Affective forecasting may impact medical ethics
Professor offers insight based on psychiatric lit
There's no doubt that physicians are the linchpin of the healthcare system. And when it comes to patient education and counsel regarding diagnoses, prognoses and possible death, they also bear the leadership role.
In a paper published earlier this year in the Cambridge Quarterly for Healthcare Ethics, one of two authors, Rosamond Rhodes, PhD, professor, medical education and director, bioethics education at the Mount Sinai School of Medicine in New York, suggests that this paternalistic role played by doctors is both necessary and good.
The reasons behind the importance of objective physician education and counseling of patients, she suggests, is due to the fact that patients are subject to what is known generically as "affective forecasting," or the fact that our judgments about what our mental state may be in the future are clouded with distortions.
Citing studies in psychology by T.D. Wilson and D.T. Gilbert, Rhodes notes that these studies found that when subjects were asked to predict their own emotional responses in the future to negative events, they were often "off target," according to Rhodes and Strain, when those predictions were compared to how the subjects actually felt after the negative events occurred.
"Although these psychological studies include no medical examples and make no claims about their application to medicine, it strikes us that this work has very significant implications for medical ethics …," the authors write.
Some of the types of distorted thinking include what is known as focalism, or instances where an individual or patient may exaggerate a certain feature of a negative event, and anticipate their future reactions accordingly. Durability bias refers to patients assuming that their negative emotions in response to a negative event will be more intense and last longer than they often do.
The fact that people are often more resilient and optimistic than they think is evidenced by examples such as how individuals responded to such catastrophes as Hurricane Katrina. Although the city was devastated, people interviewed often responded with the thought that the hurricane gave them an opportunity to rebuild and correct some of the cities problems that existed prior to the storm.
"This phenomenon of ignoring out ability to cope and failing to take it into account in predicting our future affect is called 'immune neglect,'" the authors write.
In the "medical environment," the authors note that not only are patients affected by affective forecasting, but so are doctors and families of the patients. Futhermore, the authors suggest that policymakers in healthcare also are affected by this distorted thinking.
But how does this affect medical ethics and ethics policies? For the patient diagnosed with cancer, that patient may focus only on the negative possibilities that come with such a diagnosis, such as a scar from a mastectomy or loss of hair as a result of chemotherapy. For patients either in denial or who focus on hair loss rather than overall improvements in their condition, affective forecasting can have "serious consequences for the affected patient," the authors write.
Affective forecasting might also prevent a patient from ever visiting a doctor in the first place, out of fear that they may hear bad news.
Families, often claiming they are protecting the patient from bad news, sometimes instruct physicians not to give their loved ones a negative diagnosis or prognosis. Family members often cite cultural reasons for not wanting to give the family member bad news, but the authors note that this is true regardless of whether the family is European, Asian, African or from Latin America.
Since physicians can be affected by this distorted thinking, one way to address is through awareness, first, and using cognitive behavioral therapy with patients, i.e., talking with them in such as a way as to have them think differently about their situation.
Rhodes told Medical Ethics Advisor, "There's an important place for making physicians aware of the phenomenon. And the training they need in cognitive behavioral therapy is not so deep and significant that I think it's more awareness – enough to give them confidence to raise questions and have a conversation about the judgments of patients or family members."
Another way to counter distorted thinking in patients, she said, is to "put the emphasis on the appointment of a proxy decision maker, an agent, rather than the [writing out] the details [of potential treatments]."
"I think the value of recognizing this distortion is recognizing that we can also . . . make adjustments. The greatest value is when you have someone you can speak to, so if the physician knows – if it becomes part of medical education to make doctors aware of this distortion – then it gives doctors a license to question a patient's judgement, to encourage them to think about their decisions and accept them, and the same for family members and surrogates," Rhodes said.
Knowledge, in this case, is meant to "empower" doctors to speak directly with the patient.
"It authorizes them, instead of leading them to think, 'Well, if I tell the patient [something] again and again, I'll be paternalistically interfering.' Yes, you are paternalistically interfering, but it's justified, because the patient's judgment is likely to be distorted, and if you can get them over the distortion, they can make more reasonable decisions," Rhodes told Medical Ethics Advisor.
The difficulty in mitigating the potential consequences of affective forecasting is with public policymakers, and that difficulty comes as result of not having "anyone in the role that a doctor could play," Rhodes said. The paper gives three examples in the public policy arena where distorted thinking may be a factor: organ tranplants, genetic testing in children and assisted suicide.
"It's just a mass hysteria. You hear the people in the genetics counseling community talk about why we can't test children. They all lock-step believe it, although if you look at other policies it is out of sync," Rhodes said. "If you look at what happens when you tell children that they're actually dying from some condition, none of the [negative things] happen."
In their conclusion, the authors write that "well measured medical paternalism" is not the problem associated with distorted thinking in patients and caregivers. In fact, they see such paternalism as "good medical practice." The "moral problem" they identify is when affective forecasting seems to appear as "medical beneficence."
"There, a significant danger lies in clinicians and policymakers allowing their distorted fears to move them," the authors write. "The actions and policies that reflect unchecked affective forecasting result in the imposition of biased conclusions on others in the name of promoting great good."
When such attitudes "usurp the decision of others," Rhodes and Strain suggest there is cause for alarm, because as they indicate, "significant ethical boundaries are crossed."
Reference
- Rhodes, R., Strain, J. Affective Forecasting and Its Implications for Medical Ethics. Camb Q Healthc Ethics. 2008; 17(1): 54-65.
Sources
For more information, contact:
- Rosamond Rhodes, PhD, director, bioethics education, Mount Sinai School of Medicine, Box #1108, One Gustave Levy Place, New York, NY 10029. E-mail: [email protected].
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