Making a life-altering medical decision is a daunting task. When facing high-stakes choices of serious magnitude, patients (and their families and caregivers) often embark on a campaign of meticulous research, weighing the pros and cons. This often includes imagining how they will feel after opting for a given course of action. This last process speaks to anticipated regret, which is a powerful influencer in the decision-making paradigm. There is a strong drive to avoid the remorseful experience of later wishing one had chosen differently.
Consider the patient who has been diagnosed with an incurable form of cancer. When presented with the option of potentially life-prolonging, yet risky surgery, the patient will (at least subconsciously) ask herself which decision would lead to the greatest regret. Which is worse: doing nothing in the hopes that the disease will progress slowly, and having it instead progress quickly, or opting for surgery and subsequently suffering serious complications? The decision that leads to the least anticipated regret will often be selected as the “lesser of two evils”.
Imagining how one will feel after a given decision and outcome does not necessarily lead to good decision-making. In “Regret and the Rationality of Choices,” Sacha Bourgeois-Gironde defines “anticipated regret” as a predictive error signal that the human brain considers based on the results of previous decisions. Therefore, the signals that influence the decision-making process may or may not have any actual relevance to the current situation. The degree of regret a patient will anticipate may be subject to the influence of past experiences with surgery, for example, and those prior experiences may have little in common with the decision at hand now.
Active or passive decisions also influence anticipated regret. As an illustrated, Kahneman and Tversky demonstrated that investors who lost money due to making a change in their investment strategy experienced greater levels of regret than those who lost money but had not made a change. If we use this as a model, we expect the cancer patient will anticipate greater risk associated with opting for surgery than choosing to do nothing. This is also the reason that many educators advise test takers not to change answers on a test, but stick with their first choice. There is actually no evidence to suggest that this strategy improves test scores. In a meta-analysis of 33 studies, not one was found in which the performance decreased when the participants changed their minds (Benjamin, Cavell, & Shallenberger, 1984). However, this strategy does minimize the regret associated with the choice – that it, simply “getting it wrong” seems OK, but having the right answer and the changing it to the wrong answer feels much, much worse. It is also much more memorable, and therefore, availability bias leads us to want to stick with our original choices.
Similarly, in Jain and Bearden’s “The Role of Anticipated Regret in Advice Taking,” it is stated that the anticipated regret due to a bad decision caused by following advice is greater than an error that can be attributed to making a choice based on your own thinking. This means that when a physician’s recommendation contradicts a patient’s own intuition, there is an increased amount of anticipated regret associated with the surgeon’s option. Indeed, it is not uncommon for folks to say they wish they had “listened to their gut” instead of listening to someone else’s advice. There are numerous reports of this kind of decision making influencing medical decisions, including in the decision whether to vaccinate one’s children, whether to undergo screening mammography, and more.
Whether or not anticipated regret motivates decision behavior toward the “right” choice is an interesting question to ponder. It is unlikely that we can know the answer to that, however, since from a patient-centered care perspective, the “right” choice is the choice that is most consistent with the patient’s preferences. And we know from the wide spectrum of wishes about end of life care and blood transfusions that patient preferences vary substantially.
How, then, can a physician better equip a patient to make a decision? By simply understanding the nature of anticipated regret and the role it plays in the decision-making process, you will be better able to educate and advise patients. Moreover, you will be better able to relate to your patients and understand why they make the choices they do, helping you provide better patient-centered care.
Have you ever made a decision, as a patient or as a physician, that you regretted?