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In recent
years many patients have assumed greater responsibility for decisions
concerning their own medical care. The 1993 Patient Self-Determination
Act recognizes one’s right to have a role in one’s own medical
care. The question naturally arises concerning patients’ ability
to make good health care decisions. For example, we would expect
a patient to choose to be vaccinated if the mortality rate of
allergic reactions to the vaccine is far less than the mortality
rate of the disease being prevented. We would also expect a patient
to choose to undergo a miniscule inconvenience now to minimize
the chance of a major health problem later. Are these expectations
unrealistic? Do patients make decisions in their own best interests?
Patients frequently
have to choose between symptoms. For example, to what extent
is a patient willing to accept some level of pain in order to
reduce the amount of sedation? At what point does a patient find
symptoms so aversive that he or she is willing to increase compliance
with the medication regimen? Answers to these questions have
major implications for research in several areas. For example,
medical ethicists would be interested in such questions because
if patients do not make decisions in their own best interests,
then that fact should enter into debates about paternalism and
patient autonomy. Oncologists would be interested in such questions
because many crucial end-of-life care decisions are predicated
on the patient’s or the decision-making surrogate’s ability to
consider rationally the desirability and likelihood of various
outcomes.
In
this chapter I will examine two issues concerning patients’ decision
making performance: (1) What are the factors which cause patients
to make decisions whose consequences may diverge from their own
best interests? (2) What is the role of emotion in patient decision
making?
Divergence
from Patients’ Own Self-Interest
A bedrock
assumption of allowing patients more decision-making autonomy
is that they will exercise this right in their own best interest.
By “best interest” we mean that the patient will prefer actions
with lower mortality rates to actions with higher ones and will
prefer states with higher utility to states with lower utility.
Why would anyone exhibit contrary behavior? There is evidence
that patients are sometimes unable or even unwilling to choose
in their own best interest. Often there is something patients
are trying to maximize other than probability of survival or desirability
of the outcome. These other factors--many of which are psychological
in nature--include such important goals as the minimization of
regret or blame.
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