Qualitative analysis of how patients decide that they want risk-reducing mastectomy, and the implications for surgeons in responding to emotionally-motivated patient requests.

OBJECTIVE: 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. METHODS: Qualitative face-to-face interviews with 34 patients listed for RRM surgery and two who had decided against RRM. RESULTS: 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. CONCLUSION: 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.

Evaluating medico-legal decisional competency criteria.

In this paper I get clearer on the considerations that ought to inform the evaluation and development of medico-legal competency criteria-where this is taken to be a question regarding the abilities that ought to be needed for a patient to be found competent in medico-legal contexts. In the "Decisional Competency in Medico-Legal Contexts" section I explore how the question regarding the abilities that ought to be needed for decisional competence is to be interpreted. I begin by considering an interpretation that takes the question to be asking about the abilities needed to satisfy an idealized view of competent decision-making, according to which decisional competency is a matter of possessing those abilities or attributes that are needed to engage in good or effective or, perhaps, substantially autonomous or rational decision-making. The view has some plausibility-it accords with the way decisional competency is understood in a number of everyday contexts-but fails as an interpretation of the question regarding the abilities that should be needed for decisional competence in medico-legal contexts. Nevertheless, consideration of why it is mistaken suggests a more accurate interpretation and points the way in which the question regarding the evaluation of medico-legal competency criteria is to be answered. Building on other scholarly work in the area, I outline in the "Primary and Secondary Requirements" section several requirements that decisional competence criteria ought to satisfy. Then, in the "Applying the Framework" section, I say something about the extent to which medico-legal competency criteria, as well as some models of decisional competency proposed in the academic literature, fulfil those requirements.

The ethics of distress: toward a framework for determining the ethical acceptability of distressing health promotion advertising.

Distressing health promotion advertising involves the elicitation of negative emotion to increase the likelihood that health messages will stimulate audience members to adopt healthier behaviors. Irrespective of its effectiveness, distressing advertising risks harming audience members who do not consent to the intervention and are unable to withdraw from it. Further, the use of these approaches may increase the potential for unfairness or stigmatization toward those targeted, or be considered unacceptable by some sections of the public. We acknowledge and discuss these concerns, but, using the public health ethics literature as a guide, argue that distressing advertising can be ethically defensible if conditions of effectiveness, proportionality necessity, least infringement, and public accountability are satisfied. We do not take a broad view as to whether distressing advertising is ethical or unethical, because we see the evidence for both the effectiveness of distressing approaches and their potential to generate iatrogenic effects to be inconclusive. However, we believe it possible to use the current evidence base to make informed estimates of the likely consequences of specific message presentations. Messages can be pre-tested and monitored to identify and deal with potential problems. We discuss how advertisers can approach the problems of deciding on the appropriate intensity of ethical review, and evaluating prospective distressing advertising campaigns against the conditions outlined.

Inappropriate attitudes, fitness to practise and the challenges facing medical educators.

The author outlines a number of reasons why morally inappropriate attitudes may give rise to concerns about fitness to practise. He argues that inappropriate attitudes may raise such concerns because they can lead to harmful behaviours (such as a failure to give proper care or treatment), and because they are often themselves harmful (both because of the offence that they can cause and because of the unhealthy pall that they may cast over relations between healthcare practitioners and patients). He also outlines some of the challenges that the cultivation and assessment of attitudes in students raise for medical educators and some of the ways in which those challenges may be approached and possibly overcome.