatives available when the decision is made.  If the outcome obtained is inferior to an alternative outcome that might have been obtained had another action been taken, then there is regret for having chosen the action that led to the inferior outcome.  Smith (1996) hypothesized that all of the patients he studied selected the chemotherapy, because they would have regretted not selecting that option.  Chemotherapy held out the hope of a better outcome, which all 8 patients would have regretted forsaking.

There are other factors that can trigger regret.  Consider a non-medical scenario taken from Kahneman and Tversky (1982):

Kahneman and Tversky (1982) found that those who got the “unusual route” version were likely to change that aspect of the story when completing the “if only” thought.  Those who got the “earlier departure” version were less likely to change the route and were more likely to change the time of Mr. Jones’ departure.  The point is that the unusual factor is more likely to be “mutated” or changed in order to undo the bad outcome.  This is why patients so often take the “glide path” rather than opt for some less orthodox course of action.  More regret accompanies a poor outcome that follows an atypical course of action (“Why couldn’t I just do what the doctor suggested?”) as opposed to typical (“I did what everyone else does in that situation, so my decision cannot be faulted.”)  Such reasoning probably also contributes to the omission bias, because harmful commissions are often more blameworthy than harmful omissions (Ritov and Baron, 1992). 


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