Three Shots at Prevention: The HPV Vaccine and the Politics of Medicine's Simple Solutions

Chapter Ten. Decision Psychology and the HPV Vaccine

chapter ten Decision Psychology and the HPV Vaccine Gretchen Chapman New medical advances pose new decision-making challenges for patients and their families. When a medical intervention is made available, patients must decide what information to gather about this new option and under what circumstances they would want to receive it. The introduction of a vaccine for human papillomavirus gives adolescents and their parents the responsibility of making decisions that have implications for the health of the entire population. This chapter views the HPV vaccine through the lens of theory and research on the psychology of decision making. I examine the vaccine as a case study in making decisions on behalf of others, where concern for others must include a consideration of the delayed consequences and risky outcomes of the vaccine. These issues, I argue, illuminate the complexity of the HPV debate at the level of families and society. However, my primary focus is not to analyze the HPV vaccine debate per se; rather, I use this vaccine as an important opportunity to think more broadly about vaccination behaviors, drawing on the theoretical insights of decision psychology. Chapter 9, by Jennifer Reich, examines in depth the decision processes of the primary decision makers in the cancer vaccine controversies—the parents Decision Psychology and the HPV Vaccine 183 of adolescent girls. The parents are the people who say the ultimate yea or nay regarding whether a particular girl will be vaccinated. Here, I continue Reich’s exploration of decision making but in a different framework. Rather than employing qualitative methods to answer sociological questions, I review several quantitative studies that address questions emerging out of the framework of decision theory. The Decision Theory Framework Decision theory views individual decision makers as comparing choice options based on the expected costs and benefits, weighted by the likelihood that those outcomes will occur. Four key issues about vaccination decisions generally, and about the HPV vaccine in particular, are of interest to researchers focusing on the psychology of decision making. First, the benefits of vaccination are delayed : one vaccinates now to prevent the diseases of tomorrow. In this respect, the HPV vaccine is of particular interest for decision psychology because, unlike the flu shot, for example, which accrues benefit several months after vaccination , the HPV vaccine accrues benefit several decades after vaccination. Thus, it provides a rare window onto decision making about very long-term consequences . Second, vaccination entails uncertain outcomes: one may escape the disease even if unvaccinated, and vaccination only partially reduces risk. The HPV vaccine also has uncertain consequences, but the uncertainties of effectiveness are complicated because the vaccine acts on a virus rather than directly on the cancers to which it has been linked, and, moreover, most women could avoid cervical cancer even if unvaccinated. Third, vaccination entails social dynamics: because of herd immunity, your vaccination decision benefits not only you but also me, and consequently, I have the opportunity to benefit from others’ vaccination without vaccinating myself. The HPV vaccine provides a unique opportunity to examine the role that others’ outcomes play in personal vaccination decisions. The vaccine has only recently been approved for boys and men, giving them the opportunity to protect future female partners from cancer by vaccinating themselves. Fourth, vaccination frequently entails surrogate decision making, as when a parent makes vaccination decisions on behalf of a child. Like other pediatric vaccinations, the HPV vaccine requires surrogate decision making. However, unlike other pediatric vaccinations, the HPV vaccine is delivered to adolescents, who are old enough to have views and opinions of their own. This vaccination decision thus affords a special opportunity 184 Focus on the Family to examine the extent of agreement between the surrogate decision maker and the beneficiary. Decisions with Delayed Consequences The concept of intertemporal choice, or decision making among options with consequences that occur at different times, is a useful one in exploring decision making about delayed consequences. A standard finding among researchers is that decision makers discount future outcomes; that is, they value delayed outcomes less than immediate outcomes with the same nominal value. Furthermore , the rate at which they discount future outcomes varies with factors that normatively should be irrelevant. This behavior demonstrates that a decision requiring the calculation of a delayed outcome is a complex process resulting in choices that deviate systematically from those described by normative decision theory. For example, descriptively, positive outcomes (or gains) are discounted at...