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A patient considers what course of action is his or her own best interests. Due to hyperbolic discounting, the patient’s answer to that question may be unstable. Due to the way the query is posed to the patient, the answer may also vary. Because the patient is unfamiliar with many of the consequences of the decision, the utility of the various outcomes is vague. Because of anticipated regret, the patient may choose an option that the physician thinks is sub-optimal. These are but a subset of the factors that may influence patients’ decision making in a way that escapes the approval or understanding of others. Such patient behavior is not necessarily irrational. For example, we cannot fault the patient who deems the utility of a future health state to be much worse than the utility given it by those actually in the health state. An omniscient observer may know that a poor decision is being made based on the unrealistically low rating. The patient, however, cannot be expected to make current decisions based on future experience. Many of the patient decision making problems raised in this chapter are relevant to several ethical issues. For example, to the extent patients base their decisions on inappropriate ratings of potential future outcome states, should physician paternalism be tolerated or even encouraged? May physicians honor a pre-commitment even if a competent patient subsequently wants the pre-commitment voided? What is the appropriate way to frame a question if it is known that the framing influences the answer? Many such questions fall under the rubric of “constructed preferences” (Slovic, 1995). This term means that people do not reveal their preferences by consulting an internal compendium which contains information, for example, on whether radiation is preferred to surgery. Instead, preferences are constructed de novo as the question is posed. As a result the format of the question, the emotional state of the person, and a number of other factors can contribute to the construction of the preference. To the extent preferences are constructed rather than revealed, it becomes incumbent on the researcher or practitioner to solicit preference and probability information as carefully and completely as possible. Finally,
as patients assume a larger role in
their own care, it becomes essential
that medical practitioners understand
some of the principles underlying patient
decision making. Fortunately, the grasp
of a relatively few tenets, such as
regret, omission bias, visceral influences,
and hyperbolic discounting, can help
explain a number of the behaviors patients
exhibit as they contemplate the medical
options confronting them.
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