Editor’s Notes: The Role of Emotion in Good Decision-Making: Science Is Catching Up to Society

July 22, 2016
It's been fascinating to read Jonah Lehrer's 2009 book "How We Decide," and to ponder scientists' recent discoveries around emotion in decisionmaking--and to consider the physician-patient relationship

Recently, I’ve been enjoying reading Jonah Lehrer’s 2009 How We Decide—a fascinating exploration of the science around human decision-making. This is one of those extremely enjoyable books that peels off layers of scientific research, yet only in the most readable way.

The volume’s book jacket summarizes things well. It begins, “Since Plato, philosophers have described the decision-making process as either rational or emotional: we carefully deliberate, or we ‘blink’ and go with our gut. But as scientists break open the mind’s black box with the latest tools of neuroscience, they’re discovering that this is not how the mind works. Our best decisions are a finely tuned blend of both feeling and reason—and the precise mix depends on the situation.”

In the first chapter, Lehrer tells the story of a patient named Elliot, who in 1982 met with neurologist Antonio Damasio. A few months prior to their first meeting, Elliot had had a tumor cut out of his brain, but with devastating results. He went from being a model father and husband and a senior manager in a large corporation, to losing his wife, his job, and more or less, his mind. The piece of Elliot’s brain that was removed is called the orbitofrontal cortex, and sits just behind the eyes. It turns out that “If this fragile fold of cells is damaged by a malignant tumor or a hemorrhaging artery, the tragic result is always the same”: the patient becomes devoid of emotion, and because of that, becomes incapable of rational decision-making.

So it turns out that when Elliot’s orbitofrontal cortex was damaged, normal life became impossible for him, as he would spend countless hours deliberating over such trivial decisions as whether to use a blue or black pen or where to park his car. And as Damasio interviewed more patients with damage to their orbitofrontal cortexes, he found an identical result: pathological indecision. So, as scientists are learning, it turns out that emotion is in fact not a hindrance to decision-making, but in fact, an essential element in it; without it, all choices appear equal, and baffling.

Meanwhile, those who have studied human history have noted is that one thing that makes us all human is our ability to share our stories with each other. Indeed, the literatures of all cultures were for many thousands of years purely oral, before writing systems came into being. And scientists have found that the memory retention of people in pre-literate societies was certainly greater than that of contemporary humans.

In U.S. healthcare, we are now entering a new phase in the evolution of the patient-physician relationship, with the emergence of the OpenNotes movement. As discussed in this issue’s cover story, pioneering organizations like Cleveland Clinic, Geisinger Health System, UPMC health system, and others, are moving forward to make it the norm for physician notes to be shared with patients.

This is a kind of sharing that, as a routine process, is long overdue. The concept of patients as members of their care teams is one that has been discussed for many years, but only now is that idea beginning to become a reality, and still for now only in the most progressive patient care organizations.

What’s great is that in those organizations, there is an awareness of the great value of sharing the patient narrative—with the patient. Because, really, to a large extent, we humans are our stories.

And it’s huge progress that the U.S. healthcare system is beginning to recognize that fact. So let’s not forget the human factor in all this. And the U.S. healthcare system’s recognizing that human element can only strengthen care delivery, and all those participating in it, including patients.

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