Mayo Clinic September 2017 - Special Article
Department of Marketing, Mays Business School, Texas A&M
University, College Station, TX (L.L.B.); Institute for Healthcare Improvement, Cambridge, MA (L.L.B.,K.S.M.);
Department of Marketing, Monash Business School, Monash University, Melbourne, Australia (T.S.D.);
The Beckham Company, Bluffton, SC (D.B.); Pulmonary Hypertension Program,
Department of Pulmonary and Critical Care Medicine, and Care Experience, Henry Ford Health System, Detroit, MI (R.L.A.A.);
Department of Medicine, Weill Cornell Medical College, New York, NY (K.S.M.).

Leonard L. Berry, PhD, MBA; Tracey S. Danaher, PhD; Dan Beckham, MBA;
Rana L.A. Awdish, MD; and Kedar S. Mate, MD
Patients are often reluctant to assert their interests in the presence of clinicians, whom they see as experts.
The higher the stakes of a health decision, the more entrenched the socially sanctioned roles of patient and
clinician can become. As a result, many patients are susceptible to hostage bargaining syndrome (HBS),
whereby they behave as if negotiating for their health from a position of fear and confusion. It may
manifest as understating a concern, asking for less than what is desired or needed, or even remaining silent
against ones better judgment. When HBS persists and escalates, a patient may succumb to learned
helplessness, making his or her authentic involvement in shared decision making almost impossible. To
subvert HBS and prevent learned helplessness, clinicians must aim to be sensitive to the power imbalance
inherent in the clinician-patient relationship. They should then actively and mindfully pursue shared
decision making by helping patients trust that it is safe to communicate their concerns and priorities, ask
questions about the available clinical options, and contribute knowledge of self to clinical decisions about
their care. Hostage bargaining syndrome is an insidious psychosocial dynamic that can compromise
quality of care, but clinicians often have the power to arrest it and reverse it by appreciating, paradoxically,
how patients perceptions of their power as experts play a central role in the care they provide.
When my 6-year-old son was hospitalized
for 3 months, I became acutely aware of
how my typical consumer experiences
differed from my experiences as the
parent of a child in a life-threatening
situation. If a restaurant were to present
my son with food that appeared not to
have been cooked properly, I would not
have hesitated to assert my right to send
the meal back. In a health care setting,
in contrast, when my son received poor
care (eg, a caregiver did not wash her
hands), I hesitated to be assertive for
fear of alienating the physicians and
nurses whose goodwill we needed to main-
tain. I felt dependent and powerless, as if
my son was a hostage to the care he
received and the system that delivered it.
It was as though I was compelled to nego-
tiate for his safe release from potential
harm.  This story (of a parent whose child is
receiving extended inpatient care)
could just as easily be that of a
70-year-old man with coronary artery disease
who is unsure about the cardiologists recommendation for surgery but hesitates to question it, or a 27-year-old woman with cancer
who does not express her fear of treatment-
related infertility to her oncologist. Patients
and families often hold back from openly
engaging clinicians in the thorough discussions that true shared decision making
(SDM) requires.
We refer to this phenomenon as hostage bargaining syndrome (HBS) because, in the
presence of clinicians, patients and their famlies may behave like hostages negotiating,
from a position of fear and confusion, for their
health. The behavior of adult kidnapped
hostages has been categorized as cognitive
(eg, confusion and disorientation); emotional
(eg, fear and anxiety); and social (eg, with-
drawal and avoidance).
Clinicians who
experience similar behavior in patients are un-
likely to want their patients to feel like hostages, and many will actively encourage the
patients involvement in SDM, although this
effort may be perceived as time-consuming in
the context of competing priorities.
Nevertheless, although a medical team actively works
to assist, protect, and help make the patient
well, many patients and their families still
experience HBS and are reluctant to speak up.
Although HBS can arise in any medical
context, it is especially seen when serious
illness unfolds over the course of multiple,
complex, emotionally laden interactions with
clinicians. Cancer care and intensive care
unit services, for example, each are character-
ized by a high degree of dependence and
powerlessness for patients. To address HBS
more effectively in any clinical scenario, from
minor to life-threatening, we need to under-
stand it and its causes from the perspective
of the patients themselves.
Medical care has recently become more
focused on serving patients as consumers,
but some distinctions are important. Most
commercial services are “want” services: consumers want to dine out, use a smartphone
to send text messages to friends, or buy a
ticket to attend a sporting event. Medical
care is a “need” service that consumers-
turned-patients often dread and may delay
In using most commercial services,
the consumer is in charge, deciding what ser-
vice to buy and where to buy it; in a medical
clinic or hospital, clinicians (and health care
management) typically have the greater
authority. This shift in the balance of power
has especially high stakes in cases of serious,
life-threatening illness, where anxious patients
and their families can become particularly sus-
ceptible to HBS.
Hostage bargaining syndrome, which
includes a reluctance to challenge people in
authority, assert a different point of view,
and question decisions that raise concerns, is
an adaptive response to authority figures
who retain de facto control because of attributes such as expertise, prestige, and position.
Hostage bargaining syndrome often manifests
as a form of compromise, such as understating
a concern or asking for less than what is
desired or needed. Hostage bargaining syn-
drome may be perpetuated by asymmetry of
information, an assumed hierarchy, fear of
retribution, or fear of jeopardizing an important relationship.
Patients and families who
exhibit the symptoms of HBS refrain from
questioning their doctors, hesitate to express
concern about potential errors or harm, and
worry about being perceived as troublemakers
or “difficult” for fear that it could affect the
quality of care they receive.
Hostage bargaining syndrome is an
advanced case of “white-coat silence.”
It is especially prevalent when, as clinical conditions deteriorate and the stakes of health decisions rise, patients become more dependent on
clinicians and more likely to seek favor from
them in a deferential manner. They believe that “the doctor knows best” and conform to
a socially sanctioned role of reluctance to assert
their interests in the presence of experts.
To be sure, professionals typically do
know best. Just as lawyers should draw on
their expertise instead of merely reacting to clients
requests, and teachers should use their
experience to expertly guide their classes
rather than feeling pressured by students
whims, so too must physicians use their
knowledge, training, and clinical judgment to
steer patients with competence and accuracy.
Ultimately, of course, lawyers, teachers, and
physicians bear more of the social (and often
legal) burden of accountability than do the
populations they serve; in short, the pressure
on the trained professional is high. But good
lawyers also know that justice is served best
when clients fully participate in how they
access that justice, and good teachers know
that getting students to invest themselves in
the learning process makes it easier to achieve
positive educational outcomes. So, too, do
good physicians know that achieving desirable
health outcomes is more likely when patients
understand and participate in their care.
All professionals face accountability pressures
that are very stiff, but the people they serve
may be profoundly affected by the outcomes
and, therefore, deserve to be intimately
involved in how those outcomes are pursued.
Part of the professionals expertise is in
knowing how to fully bring the person he or
she serves into the process; it ’s a core element of the job.
September 2017