Emotions and affects: the missing piece of the jigsaw puzzle of understanding risk attitudes in medical decision-making.

Nicholas Makins argues persuasively that medical decisions should be made with consideration for patients’ higher order risk attitudes. I will argue that an understanding of risk attitudes in medical decisionmaking is incomplete without critical engagement with emotions and affects (feelings associated with something good or bad). The primary aim of this commentary is to emphasise that clinical decisions are often emotionally charged, and it is crucial to engage closely with emotions and affects that shape these decisions, particularly when navigating complex and uncertain situations. In the face of uncertainty, emotions such as fear, sadness or anxiety play a significant role in risk attitudes and medical decisions. I contend that recognising risk as a feeling is crucial to respecting patients’ values, preferences and decisions in light of the substantial body of research on risk perception and attitudes that suggests individuals make decisions based not only on what they think, but also on how they feel. In recent years, scholars have begun to acknowledge the value of emotions in understanding medical decisions and healthcare decisionmaking processes, especially under uncertainty. Furthermore, some philosophers and social scientists in field of risk research acknowledge emotions as both affective and cognitive in nature, and influence risk perceptions and attitudes. Risk is often understood in terms of its possible outcomes and probabilities. For example, in case of stock trading, one might understand the risk of an investment as the likelihood of losing money, and the probability of that loss being 10%. When it comes to medical decisions, however, the concept of risk is often more complex, as it must take into account not only the likelihood of a given outcome, but also its potential impact on the patient’s health and wellbeing under uncertain probabilities and varied contexts. Medical decisions often understand risk in terms of the probability of a negative outcome, such as a poor prognosis or a lifethreatening complication. The risk of a medical decision is also understood in terms of its potential costs, such as the cost of treatment or the cost of not treating a condition. As such, medical decisionmaking requires thoughtful consideration of the risks associated with any proposed plan of action or not, along with a comprehensive understanding of the probable outcomes and their potential consequences. The influence of emotion and affect on decisions cannot be avoided in the context of clinical medicine when understanding risk perception and risk attitudes. For instance, anxiety about undergoing a procedure can give rise to a person making a riskaverse decision, even if the risks of the procedure are quite low. Physicians can also be influenced by their emotions when assessing risk perception. For instance, a physician’s fear of making a mistake can lead to an overly cautious recommendation, or a physician’s desire to be liked can lead to an overly optimistic risk assessment. When discussing examplitis and caseopathy, as discussed by Makins, it becomes clear that treatment decisions are based on uncertain and/or different states, and possible outcomes. As there is no control over the situation, strong emotional responses might occur that influence risk perception and attitude. Having said that, one should not assume that risk attitudes influenced by emotional responses are ‘irrational’, as there is no doubt that some emotions and affects can also be intentional beliefs and deliberative states that allow reflection. Let’s understand this situation through the affective state of ‘fear’, which is a common emotional and affective response in clinical medicine when uncertainty exists. There is evidence that affect heuristics contribute to the perception of risk. If a physician is afraid of committing a mistake, they will act in a riskavoidant manner and may withhold treatment as a result. Decisionmaking studies show fear triggers more riskaverse decisions. However, if a patient is experiencing sadness which can influence decisions that involve valuation, they will be less susceptible to status quo bias. For example, a patient who is feeling sad may be more likely to make a risky decision, as they are less likely to be influenced by the status quo. In the case of examplitis and caseopathy, a patient may want to pursue treatment if they are feeling sad, as they may be more willing to take a risk and decide to go ahead with treatment. Therefore, it could have implications for treatmentrelated tradeoffs, whether to pursue treatment or not. However, if the patient experiences fear, they might make riskaverse decisions. Studies show that different emotions in tradeoff and nontradeoff contexts vary and influence risk perceptions and decisions. It is important to note that most emotions and affects rely on justifiable factual beliefs about possible consequences as well as evaluative beliefs regarding whether those consequences are desirable. This applies to fear, sadness, sympathy and compassion, among others. In view of this, emotions and affects need to be considered as justified, reasonable concerns that can play a critical role in people’s response to risk attitudes. The understanding of risk as feelings, which provides moral knowledge about risks, allows us to integrate emotions and affects into our understanding of risk attitudes, risk perceptions and risk decisions. It becomes necessary in order to respect patients’ higher order risk attitudes as suggested by Makins, one has to acknowledge that emotion and affect play a significant role in risk attitudes and medical decisions. In light of the high degree of risk aversion present in most health contexts as a result of certain emotions and affective states, such as fear, an affective deliberative approach to risk would help both doctors and patients make medical decisions based on emotional, intersectional and contextual factors. Furthermore, this will facilitate open discussions about individuals underlying concerns while understanding the risks, and it will provide space to acknowledge emotions, which provide epistemic justification for moral judgements about risks, as well as influence risk attitudes and decisions. The Faculty of Medicine and Health, Sydney Health Ethics, University of Sydney, Sydney, New South Wales, Australia