Opinion
A PIECE OF MY MIND Katie Watson, JD Medical Humanities and Bioethics Program, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
Corresponding Author: Katie Watson, JD (k-watson @northwestern.edu). Section Editor: Roxanne K. Young, Associate Senior Editor.
Reframing Regret Driving through my home state of Indiana, I was startled by a new billboard—enormous letters proclaiming, “Many women regret their abortion.” The concept of “abortion regret” leapt to the fore in 2007, when Justice Anthony Kennedy wrote that the possibility of patient regret was one reason for upholding the federal ban on intact dilation and extraction (“partial birth abortion”).1,2 Now some former patients carry massproduced signs announcing “I regret my abortion” at protests, and others are beginning to carry counterstatements: “I do not regret my abortion.” What’s rarely acknowledged in the abortion debate is how the risk of regret pervades all of medicine. For example, Raiten and Neuman reflected on regret in the intensive care unit (ICU). After the “real, albeit remote, concern” of a long, complicated recovery occurred, their patient “now looks back on her decision to undergo [heart] surgery with regret, telling her family and her doctors that if only she had known what to expect, she might have chosen differently.”3 Without perfect knowledge of the future, the possibility a wellinformed patient might later wish he or she had not chosen back surgery, kidney transplant, or a panoply of other procedures can never be eliminated. That’s why framing the risk of regret as an adverse effect of abortion raises difficult questions for the rest of medicine: If the possibility of “abortion regret” justifies waiting periods, state-scripted informed consent speeches, and procedure bans in one area of medicine, why doesn’t medical ethics—and maybe even the constitutional guarantee of equal protection—require similar measures to protect patients from regret in all areas of medicine? How should physicians in every specialty respond to the possibility of patient regret? The first step in answering these questions is dividing patient regret into two types. Situational regret is beyond the scope of medicine, and decisional regret tests the modern understanding of patient autonomy. Situational regret describes negative emotions about external factors motivating a patient’s medical decision. A patient who chooses knee replacement instead of joint pain might regret choices he made years before on the football field; a patient consenting to painful cancer treatment might regret she ever started smoking. These patients might have negative feelings about their medical procedures, and if they could travel back in time to change thebehaviorsthatcreatedtheirmedicalneedstheymight, but they still view medical intervention to restore the body to its prior status as the best of two undesirable options. In the abortion context, poverty, the demands of graduate school, a boyfriend’s refusal to co-parent, or severe fetal anomaly are examples of factors that might inspire situational regret. These patients might regret getting pregnant,ormighthavenegativeemotionsaboutthesituation that led them to conclude they shouldn’t have a baby
at this time, but abortion patients with situational regret don’t wish they had remained pregnant. Situational regret can link any medical procedure the patient chose with feelings of loss, sorrow, disappointment, or dissatisfaction, but this type of regret is not an indictment of any area of medicine—in these cases, physician intervention typically prevented a bad situation (as defined by the patient) from becoming worse. The fact that most abortion decisions are driven by complex emotional and social factors might increase situational regret around this procedure as compared to others, but there is no logical relationship between situational regret and regulation of the practice of medicine in any specialty. It’s the second type of regret that haunts physicians and troubles policymakers. Decisional regret is illustrated bytheICUpatientdescribedabove—apatient’sfeelingthat ifhecouldtravelbackintimeknowingwhatheknowsnow, he would make a different medical decision in the face of the same facts. This type of regret is addressed in traditional informed consent doctrine—in Canterbury v Spence, concern about hindsight led the court to establish an objectivestandardforevaluatingcausationwhenpatientssue physiciansclaimingmoreinformationwouldhavechanged a decision.4 Sociologist Katrina Kimport interviewed abortion patients who reported “emotional difficulty” around their abortion, and only one of the 18 reactions Kimport documents fits the category of decisional regret. “Brandy” was 20 years old when she became pregnant. She sat down with her mother and went over the positives and negatives before she chose to terminate. A year later she said, “If I could go back and change it, I wouldn’t have had the abortion. … No matter if the father was there or not, no matter if I was going to be a single mom struggling, I would’ve not had the abortion. … I think I would be much more happier now.”5 (In contrast, the narratives of patients who had what Kimport calls “head vs heart” conflicts about their abortion decisions look more like situational regret—for example, a Catholic rape survivor or a married40-year-oldmotherwhosawherpregnancyasmiraculous but needed to stay on teratogenic drugs for her own health.) Any physician, bioethicist, or policymaker would feel sympathy for patients like Brandy and the cardiac patient who regretted implantation of a ventricular assist device. One had a successful procedure and one was in the unfortunate minority who have medical complications; both now have new information that makes them unhappy with their earlier decision. Does their distress mean they were denied some additional protection they were due? Not necessarily. Instead, a helpful lens for understanding the consequence of decisional regret is “the dignity of risk.” The dignity of risk is a concept articulated in the 1970s to challenge clinicians’ impulse to withhold options from people with disabilities unless good outcomes were guaranteed, and it’s shorthand for the
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JAMA January 1, 2014 Volume 311, Number 1
Copyright 2014 American Medical Association. All rights reserved.
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27
Opinion A Piece of My Mind
fact there is no opportunity for success without a right to failure.6,7 Acknowledging the dignity of risk doesn’t mean physicians should stop trying to help patients. Instead, when patients “internalise the locus of control for their choices and actions,” informed decisions they later regret are viewed as an opportunity for growth; a time when health professionals can help patients use the experience to redefine or strengthen life goals, devise new strategies for achieving them, and develop resilience.8 The dignity of risk reminds us that overprotection is harmful too. American patients’ modern status as autonomous decision makers is grounded in the foundational premise of bioethics: that competent adults must be allowed to take chances and risk pain in pursuit of a better life. The unstated premise of the abortion regret claim is that regret is bad—regret harms patients in some way, and patients should be protected from harm—but we can’t have it both ways. To the degree decisional regret is harmful, the regressive remedy of eliminating or reducing competent adults’ decision-making authority is worse. “While we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude some women come to regret their choice to abort …,” Justice Kennedy wrote in Gonzales v Carhart. It’s the high base rate that makes this conclusion unexceptionable—we can’t expect uniformly positive reactions from any procedure approximately 30% of American women ask a physician to do at some point in their lifetime (approximately 1.2 million procedures per year) as is thecasewithabortion.9 Italsoseemsunexceptionabletoconcludethat some people regret their choice to have heart surgery, but I’d be even more startled to see that proclaimed on a billboard. The truth of informed consent for all procedures is that our best decisions are really best guesses—I think this will be best for me, but only time will tell. We know this is true of other life-altering decisions like marriage or job choice, yet we seem to expect a different type of clairvoyance for major medical decisions. As Raiten and Neuman put it, “medicine and surgery are uncertain enterprises. … [I]t remains impossible to foresee the specific course that any individual patient’s recovery will take. … Such considerations highlight the inherent fallibility of medical decisions.”3 And they are only referring to medical complications in recovery; emotional complications are even further outside physicians’ ability to predict. Every patient assumes some risk of physical or psychological harm when they ask a physician to alter their body, and some—hopefully few, but always some—will regret their decision. Perhaps regret is debated more in abortion than other specialties because the existence of a fetus makes abortion different in some
Should a report of decisional regret inspire physician regret? Sometimes it should. If a physician in any specialty learns of this outcome, he or she should review the case to determine if they unintentionally omitted information that would have helped the patient make a decision that better fit his or her life and goals. If not, the physician should be reassured that that decisional regret is not a clinical complication, it is a feature of life. It is virtuous to want the best for patients, and it’s painful for any physician to learn something done at a patient’s request with the intention of helping was later experienced as harm. But physiciansareinstrumentsofchangeandpatientsareagentsofchange. The fact that the patient is the one who must live with the consequences of a medical decision is both the justification for patient autonomy and its cost, in abortion and every other area of medicine.
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported.
3. Raiten JM, Neuman MD. “If I had only known”—on choice and uncertainty in the ICU. N Engl J Med. 2012;367(19):1779-1781.
9. Guttmacher Institute. Facts on Induced Abortion in the United States. http://www.guttmacher.org/pubs /fb_induced_abortion.html. Accessed July 8, 2013.
4. Canterbury v Spence, 464 F2d 772 (DC Cir 1972).
Additional Contributions: Thanks to The Hastings Center for time during a visiting scholar stay to write this piece, and to Megan Crowley Matoka and Debjani Mukherjee for helpful comments.
5. Kimport K. (Mis)understanding abortion regret. Symbolic Interact. 2012;35(2):105-122.
10. Manian M. The irrational woman: informed consent and abortion decision-making. Duke J Gend Law Policy. 2009;16(2):223-292.
Correction: This article was corrected on February 4, 2014, to remove an extra word in the second sentence of the article. 1. Gonzales v Carhart, 550 US 124 (2007). 2. Frelich Appleton S. Reproduction and regret. Yale J Law Fem. 2011;23(2):255-333.
28
critical way—is it worse to change one’s mind about a decision to end fetal life than to have decisional regret about other medical procedures?Somewouldsayyes,thatthemoralstatusofafetusmakesabortionauniquelyhigh-stakesdecision.Otherswouldsayno,thefactmany patients can carry a future pregnancy to term to become a parent actually makes this decision more “reversible” than other interventions patients regret. Or, if decisional regret flows both ways (as it logically must), is it worse to regret a decision to abort or a decision to carry a pregnancy to term? The debate these questions inspire points out how the abortion regret claim ultimately circles back to an estimation of the moral value of the fetus, a matter constitutional law leaves to individual patient conscience before viability. The degree to which principles of patient moral agency and autonomy don’t seem to address the possibility of patient regret in abortion reveals the degree to which the regret claim is about protecting fetuses, not women.10 As one might guess is the case for most medical interventions patients seek, relief might be the dominant emotional reaction to abortion.11,12 However, in an editorial titled “You say ‘regret’ and I say ‘relief’: a need to break the polemic about abortion,” Weitz et al suggest a clinical solution. To test if their prescription rings true for the rest of medicine, I have substituted broader terms for “women” and “abortion” in the quote below: Complex feelings are a normal part of major life decisions, and having strong feelings, even negative ones, does not represent pathology. [Patients] do not need to be protected from their emotional responses to [medical interventions they have selected]. However, as with any stressful event, some [patients] will have more severe responses; these [patients] need support and access to mental health services.13
6. Perske R. The dignity of risk and the mentally retarded. Ment Retard. 1972;10(1):24-27. 7. Smith K, Savage TA. Policies, legislation, and ethical/legal issues. In: Betz CL, Nehring WM, eds. Nursing Care for Individuals With Intellectual and Developmental Disabilities: An Integrated Approach. Baltimore, MD: Paul H Brookes; 2010:362. 8. Parsons C. The dignity of risk: challenges in moving on. Aust Nurs J. 2008;15(9):28.
11. Adler NE, David HP, Major BN, Roth SH, Russo NF, Wyatt GE. Psychological factors in abortion. A review. Am Psychol. 1992;47(10):1194-1204. 12. Major B, Appelbaum M, Beckman L, Dutton MA, Russo NF, West C. Abortion and mental health: Evaluating the evidence. Am Psychol. 2009;64(9):863-890. 13. Weitz TA, Moore K, Gordon R, Adler N. You say “regret” and I say “relief”: a need to break the polemic about abortion. Contraception. 2008;78(2):87-89.
JAMA January 1, 2014 Volume 311, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/17/2015
jama.com
A PIECE OF MY MIND Katie Watson, JD Medical Humanities and Bioethics Program, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
Corresponding Author: Katie Watson, JD (k-watson @northwestern.edu). Section Editor: Roxanne K. Young, Associate Senior Editor.
Reframing Regret Driving through my home state of Indiana, I was startled by a new billboard—enormous letters proclaiming, “Many women regret their abortion.” The concept of “abortion regret” leapt to the fore in 2007, when Justice Anthony Kennedy wrote that the possibility of patient regret was one reason for upholding the federal ban on intact dilation and extraction (“partial birth abortion”).1,2 Now some former patients carry massproduced signs announcing “I regret my abortion” at protests, and others are beginning to carry counterstatements: “I do not regret my abortion.” What’s rarely acknowledged in the abortion debate is how the risk of regret pervades all of medicine. For example, Raiten and Neuman reflected on regret in the intensive care unit (ICU). After the “real, albeit remote, concern” of a long, complicated recovery occurred, their patient “now looks back on her decision to undergo [heart] surgery with regret, telling her family and her doctors that if only she had known what to expect, she might have chosen differently.”3 Without perfect knowledge of the future, the possibility a wellinformed patient might later wish he or she had not chosen back surgery, kidney transplant, or a panoply of other procedures can never be eliminated. That’s why framing the risk of regret as an adverse effect of abortion raises difficult questions for the rest of medicine: If the possibility of “abortion regret” justifies waiting periods, state-scripted informed consent speeches, and procedure bans in one area of medicine, why doesn’t medical ethics—and maybe even the constitutional guarantee of equal protection—require similar measures to protect patients from regret in all areas of medicine? How should physicians in every specialty respond to the possibility of patient regret? The first step in answering these questions is dividing patient regret into two types. Situational regret is beyond the scope of medicine, and decisional regret tests the modern understanding of patient autonomy. Situational regret describes negative emotions about external factors motivating a patient’s medical decision. A patient who chooses knee replacement instead of joint pain might regret choices he made years before on the football field; a patient consenting to painful cancer treatment might regret she ever started smoking. These patients might have negative feelings about their medical procedures, and if they could travel back in time to change thebehaviorsthatcreatedtheirmedicalneedstheymight, but they still view medical intervention to restore the body to its prior status as the best of two undesirable options. In the abortion context, poverty, the demands of graduate school, a boyfriend’s refusal to co-parent, or severe fetal anomaly are examples of factors that might inspire situational regret. These patients might regret getting pregnant,ormighthavenegativeemotionsaboutthesituation that led them to conclude they shouldn’t have a baby
at this time, but abortion patients with situational regret don’t wish they had remained pregnant. Situational regret can link any medical procedure the patient chose with feelings of loss, sorrow, disappointment, or dissatisfaction, but this type of regret is not an indictment of any area of medicine—in these cases, physician intervention typically prevented a bad situation (as defined by the patient) from becoming worse. The fact that most abortion decisions are driven by complex emotional and social factors might increase situational regret around this procedure as compared to others, but there is no logical relationship between situational regret and regulation of the practice of medicine in any specialty. It’s the second type of regret that haunts physicians and troubles policymakers. Decisional regret is illustrated bytheICUpatientdescribedabove—apatient’sfeelingthat ifhecouldtravelbackintimeknowingwhatheknowsnow, he would make a different medical decision in the face of the same facts. This type of regret is addressed in traditional informed consent doctrine—in Canterbury v Spence, concern about hindsight led the court to establish an objectivestandardforevaluatingcausationwhenpatientssue physiciansclaimingmoreinformationwouldhavechanged a decision.4 Sociologist Katrina Kimport interviewed abortion patients who reported “emotional difficulty” around their abortion, and only one of the 18 reactions Kimport documents fits the category of decisional regret. “Brandy” was 20 years old when she became pregnant. She sat down with her mother and went over the positives and negatives before she chose to terminate. A year later she said, “If I could go back and change it, I wouldn’t have had the abortion. … No matter if the father was there or not, no matter if I was going to be a single mom struggling, I would’ve not had the abortion. … I think I would be much more happier now.”5 (In contrast, the narratives of patients who had what Kimport calls “head vs heart” conflicts about their abortion decisions look more like situational regret—for example, a Catholic rape survivor or a married40-year-oldmotherwhosawherpregnancyasmiraculous but needed to stay on teratogenic drugs for her own health.) Any physician, bioethicist, or policymaker would feel sympathy for patients like Brandy and the cardiac patient who regretted implantation of a ventricular assist device. One had a successful procedure and one was in the unfortunate minority who have medical complications; both now have new information that makes them unhappy with their earlier decision. Does their distress mean they were denied some additional protection they were due? Not necessarily. Instead, a helpful lens for understanding the consequence of decisional regret is “the dignity of risk.” The dignity of risk is a concept articulated in the 1970s to challenge clinicians’ impulse to withhold options from people with disabilities unless good outcomes were guaranteed, and it’s shorthand for the
jama.com
JAMA January 1, 2014 Volume 311, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/17/2015
27
Opinion A Piece of My Mind
fact there is no opportunity for success without a right to failure.6,7 Acknowledging the dignity of risk doesn’t mean physicians should stop trying to help patients. Instead, when patients “internalise the locus of control for their choices and actions,” informed decisions they later regret are viewed as an opportunity for growth; a time when health professionals can help patients use the experience to redefine or strengthen life goals, devise new strategies for achieving them, and develop resilience.8 The dignity of risk reminds us that overprotection is harmful too. American patients’ modern status as autonomous decision makers is grounded in the foundational premise of bioethics: that competent adults must be allowed to take chances and risk pain in pursuit of a better life. The unstated premise of the abortion regret claim is that regret is bad—regret harms patients in some way, and patients should be protected from harm—but we can’t have it both ways. To the degree decisional regret is harmful, the regressive remedy of eliminating or reducing competent adults’ decision-making authority is worse. “While we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude some women come to regret their choice to abort …,” Justice Kennedy wrote in Gonzales v Carhart. It’s the high base rate that makes this conclusion unexceptionable—we can’t expect uniformly positive reactions from any procedure approximately 30% of American women ask a physician to do at some point in their lifetime (approximately 1.2 million procedures per year) as is thecasewithabortion.9 Italsoseemsunexceptionabletoconcludethat some people regret their choice to have heart surgery, but I’d be even more startled to see that proclaimed on a billboard. The truth of informed consent for all procedures is that our best decisions are really best guesses—I think this will be best for me, but only time will tell. We know this is true of other life-altering decisions like marriage or job choice, yet we seem to expect a different type of clairvoyance for major medical decisions. As Raiten and Neuman put it, “medicine and surgery are uncertain enterprises. … [I]t remains impossible to foresee the specific course that any individual patient’s recovery will take. … Such considerations highlight the inherent fallibility of medical decisions.”3 And they are only referring to medical complications in recovery; emotional complications are even further outside physicians’ ability to predict. Every patient assumes some risk of physical or psychological harm when they ask a physician to alter their body, and some—hopefully few, but always some—will regret their decision. Perhaps regret is debated more in abortion than other specialties because the existence of a fetus makes abortion different in some
Should a report of decisional regret inspire physician regret? Sometimes it should. If a physician in any specialty learns of this outcome, he or she should review the case to determine if they unintentionally omitted information that would have helped the patient make a decision that better fit his or her life and goals. If not, the physician should be reassured that that decisional regret is not a clinical complication, it is a feature of life. It is virtuous to want the best for patients, and it’s painful for any physician to learn something done at a patient’s request with the intention of helping was later experienced as harm. But physiciansareinstrumentsofchangeandpatientsareagentsofchange. The fact that the patient is the one who must live with the consequences of a medical decision is both the justification for patient autonomy and its cost, in abortion and every other area of medicine.
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported.
3. Raiten JM, Neuman MD. “If I had only known”—on choice and uncertainty in the ICU. N Engl J Med. 2012;367(19):1779-1781.
9. Guttmacher Institute. Facts on Induced Abortion in the United States. http://www.guttmacher.org/pubs /fb_induced_abortion.html. Accessed July 8, 2013.
4. Canterbury v Spence, 464 F2d 772 (DC Cir 1972).
Additional Contributions: Thanks to The Hastings Center for time during a visiting scholar stay to write this piece, and to Megan Crowley Matoka and Debjani Mukherjee for helpful comments.
5. Kimport K. (Mis)understanding abortion regret. Symbolic Interact. 2012;35(2):105-122.
10. Manian M. The irrational woman: informed consent and abortion decision-making. Duke J Gend Law Policy. 2009;16(2):223-292.
Correction: This article was corrected on February 4, 2014, to remove an extra word in the second sentence of the article. 1. Gonzales v Carhart, 550 US 124 (2007). 2. Frelich Appleton S. Reproduction and regret. Yale J Law Fem. 2011;23(2):255-333.
28
critical way—is it worse to change one’s mind about a decision to end fetal life than to have decisional regret about other medical procedures?Somewouldsayyes,thatthemoralstatusofafetusmakesabortionauniquelyhigh-stakesdecision.Otherswouldsayno,thefactmany patients can carry a future pregnancy to term to become a parent actually makes this decision more “reversible” than other interventions patients regret. Or, if decisional regret flows both ways (as it logically must), is it worse to regret a decision to abort or a decision to carry a pregnancy to term? The debate these questions inspire points out how the abortion regret claim ultimately circles back to an estimation of the moral value of the fetus, a matter constitutional law leaves to individual patient conscience before viability. The degree to which principles of patient moral agency and autonomy don’t seem to address the possibility of patient regret in abortion reveals the degree to which the regret claim is about protecting fetuses, not women.10 As one might guess is the case for most medical interventions patients seek, relief might be the dominant emotional reaction to abortion.11,12 However, in an editorial titled “You say ‘regret’ and I say ‘relief’: a need to break the polemic about abortion,” Weitz et al suggest a clinical solution. To test if their prescription rings true for the rest of medicine, I have substituted broader terms for “women” and “abortion” in the quote below: Complex feelings are a normal part of major life decisions, and having strong feelings, even negative ones, does not represent pathology. [Patients] do not need to be protected from their emotional responses to [medical interventions they have selected]. However, as with any stressful event, some [patients] will have more severe responses; these [patients] need support and access to mental health services.13
6. Perske R. The dignity of risk and the mentally retarded. Ment Retard. 1972;10(1):24-27. 7. Smith K, Savage TA. Policies, legislation, and ethical/legal issues. In: Betz CL, Nehring WM, eds. Nursing Care for Individuals With Intellectual and Developmental Disabilities: An Integrated Approach. Baltimore, MD: Paul H Brookes; 2010:362. 8. Parsons C. The dignity of risk: challenges in moving on. Aust Nurs J. 2008;15(9):28.
11. Adler NE, David HP, Major BN, Roth SH, Russo NF, Wyatt GE. Psychological factors in abortion. A review. Am Psychol. 1992;47(10):1194-1204. 12. Major B, Appelbaum M, Beckman L, Dutton MA, Russo NF, West C. Abortion and mental health: Evaluating the evidence. Am Psychol. 2009;64(9):863-890. 13. Weitz TA, Moore K, Gordon R, Adler N. You say “regret” and I say “relief”: a need to break the polemic about abortion. Contraception. 2008;78(2):87-89.
JAMA January 1, 2014 Volume 311, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/17/2015
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