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January 25, 1995, Vol 273, No. 4 >
ARTICLE | January 25, 1995

Medical Decision Making in Situations That Offer Multiple Alternatives FREE

Donald A. Redelmeier, MD; Eldar Shafir, PhD
[+] Author Affiliations

Reprint requests to The Wellesley Hospital, Jones Bldg 123, 160 Wellesley St E, Toronto, Ontario, Canada M4Y 1J3 (Dr Redelmeier).


JAMA. 1995;273(4):302-305. doi:10.1001/jama.1995.03520280048038
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References

Objective.  —To determine whether situations involving multiple options can paradoxically influence people to choose an option that would have been declined if fewer options were available.

Design.  —Mailed survey containing medical scenarios formulated in one of two versions.

Participants.  —Two groups of physicians: members of the Ontario College of Family Physicians (response rate=77%; n=287) and neurologists and neurosurgeons affiliated with the North American Symptomatic Carotid Endarterectomy Trial (response rate=84%; n=352). One group of legislators belonging to the Ontario Provincial Parliament (response rate=32%; n=41).

Intervention.  —The basic version of each scenario presented a choice between two options. The expanded version presented three options: the original two plus a third. The two versions otherwise contained identical information and were randomly assigned.

Outcome Measures.  —Participants' treatment recommendations.

Results.  —In one scenario involving a patient with osteoarthritis, family physicians were less likely to prescribe a medication when deciding between two medications than when deciding about only one medication (53% vs 72%; P<.005). Apparently, the difficulty in deciding between the two medications led some physicians to recommend not starting either. Similar discrepancies were found in decisions made by neurologists and neurosurgeons concerning carotid artery surgery and by legislators concerning hospital closures.

Conclusions.  —The introduction of additional options can increase decision difficulty and, hence, the tendency to choose a distinctive option or maintain the status quo. Awareness of this cognitive bias may lead to improved decision making in complex medical situations.(JAMA. 1995;273:302-305)

REFERENCES

1 +
Kahneman D, Slovic P, Tversky A, eds. Judgment Under Uncertainty: Heuristics and Biases . New York, NY: Cambridge University Press; 1982;.
2 +
Bell DE, Raiffa H, Tversky A, eds. Decision Making . New York, NY: Cambridge University Press; 1988;.
3 +
Tversky A.  Cognitive illusions in judgment and choice.  In: Ullmann-Margalit E, ed. The Kaleidoscope of Science . Dordrecht, the Netherlands: Reidel Publishing Co; 1986;.
4 +
Redelmeier DA, Rozin P, Kahneman D.  Understanding patients' decisions: cognitive and emotional perspectives. JAMA . 1993;;270:72-76.
5 +
Tversky A, Shafir E.  Choice under conflict: the dynamics of deferred decision. Psychol Sci . 1992;; 3:358-361.
6 +
Simonson I, Tversky A.  Choice in context: tradeoff contrast and extremeness aversion. J Marketing Res . 1992;;29:281-295.
7 +
Huber J, Payne JW, Puto C.  Adding asymmetrically dominated alternatives: violations of regularity and the similarity hypothesis. J Consumer Res . 1982;;9:90-98.
8 +
Janis IL, Mann L. Decision Making: A Psychological Analysis of Conflict, Choice, and Commitment . New York, NY: Free Press; 1977;.
9 +
Slovic P, Lichtenstein A.  Preferences reversals: a broader perspective. Am Econ Rev . 1983;;73:596-605.
10 +
Shafir E.  Reason-based choice.  In: American Psychological Association 101st Annual Convention Program . Toronto, Ontario: American Psychological Association; 1993;:35.
11 +
Borgeil AEM, Williams JI, Bass M, et al.  Quality of care in family practice: does residency training make a difference? Can Med Assoc J . 1989;;140: 1035-1043.
12 +
North American Symptomatic Carotid Endarterectomy Trial Collaborators.  Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis. N Engl J Med . 1991;;325: 445-453.
13 +
Treasurer of Ontario and Minister of Economics. 1992 Ontario Budget . Toronto: Queen's Printer for Ontario; 1992;.
14 +
Samuelson W, Zeckhauser R.  Status quo bias in decision making. J Risk Uncertainty . 1988;;1:7-59.
15 +
Dowd AE, ed. Physicians' Desk Reference . 47th ed. Montvale, NJ: Medical Economics Co Inc; 1993;.
16 +
Ransohoff DF, Lang CA, Kuo HS.  Colonoscopic surveillance after polypectomy: considerations of cost effectiveness. Ann Intern Med . 1991;;114:177-182.
17 +
Helfand M, Crapo LM.  Screening for thyroid disease. Ann Intern Med . 1990;;112:840-849.
18 +
Quebec Task Force on Spinal Disorders.  Treatment of activity-related spinal disorders. Spine . 1987;;12:522-530.
19 +
Neipp J, Zeckhauser R.  Persistence in the choice of health plans.  In: Scheffler R, Rossiter L, eds. Advances in Health Economics and Health Services Research . Greenwich, Conn: JAI Press; 1985;.
20 +
Fuchs VR. Who Shall Live: Health, Economics, and Social Choice . New York, NY: Basic Books Inc Publishers; 1974;.
21 +
Fiscchoff B.  Hindsight does not equal foresight: the effect of outcome knowledge on judgment under uncertainty. J Exp Psychol Hum Percept Perform . 1975;;41:288-299.
22 +
Bell DE.  Regret in decision making under uncertainty. Operations Res . 1982;;30:961-981.
23 +
Fong GT, Krantz DH, Nisbett R.  The effect of statistical training on thinking about everyday problems. Cognitive Psychol . 1986;;18:253-292.

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1 +
Kahneman D, Slovic P, Tversky A, eds. Judgment Under Uncertainty: Heuristics and Biases . New York, NY: Cambridge University Press; 1982;.
2 +
Bell DE, Raiffa H, Tversky A, eds. Decision Making . New York, NY: Cambridge University Press; 1988;.
3 +
Tversky A.  Cognitive illusions in judgment and choice.  In: Ullmann-Margalit E, ed. The Kaleidoscope of Science . Dordrecht, the Netherlands: Reidel Publishing Co; 1986;.
4 +
Redelmeier DA, Rozin P, Kahneman D.  Understanding patients' decisions: cognitive and emotional perspectives. JAMA . 1993;;270:72-76.
5 +
Tversky A, Shafir E.  Choice under conflict: the dynamics of deferred decision. Psychol Sci . 1992;; 3:358-361.
6 +
Simonson I, Tversky A.  Choice in context: tradeoff contrast and extremeness aversion. J Marketing Res . 1992;;29:281-295.
7 +
Huber J, Payne JW, Puto C.  Adding asymmetrically dominated alternatives: violations of regularity and the similarity hypothesis. J Consumer Res . 1982;;9:90-98.
8 +
Janis IL, Mann L. Decision Making: A Psychological Analysis of Conflict, Choice, and Commitment . New York, NY: Free Press; 1977;.
9 +
Slovic P, Lichtenstein A.  Preferences reversals: a broader perspective. Am Econ Rev . 1983;;73:596-605.
10 +
Shafir E.  Reason-based choice.  In: American Psychological Association 101st Annual Convention Program . Toronto, Ontario: American Psychological Association; 1993;:35.
11 +
Borgeil AEM, Williams JI, Bass M, et al.  Quality of care in family practice: does residency training make a difference? Can Med Assoc J . 1989;;140: 1035-1043.
12 +
North American Symptomatic Carotid Endarterectomy Trial Collaborators.  Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis. N Engl J Med . 1991;;325: 445-453.
13 +
Treasurer of Ontario and Minister of Economics. 1992 Ontario Budget . Toronto: Queen's Printer for Ontario; 1992;.
14 +
Samuelson W, Zeckhauser R.  Status quo bias in decision making. J Risk Uncertainty . 1988;;1:7-59.
15 +
Dowd AE, ed. Physicians' Desk Reference . 47th ed. Montvale, NJ: Medical Economics Co Inc; 1993;.
16 +
Ransohoff DF, Lang CA, Kuo HS.  Colonoscopic surveillance after polypectomy: considerations of cost effectiveness. Ann Intern Med . 1991;;114:177-182.
17 +
Helfand M, Crapo LM.  Screening for thyroid disease. Ann Intern Med . 1990;;112:840-849.
18 +
Quebec Task Force on Spinal Disorders.  Treatment of activity-related spinal disorders. Spine . 1987;;12:522-530.
19 +
Neipp J, Zeckhauser R.  Persistence in the choice of health plans.  In: Scheffler R, Rossiter L, eds. Advances in Health Economics and Health Services Research . Greenwich, Conn: JAI Press; 1985;.
20 +
Fuchs VR. Who Shall Live: Health, Economics, and Social Choice . New York, NY: Basic Books Inc Publishers; 1974;.
21 +
Fiscchoff B.  Hindsight does not equal foresight: the effect of outcome knowledge on judgment under uncertainty. J Exp Psychol Hum Percept Perform . 1975;;41:288-299.
22 +
Bell DE.  Regret in decision making under uncertainty. Operations Res . 1982;;30:961-981.
23 +
Fong GT, Krantz DH, Nisbett R.  The effect of statistical training on thinking about everyday problems. Cognitive Psychol . 1986;;18:253-292.

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