Brown Stephen L, Whiting Demian, Fielden Hannah G, Saini Pooja, Beesley Helen, Holcombe Christopher, Holcombe Susan, Greenhalgh Lyn, Fairburn Louise, Salmon Peter
Department of Psychological Sciences, University of Liverpool, Liverpool, United Kingdom.
Hull York Medical School, Hull, United Kingdom.
PLoS One. 2017 May 26;12(5):e0178392. doi: 10.1371/journal.pone.0178392. eCollection 2017.
Contemporary approaches to medical decision-making advise that clinicians should respect patients' decisions. However, patients' decisions are often shaped by heuristics, such as being guided by emotion, rather than by objective risk and benefit. Risk-reducing mastectomy (RRM) decisions focus this dilemma sharply. RRM reduces breast cancer (BC) risk, but is invasive and can have iatrogenic consequences. Previous evidence suggests that emotion guides patients' decision-making about RRM. We interviewed patients to better understand how they made decisions about RRM, using findings to consider how clinicians could ethically respond to their decisions.
Qualitative face-to-face interviews with 34 patients listed for RRM surgery and two who had decided against RRM.
Patients generally did not use objective risk estimates or, indeed, consider risks and benefits of RRM. Instead emotions guided their decisions: they chose RRM because they feared BC and wanted to do 'all they could' to prevent it. Most therefore perceived RRM to be the 'obvious' option and made the decision easily. However, many recounted extensive post-decisional deliberation, generally directed towards justifying the original decision. A few patients deliberated before the decision because fears of surgery counterbalanced those of BC.
Patients seeking RRM were motivated by fear of BC, and the need to avoid potential regret for not doing all they could to prevent it. We suggest that choices such as that for RRM, which are made emotionally, can be respected as autonomous decisions, provided patients have considered risks and benefits. Drawing on psychological theory about how people do make decisions, as well as normative views of how they should, we propose that practitioners can guide consideration of risks and benefits even, where necessary, after patients have opted for surgery. This model of practice could be extended to other medical decisions that are influenced by patients' emotions.
当代医学决策方法建议临床医生应尊重患者的决定。然而，患者的决定往往受到启发法的影响，比如受情感引导，而非客观的风险和益处。降低风险的乳房切除术（RRM）决策使这一困境更为突出。RRM可降低乳腺癌（BC）风险，但具有侵入性且可能产生医源性后果。先前的证据表明，情感引导患者做出关于RRM的决策。我们对患者进行了访谈，以更好地了解他们如何做出关于RRM的决策，并利用研究结果思考临床医生如何从伦理角度回应他们的决定。
对34名列入RRM手术名单的患者以及两名决定不进行RRM手术的患者进行了定性面对面访谈。
患者通常不使用客观风险评估，实际上也不考虑RRM的风险和益处。相反，情感引导他们的决定：他们选择RRM是因为害怕患乳腺癌，并且想“竭尽全力”预防。因此，大多数人认为RRM是“显而易见”的选择，并且很容易做出决定。然而，许多人讲述了决策后的大量思考，通常是为最初的决定寻找理由。少数患者在做决定前进行了思考，因为对手术的恐惧抵消了对患乳腺癌的恐惧。
寻求RRM的患者出于对患乳腺癌的恐惧，以及避免因未竭尽全力预防而产生潜在遗憾的需要。我们建议，像RRM这样基于情感做出的选择，如果患者已经考虑了风险和益处，可以被视为自主决定而得到尊重。借鉴关于人们如何做出决策的心理学理论以及关于人们应该如何做决策的规范性观点，我们建议从业者即使在患者选择手术后，如有必要，也可以引导他们考虑风险和益处。这种实践模式可以扩展到其他受患者情感影响的医疗决策中。
