Table 2 Scenario 4: Influence of disposition on medical decision making (micro level)

A cardiologist sees a patient with stable coronary artery disease and low ischemic burden, and consequently no indication for coronary angioplasty. The patient reports four occurrences of chest pain per day. Due to high trait anxiety, he is not only vulnerable to over-perceiving heart symptoms, but also inclined to catastrophize the occurrences of chest pain. [13] Furthermore, his anxiety about the chest pain results in a strong preference for angioplasty over continuing conservative treatment (medication). Finally, the cardiologist decides to refer the patient for angioplasty, leading to medically unnecessary treatment [14] and consequently unnecessary medical risks.

The disposition of the cardiac patient influences his self-evaluation as well as his treatment preference (requesting angioplasty). The consequent unnecessary treatment is in conflict with both the beneficence and nonmaleficence principles. As there are no health benefits that outweigh the health risks of the intervention, the treatment is not in the best interest of the patient and the health risks imply possible harm. Whereas the treatment may comfort this anxious patient, leading to a (presumably temporary) improvement in self-reported health or wellbeing, it would have been better to refer the patient for treatment of his anxiety. Concerning the principle of autonomy, the situation does not seem problematic as it is the patient’s own self-evaluation and preference that informs the decision leading to sub-optimal care. However, the patient is probably unaware of the influence of disposition on his self-evaluation. Not being able to take this into account raises the question of whether the decision is optimally informed and, consequently, autonomous.