AMA Journal of Ethics^®

Brock DW, Wartman SA. When competent patients make irrational choices. N Engl J Med. 1990;322(22):1595-1599.

As more value is placed on the patient-physician partnership and joint decision-making, physicians increasingly face the dilemma of how to respond to patients' treatment choices that appear irrational. In a 1990 Sounding Board article for New England Journal of Medicine, a bioethicist and physician explore the dilemma in a way that has retained its currency and offers practical suggestions for today's clinicians. Dan Brock's and Steven Wartman's "When Competent Patients Make Irrational Choices" discusses (as their title makes clear) only decisions of competent patients whose request for or refusal of treatment appears to frustrate their own medical goals¹.

An "irrational" decision, Brock and Wartman say, is one that satisfies the patient's "aims and values less completely than other available choices"². So, for example, a patient who wishes to go on living a healthy, productive life yet refuses a life-saving intervention has made an irrational choice in the context of his or her own values and future plans. The authors present a taxonomy of irrational choices and their causes. (1) It is irrational, they say, to bias one's decision toward the present and near future, e.g., to refuse to undergo a painful experience now if it will prevent a much worse experience in the future. (2) A second source of irrational decisions is the believe that a given unwanted outcome "won't happen to me." Here patients might be denying the risk (as invulnerable adolescents might); acknowledging the risk but deciding to take the odds; entertaining magical beliefs about the situation; or simply viewing the medical problem in a different way. It is important for physicians to distinguish among the causes for "it won't happen to me" decisions, because they may be able to help the patient understand the risk more realistically or might need to see that the patient gets counseling or psychiatric evaluation. (3) Patients frequently refuse or delay a diagnostic procedure because they fear it will uncover a dreaded disease; they refuse or delay treatment because they fear the experience—being put to sleep, being cut open. To assist such patients, physicians should respect the value they place on avoiding pain and suffering while helping them overcome unrealistic fear that prevents them from consenting to beneficial treatment. (4) A most troubling instance for physicians occurs when patients make choices that just don't make sense. If a decision of this type accords with a well recognized though unusual belief or cultural value (e.g., no blood transfusions), physicians generally respect it. When the decision is not attributable to a religious belief or cultural value, the physician should try to determine whether it is, nevertheless, a strongly held value or a "distortion of values caused by a treatable condition such as depression"³.

Physicians might unwittingly contribute to irrational decision making by the way they frame choices. The authors suggest, for example, that risk of loss "looms larger" than possibility of gain in decision-making. Understanding irrational decisions and their causes is important because physicians must decide when to accept patients' decisions—even those that seem not to be in their best medical interest—and when to try to persuade patients to change them. While physicians have a responsibility to try to change the irrational decisions of competent patients, in the end, such decisions must be respected if the patient is competent and cannot be persuaded non-coercively to change them.

Questions for Discussion

1. Do you agree with the authors that, as long as patients are competent, all of their decisions, even irrational ones, must in the end be respected? Are there situations in which a physician can override a competent patient's irrational decision?
2. Does the physician have any responsibility for the patient after attempting and failing to persuade him or her to accept treatment that is in his or her best medical interest? When the patient remains firm in his or her decision, what can or should the physician do next?