Abstract
Most individuals prefer not to know when they will die or if they carry the gene associated with a fatal disease.1,2 Consequently, when it comes to medical information and shared decision making (SDM), people tend to be (medical) “Homo ignorans” in the sense that we often choose to avoid, neglect, and even distort information that is accessible and carries potential value. Medical information and decision making are deeply intertwined with emotions, affecting both patients and physicians. Emotions such as fear, hope, and anxiety can significantly influence a patient’s perception of their condition but also their choices regarding treatment options. As argued by Vickers and Bennett, 3 SDM often falls short because it merely involves presenting patients with a plethora of information without helping them make sense of it. We agree but think it is important to emphasize the key role of emotions in understanding how SDM can be effectively used in practice. In our view, 3 aspects of how emotions affect decision making are particularly important to consider for SDM to contribute to sensemaking and balanced medical decision making.
Prominence Thinking
An often-overlooked aspect of SDM is the psychological difference between making a choice and an evaluation. The literature on judgment and decision making well establishes the psychological discrepancy between evaluating options and making a choice among them, particularly emphasizing the key role of emotions. 4 During evaluation, typically the cognitive mindset of physicians, people typically adopt a more analytical and objective approach, systematically weighing the pros and cons of each option. However, the process of making a choice brings emotions more to the forefront. Emotions such as fear, hope, anxiety, and uncertainty become more pronounced as individuals grapple with the potential consequences of their decisions. This emotional engagement often leads patients to shy away from tradeoff thinking and instead choose treatment options based on the most emotionally salient attribute, such as immediate relief from symptoms or the lowest perceived risk, thereby neglecting the bigger picture and potentially more balanced or long-term beneficial options.
Preferences for More versus Less Health Care
Both patients and physicians differ in their approaches to medical decision making, making SDM an iterative process that must be adapted on a case-by-case basis. Individual preferences for health care can differ widely, with some people inclined to seek extensive medical services, while others prefer a more restrained approach.5,6 Those who favor more intensive engagement with health care—referred to as “medical maximizers”—typically seek numerous health care visits, medications, tests, and treatments. Conversely, “minimizers” are individuals who opt for fewer medical services, demonstrating a preference for a less intensive health care experience. In addition, physicians are likely to vary along the spectrum of being maximizers or minimizers when it comes to recommending medications, tests, and treatments. This makes SDM a balancing act in which physicians need to promote active care more to minimizers than to maximizers. If not managed well, SDM can result in a serious mismatch, potentially leading to devastating consequences. Therefore, SDM requires physicians to have strong social skills to understand the patient’s needs, preferences, and values from both a medical and a nonmedical perspective. Moreover, physicians must have a deep insight into their own inclinations and values to recognize how these might affect different patients in varied ways.
Risk as Feelings versus Risk as Analysis
Emotions also play a key role in how patients judge risks and benefits in medical situations. Although risks and benefits tend to be positively correlated across hazardous activities in the real world (i.e., high-risk activities often have greater benefits than low-risk ones do), they are often negatively correlated in people’s minds. This means that high risk is frequently associated with low benefit and vice versa. Consequently, physicians need to consider the inverse relationship between the perceived risk and perceived benefit that often drives decisions in situations involving risk. For example, when considering a new medication, if patients feel positive about it—perhaps due to a trusted recommendation or positive testimonials—they tend to judge the risks as low and the benefits as high. Conversely, if their feelings toward the medication are unfavorable, they are likely to perceive high risk and low benefit. This implies that patients judge a risk in terms of probabilities of adverse events but also how they emotionally feel about it. 7 The downside to this affect heuristic in medical decision making is that it can lead to suboptimal choices, prioritizing short-term comfort over long-term health benefits. Patients may underestimate the risks of favored treatments or overestimate the risks of beneficial ones, leading to poor outcomes. SDM should help patients see beyond their emotions. Therefore, the physician’s role in SDM should be not only to assist patients with facts and figures about different options but also to help patients process this information in the context of their values and emotions. For SDM to be truly effective in creating sensemaking, physicians need to engage in what we call affective paternalism, helping patients to balance their emotions with factual information. This approach helps patients to process information in the context of their values and emotions, leading to more informed and balanced decisions.
Affective Paternalism
The case for affective paternalism in medical decision making centers on the need to balance emotional and rational considerations to optimize patient outcomes. At the core of affective paternalism is the observation that affect and emotions are not good or bad per se. However, they play a crucial role in motivating behavior and facilitating the process of sensemaking when processing information. 8 Rather than using affectless decision analysis or nudges/choice architecture to steer behavior (as in libertarian paternalism), 9 affective paternalism acknowledges that emotions significantly influence patients’ decisions. This often leads them to prioritize immediate relief or perceived safety over long-term benefits.
By engaging in affective paternalism, physicians can acknowledge and use the sensemaking component of affect. In this approach, physicians help patients to navigate their emotions by providing not just factual information but also emotional support and guidance. This approach involves recognizing and addressing patients’ fears, hopes, and anxieties, helping them to process information more comprehensively. For example, learning about the mortality risks associated with various cancer treatments can provoke strong emotions in many patients. These emotional responses are often insensitive to the survival rate associated with each option (a phenomenon known as probability neglect 10 ). For example, physicians can visualize outcomes using affect-rich presentations to increase sensitivity to probabilities, 11 thereby inducing differentiated emotional responses to various treatment options. Affective paternalism, thus, allows physicians to utilize emotions rather than avoid them in SDM.
Ultimately, affective paternalism aims to create a more balanced decision-making process in which patients’ values and emotions are integrated with medical expertise, leading to more informed and better choices. This nuanced approach fosters better sensemaking and aligns treatment decisions with patients’ overall well-being. An essential component of this form of SDM is helping patients confront negative emotional information in a way that prevents avoidance and encourages its use in decisions. Techniques like emotion regulation strategies, such as cognitive reappraisal, can be used to achieve this. Thus, affective paternalism not only addresses the emotional dimensions of medical decision making but also enhances the quality of patient outcomes by ensuring that decisions are both emotionally and rationally grounded.
