By Ajay K. Singh, MBBS, FRCP, MBA
April 4, 2017
“There is a tide in the affairs of men
Which taken at the flood, leads on to fortune;
Omitted, all the voyage of their life
Is bound in shallows and in miseries”
William Shakespeare: Julius Caesar, Act 4 Scene 3
This idea of opportunity versus regret from Shakespeare was recently addressed by Anjana Ahuja a science writer for the Financial Times as she discusses the conflicting emotions generated around Brexit: opportunity in the minds of some and regret among others.
Ahuja writes: “Regret is a powerful emotion, and a universal one. Who among us has not felt a pang, even a churn in the stomach… that, in retrospect, was the wrong one?”
Regret, guilt, shame, and remorse are defined as follows: regret is a negative conscious and emotional reaction to personal past acts and behaviors. Guilt is an intense emotional form of regret (where one acts in a manner and later wishes not to have done so). On the other hand, shame is the social consequence of either regret or guilt. Remorse is a form of regret over a “past action that is considered by society to be hurtful, shameful, or violent.”
Many decisions in history have been followed by remorse, because they are associated with some form of an apology. An example might be an apology for taking a country to war on false pretenses. In contrast, regret often is a personal emotion, and usually doesn’t result in an apology. For example, voting for a certain president, voting for Brexit (as discussed by Ahuja in her FT article), or not accepting a scientific paper for a journal that, published somewhere else, goes onto become a landmark publication.
In the clinical sphere, understanding how decisions are made, especially through the lens of regret theory, and anticipated regret, may have quite far-reaching implications around how patients make decisions around life-or-death decisions, deciding to have surgery, making a “do-not-resuscitate” (DNR) decision, or even decisions about whether to participate in a clinical trial. Understanding that there is complexity makes for greater empathy from caregivers.
Ahuja discusses an article published recently in Frontiers in Psychology that reviews several theories of regret.
One prominent theory, advanced by Gilovich and Medvec in the 1990s, points to the intensity of regret being driven by the type or nature of regret. Regret may be more intense when it involved deciding not to do something. Further, the temporal theory of regret suggests that decisions or actions produce greater regret in the short-term, whereas a lack of a decision or inaction results in greater regret in the longer term.
In a variation on this, Bieke, Markman and Karadogan suggest that lost opportunity rather than future opportunity generates the greater intensity of regret.
A second theory, termed “decision-justification theory,” and advanced by Connolly and Zeelenburg in 2002 focuses on outcome – decisions or actions that result in poor outcomes are associated with greater regret than those that generate good outcomes. Further, justification modulates the degree of regret even if the outcome was poor. In other words, if collateral damage results from a drone attack, the regret is less if there was a priori justification in conducting the action.
A third theory of regret termed “belonging” and advanced in 2012 by Morrison posits that the context of the action or decision modulates the intensity of regret. Decisions made in a social context around “belonging” (for example, around family or relationships) are more intensely felt than decisions made in social circumstances where individuals may be more detached (for example, in a work project).
Regret theory proposed in 1982 by Loomes and Sugden points out (wikipedia quote), “…that when facing a decision, individuals might anticipate regret and thus incorporate in their choice their desire to eliminate or reduce this possibility.” In auctions and lotteries, providing feedback can result in anticipated regret, which in turn may modify the decisions that are made around how much to bid or many lottery tickets to buy.
Regret aversion is a concept that also has clinical applicability. Ritov and Baron cite the example of parents unwilling to vaccinate a child because of the risk of death or other complications from the vaccine, even though the risk of these potential complications are much lower than the developing disease; because the former is a deliberate action of the parent, there is an aversion to taking the risk.
Understanding how people make decisions, framed by the nature of regret and the degree of regret aversion allows for some insights into why people do the things they do. Making an active decision to switch off the ventilator or remove a feeding tube resulting in the death of a loved one is much more challenging than the more passive decision of agreeing to not resuscitate a loved one in the event that their heart stops or there is respiratory failure.
Developing some appreciation of regret theory and regret aversion is likely to make care givers more empathetic about what others, and ultimately we ourselves, will go through at the end of life.
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Dr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.