Decision Making in the Shadow of Death

26 April 2017

It is often assumed that decision-making is a completely rational process. In reality, of course, numerous heuristics and biases influence the way we think and the decisions we make in clinical, research and policy contexts. While Blumenthal-Barby elegantly describes various types of heuristics and biases, and the effect that they may have on one’s autonomy, we suggest that there is insufficient attention given to the heuristics that may be most determinative in medical contexts – hope, and its attendant emotion, fear. Our insights are drawn from an empirical study of the legal and ethical 'limits' of consent in the setting of decision-making around a high risk medical interventions (bone marrow transplantation - BMT) which revealed that every formal element of consent is shaped or transmogrified by a patient’s ‘hope for a future’. In this qualitative study we examined the accounts of patients with haematological malignancies, their loved ones and the health care professionals caring for them regarding the decision to offer, and go through with, BMT - where BMT provided the possibility of ‘cure’ but carried a high risk of death (particularly in the first year post-BMT) and long-term morbidity. While the heuristics described by Blumenthal-Barby were evident in the narratives of all of the participants in this study and undoubtedly impacted upon understanding, intentionality and effective autonomy, what was most striking was the degree to which hope, and its attendant emotion, fear, impacted upon decision-making and overwhelmed all other considerations that may have been relevant to the decision to proceed to BMT.