Notes on Botti et al (2009) – Tragic Choices

Main Topic or Phenomenon

This paper examines how making highly consequential, highly undesirable decisions (termed “tragic choices”) affects individuals’ emotions and their preference for autonomy. The specific context focuses on medical decisions, particularly parents’ decisions about withdrawing life support for their critically ill infants.

Theoretical Construct

Tragic Choices: Decisions that fall at the extreme ends of two continua - highly undesirable outcomes and highly consequential importance. These choices are so emotionally painful that they transcend normal concepts of choice, causing severe emotional upset regardless of which option is selected.

Perceived Personal Causality: The extent to which individuals perceive themselves as causal agents in their experiences. When people make choices themselves (internal locus of control), they experience stronger causal ascriptions compared to when choices are externally imposed (external locus of control).

Autonomy Preference: The desire to make decisions oneself rather than having others decide, typically assumed to be beneficial for well-being in consumer behavior and medical literature.

Key Findings

1. Emotional Impact: Parents who personally made the decision to withdraw life support experienced more intense negative emotions (grief, guilt, self-blame) compared to parents who witnessed physicians making the same decision.

2. Autonomy Ambivalence: Both groups of parents showed ambivalent attitudes toward decision autonomy - they simultaneously desired and resented having decision-making power over their children’s lives.

3. Causality Mechanism: The greater perceived personal causality associated with making tragic choices (vs. having them externally made) magnifies negative emotional responses to tragic outcomes.

4. Information Preference: Despite ambivalence about decision-making, both groups strongly desired to be informed about medical conditions and treatment alternatives.

5. Framing Effects: When the medical decision was framed as objectively superior (reducing perceived causality), the emotional disadvantage of choosing was eliminated.

Boundary Conditions and Moderators

Decision Framing: When physicians framed the treatment option as medically inevitable rather than a matter of personal choice, choosers’ negative emotions were reduced to the level of non-choosers.

Information Availability: The emotional advantage of non-choosers disappeared when they were uninformed about alternative treatments, suggesting the importance of transparency in the decision process.

Treatment Preferences: The negative emotional effects persisted regardless of whether the chosen option aligned with individuals’ personal preferences.

Decision Confidence: Effects occurred even when choosers were more confident they had made the right decision.

Building on Previous Work

Challenges Cognitive Dissonance Theory: Contradicts predictions that choosers would subjectively bolster their decisions to reduce dissonance. Instead, choosers experienced more negative emotions despite making objectively optimal choices.

Extends Choice Literature: Builds on research showing choice can sometimes be detrimental (Botti & Iyengar, 2004) by identifying a specific mechanism (perceived causality) and context (tragic choices) where this occurs.

Challenges Medical Autonomy Paradigm: Questions the assumed benefits of patient autonomy in medical decision-making, contrasting the shift from paternalistic to autonomous models.

Expands Emotion-Choice Research: Extends beyond mundane choice contexts to examine truly high-stakes decisions where emotional distress stems from the stakes themselves, not uncertainty about options.

Major Theoretical Contribution

The paper introduces the concept of “tragic choices” as a distinct category where normal choice benefits break down. It demonstrates that perceived personal causality can intensify negative emotions from undesirable outcomes, challenging the universal assumption that autonomy enhances well-being. The research reveals a psychological mechanism explaining when and why choice can be detrimental, contributing to a more nuanced understanding of autonomy’s effects.

Major Managerial/Practical Implications

Healthcare Policy: Suggests that mandatory patient autonomy models may not always serve patients’ psychological well-being. Healthcare systems should consider patients’ readiness for decision-making rather than imposing uniform autonomy requirements.

Physician Training: Doctors should be trained to assess patients’ desire for involvement in decision-making and use appropriate framing to reduce perceived causality when beneficial.

Decision Framing Strategy: When patients must make tragic choices, framing decisions as medically determined rather than matters of personal preference can preserve autonomy while protecting emotional well-being.

Support Systems: Healthcare institutions should focus on relationship quality and emotional support rather than simply providing choice options.

Unexplored Theoretical Factors

Temporal Factors: How does the timing of decisions (immediate vs. delayed) affect the causality-emotion relationship in tragic choices?

Social Support: Could the presence of family members or support groups moderate the relationship between choice and negative emotions?

Cultural Values: How do individualistic vs. collectivistic cultural orientations influence preferences for autonomy in tragic decisions?

Personality Factors: Do individual differences in need for control, anxiety sensitivity, or coping styles moderate these effects?

Decision Reversibility: How does the perceived reversibility of tragic choices influence emotional responses?

Expertise Levels: Does medical knowledge or previous experience with similar decisions moderate the choice-emotion relationship?

Alternative Decision Makers: How do relationships with alternative decision makers (family vs. physicians vs. ethics committees) influence emotional outcomes?

Outcome Severity: Are there gradations within “tragic” outcomes that influence the strength of these effects?

Reference

Botti, Simona, Kristina Orfali, and Sheena S. Iyengar (2009), “Tragic Choices: Autonomy and Emotional Responses to Medical Decisions,” Journal of Consumer Research, 36 (3), 337–52.