Something Not Unlike Research

Informed Consent and Standards of Care

post by Paul Kelleher

Austin Frakt has an important post today about the still rocky terrain of informed consent in medicine. You should read the whole (short) post, which revolves around this case:

The date was July 19, 1999, when as a third-year resident I saw a highly educated 53-year-old patient. In June 2002, my residency and I were served with court papers.[...]

On that day in July 1999 I saw the 53-year-old man for a physical examination. I discussed with him, and documented in his chart, the importance of colon cancer screening, seat belts, dental care, exercise, improved diet, and sunscreen use. I also presented the risks and benefits of screening for prostate cancer and documented the discussion. I never saw the patient again, and after I graduated, he went to another office. His new doctor ordered prostate-specific antigen (PSA) testing without discussing the risks and benefits of screening with him. Unfortunately for the patient, his PSA level was very high and he was subsequently diagnosed with incurable advanced prostate cancer. [...]

My residency was found liable for $1 million.

Frakt gives a little more background on the trial that led to this verdict:

[S]everal physicians testified that it was standard to conduct a PSA test without asking the patient. Hence, in the eyes of the law and despite the shared decision making process he employed, Merenstein delivered sub-standard care.

Perhaps the rationale for defining adequate care as that which would be provided by most of one's peers can be ratified by adapting that old Churchillian quip: it's the worst form of government, except for all the rest. After all, do we really want courts to be making decisions about what appropriate medical care consists in, especially when so much of the profession is united on what should be done? On the other hand, it is just as easy--and maybe easier---to raise important worries about determining the standard of care in this "prevailing practice"-based way. Perhaps Frakt's case of the resident and the PSA test is enough to convince you that we need a different standard. If not, consider this case, which comes from Rebecca Skloot's book The Immortal Life of Henrietta Lacks (pp. 129-135): 

Southam injected HeLa and other living cancer cells into more than six hundred people for his research...Patients who'd unknowingly been injected with cancer cells by Southam read the articles and began contacting reporters. New York State Attorney General Louis Lefkowitz learned about Southam's research through media as well, and immediately lauched his own investigation. In a scathing five-page document filled with exclamation points, he accused Southam and Mandel of fraud and unprofessional conduct, and demanded that the Board of Regents of the University of the State of New York revoke their medical licenses. [...]

Many doctors testified before the Board of Regents and in the media on Southam's behalf, saying they'd been conducting similar research for decades. They argued that it was unnecessary to disclose all information to research subjects or get consent in all cases, and that Southam's behavior was considered ethical in the field. Southam's lawyers argued, "If the whole profession is doing it, how can you call it 'unprofessional conduct'?" [...]

The suspensions of Southam's and Mandel's licenses were stayed...[and] soon after the end of his [one year] probationary period, Southam was elected president of the American Association for Cancer Research. 

Our mothers were right: just because everyone else is pushing cancer patients off the Brooklyn bridge doesn't mean it's OK for us to do it. And perhaps, just perhaps, the fact that most other doctors conduct the PSA test without first getting informed consent from the patient does not mean that this is acceptable conduct either. I won't pretend there aren't forcing pulling in different directions. But that is why we need clear examples of when informed consent is required, so we can distill generalized lessons from them.  

Ubel on Bloomberg's Soda "Ban"

post by Paul Kelleher

Peter Ubel writes:

Unfortunately, the Big Gulp ban is a bad idea.

...

Where the trans-fat and soda bans differ, however, is in the coherence with which New York City officials can explain how they draw the line between banned and unbanned goods.

...

Coke and Pepsi are artificially manufactured processed foods, too. And they contain an undeniably harmful substance. But herein lies the problem. The harmful substance is sugar, and the sugar in Coca-Cola is no more harmful than the sugar in apple juice or a milkshake.

This is understandably confusing to the public, who can’t understand why New York City is planning to ban large sodas but not triple-decker chocolate cakes, or why the 280 calories in a 24-ounce Coke are somehow worse for them than the 330 calories in a Starbucks peppermint mocha.

The success of most policies depends upon public support. But incoherent policies are difficult to embrace.

If Mayor Bloomberg were defending his policy in front of the Supreme Court, the justices would be asking him for a limiting principle – a rationale that would help us know where this policy begins and ends. The ban on large sodas doesn’t pass this test.

I think a lot more rides in this case on pragmatic and context-specific considerations than Ubel acknowledges here. Ubel adopts the language of the Supreme Court oral arguments over the ACA when he says that Bloomberg cannot provide a "limiting principle" that explains why large sodas should be banned but not Starbucks peppermint mochas. But I wonder: is there a limiting principle that explains why one can buy Tylenol over the counter but not fentanyl patches? Each one can be very harmful if used improperly, and each works by containing narcotics, just as both soda and milkshakes taste delicious because of their sugar content. This suggests that sometimes pragmatic, context-specific considerations can serve to justify otherwise "incoherent" policies governing the sale of similar substances. A paradigm example of a pragmatic consideration is how likely it is that Tylenol (or soda) will be consumed in degrees that trigger the public's interest. Another example may well be how likely it is that a key demographic--kids and adolescents, e.g.--will overconsume one product rather than another. (Another may concern the degree to which specific consumption patterns negatively impact the already cash-strapped budgets for essential social services.)

I'm not yet saying that the consumption patterns of soda raise do in fact raise pragmatic concerns that render Bloomberg's specific proposal justified in the final analysis. (I need to read more of the empirical work on the issue.) I'm only pointing out that sometimes pragmatic considerations can justify a policy response that can't be neatly expressed in a tidy limiting principle.  

Gaps in the Recent Infanticide Argument

post by Paul Kelleher

Bill and I have already posted some "meta" comments on the controversial paper by Giubilini and Minerva that purports to prove that infanticide is permissible in cases involving all the same reasons that would've made early abortion permissible. I noted that even if philosophical argument seems airtight, we can have commonsensical reasons to doubt the conclusion (and to believe there must be something wrong somewhere with the argument). But I actually don't think that G&M's argument is airtight. Instead, I think we can point to some real gaps in their reasoning.

Here is their argument as I understand it. Quoted parts come straight from the paper. Everything else is intended as a faithful reconstruction of their argument.

1. "A necessary condition for a subject to have a right to X is that she is harmed by a decision to deprive her of X." 
2. Full-fleged persons are harmed when their aims or life-goals are thwarted.
3. Fetuses and newborns don't have aims or life-goals.
4. So fetuses and newborns cannot be harmed in the goal-thwarting sense of harm.
5. However, fetuses and newborns do in fact have the potential to form life-goals.
6. But "in order for harm to occur, it is necessary that someone is in the condition to be harmed."
7. Fetuses and newborns are not in fact in the condition to be harmed in the goal-thwarting sense.
8. Therefore, "there is no harm at all" when a fetus or newborn is killed (assuming it is done painlessly).  
9. "Therefore, the rights and interests of the actual people involved should represent the prevailing consideration in a decision about abortion and after-birth abortion."
10. "Among these interests, we also need to consider the interests of the mother who might suffer phychological distress from givign her child up for adoption."
11. Therefore, "if the interests of actual people prevail, then after-birth abortion should be considered a permissible option for women who would be damaged by giving up their newborns after adoption."

Assume for the sake of argument (but only for the sake of argument) that G&M's argument from 1 to 10 works perfectly. That is, assume that it is only the interests of actual people that matter in deciding whether abortion and infanticide are permissible (and of course that the mother's interests are relevant). Does it follow from this that no one else's interests are relevant? It does not. And G&M never argue that other people's interests and feelings about infanticide are irrelevant. All they claim is that a woman may be so distressed by adoption that she'd rather kill her baby. They don't even take pains to argue (as they must) that being driven to choose infanticide by post-partum distress really is in the woman's interests. 

So the leap from 1-10 to conclusion 11 is a HUGE leap. The gap that must be traversed includes arguing that the mother really would be better off in some circumstances if infanticide would occur, and that other people's interests and feelings about infanticide can never, ever, ever trump a woman's desire that the newborn die. (If other people's feelings about trees and wetlands can justify protections of them, why not feelings about newborns?) M&G do not do the work to close this gap. They are therefore not entitled to their very strong conclusion #11.

Infanticide and the thing about philosophical argument

post by Paul Kelleher

Philosophical argumentation is a wonderful thing. It promotes clear thinking about the structure and substance of lines of reasoning, and it helps to locate problematic logical gaps. Sometimes, however, it is not philosophical argument that identifies the gaps, but rather our common sense. Sometimes, we just know there's a mistake somewhere, even if philosophical argument presents itself as ironclad. Consider The Surprise Test Paradox:

A teacher announces that there will be a surprise test next week. A student objects that this is impossible: “The class meets on Monday, Wednesday, and Friday. If the test is given on Friday, then on Thursday I would be able to predict that the test is on Friday. It would not be a surprise. Can the test be given on Wednesday? No, because on Tuesday I would know that the test will not be on Friday (thanks to the previous reasoning) and know that the test was not on Monday (thanks to memory). Therefore, on Tuesday I could foresee that the test will be on Wednesday. A test on Wednesday would not be a surprise. Could the surprise test be on Monday? On Sunday, the previous two eliminations would be available to me. Consequently, I would know that the test must be on Monday. So a Monday test would also fail to be a surprise. Therefore, it is impossible for there to be a surprise test.” 

But obviously logic does not make it impossible for the teacher to throw a surprise test. Indeed, do you know what would make a surprise test an absolute certainty? Yep, that's right: if all the students accepted the seemingly ironclad line of reasoning presented above. If they all believe a surprise test is impossible, they will all be in a rude awakening when they don't study for it and then find blue books on their desks on Wednesday.

The lesson here is that one's intellect must always be on guard, even against seemingly airtight philosophical argumentation. Common sense always retains a key role, even while it itself undergoes continuous scrutiny. That's our predicament.

All this leads me to be less sanguine than Bill about a recent paper in Journal of Medical Ethics by Alberto Giubilini and Francesca Minerva that defends infanticide. Bill clearly states that he wishes to "defend Giubilini and Minerva's arguments, while disagreeing strongly with their conclusions." In particular, he says that "G & M are doing what ethicists are supposed to do: pursuing ethical arguments to their conclusions." In G & M's case, that conclusion is this:

[W]e argue that when circumstances occur after birth such that they would have justified abortion, what we call after-birth abortion should be permissible.

However, given the lesson of the Surprise Test Paradox, there is another thing the authors could have concluded. They could've said:

We have constructed a very strong argument for the conclusion that post-birth abortion is permissible. If that conclusion is false, then (1) there must be a problem with one of our premises, or (2) there must be a problem with the logical structure of the argument. We do not find either sort of problem, although it is of course possible one exists. We do not wish to advocate for permitting infanticide (at least not yet). But that seems to be where the argument leads. Evidently, those who oppose this controversial conclusion have some work to do.

Instead, the authors chose to declare--assert--that that infanticide really is permissible. If I sit here and declare that they should have deferred more to common sense, am I thereby claiming that I have a more highly evolved common sense than they do? I guess so. But at least I'll be prepared for Wednesday's surprise exam.

(I'll post Monday on what I do think is a clear substantive flaw in M & G's argument.)

Is mandated insurance coverage of contraception an assault on religious liberty?

post by Bill Gardner

The health insurance reform that was part of the Affordable Care Act requires health insurance plans to pay for prescribed contraceptive services. Some, but not all religious institutions are exempted from this requirement. An exemption means that is they offer their employees health insurance, that health insurance does not need to require coverage of prescribed contraception. Under current rules, churches are exempted, but a church-run hospital or hospital is not. There is currently a dispute about whether the exemption should be broadened to include all church-run institutions.

As a matter of health policy, I support the broadest possible access to contraception. Control over reproductive decision making is a fundamental freedom. However, I agree with the editorialist in the Christian Century, that there was a competing public good that would have justified a broader exemption:

we think the common good is also enhanced when religious believers—and religious institutions—are free to act in the public square without sacrificing their religious identity.

The Catholic Bishop of Charleston, however, takes the stronger view that the failure to broaden the exemption is an assault on

the fundamental right to religious liberty  for all citizens of any faith.

This is, I think, an overstatement: I don't think this rises to the level of an assault on a fundamental right and I do not think he is speaking for all US citizens of any faith. Try looking at this from my point of view.

1. I am a Buddhist who has taken a number of religious vows, including not killing. If I were an absolute pacificist, which I am not, I could conscientiously object to military service. But I cannot conscientiously refuse to pay any portion of my taxes, even though I am thereby funding killing in wars that have, in my view, no moral justification. Is this an assault on my religious liberty? 
2. I am absolutely opposed, on religious and ethical grounds, to capital punishments (the graph tracks capital punishments in the US). Nevertheless, they are regularly carried out in my name and paid for with my taxes. Is this an assault on my religious liberty? 
3. I abstain from eating meat, because it kills animals. However, the US government purchases many tons of meat every day for the armed forces, and hence procures the slaughter of thousands of animals. So again, I am paying for this killing. Is this an assault on my fundamental right to religious liberty?
4. Finally, the Catholic Church has historically supported the banning of contraception. Wasn't this religiously-motivated restriction of access an assault on the fundamental right to religious liberty of persons whose religion (or lack thereof) did not bar them from using contraceptives?

The answer to each question is, to some degree, yes: my religious liberty is infringed by points 1-3 and it would have been infringed if there were still restrictions on access to contraception. The government makes me pay for executions. I think that's a more serious  assault on my religious liberty than forcing a Catholic hospital to pay for a diaphragm. Where was the Bishop when I needed him?

The thing is, it turns out that if you are a religious person in a religiously diverse society there will always be some important infringements on your liberties. 

I'm for raising taxes on the affluent. Am I a hypocrite?

post by Bill Gardner

I support an increase in the taxes paid by the wealthiest and highest income Americans. I want this to happen to reduce the deficit and to fund some essential services to benefit the poor. This is not retribution. I don't think incomes are or could be based on what people 'deserve.' Finally, I am not motivated by envy, because I am in the group that should be taxed.

At this point, you may respond, "If you believe in increased taxes on persons like yourself, take the option to give the government more." And if I do not take that option -- which I do not -- I am a hypocrite.

So, there is no question that I am not nearly as generous or charitable a person as I should be. But that is a separate issue. I want the US to be a society where every child gets essential health care and education. Charities have never achieved these goals. Governments funded by progressive taxation get closer, in many developed societies. 

Inequality? Oh we'd love to help, but...

post by Bill Gardner

Arnold Kling and Nick Schulz argue that the growth in US inequality derives from two factors:

• Technology that allows a few very able persons to achieve extraordinary things (think Sergey Brin), and
• Defective families and assortative mating based on ability that result in large groups of people at the bottom who lack the talent to produce much of value.

These are important causes of inequality. Kling and Schulz would do something about these things if they could, they really would, but 

there may be less that government can do than one might hope. Research from Heckman suggests that education is a relatively feeble remedy for the effects of family background (although Heckman believes that early intervention, in preschool or even before, shows promise). In order to make a dramatic impact on inequality, government would have to do something about the fundamental causes: technology and marriage patterns. However, putting a brake on technological progress seems hardly feasible or desirable. And forcing people to select mates at random rather than on the basis of similar backgrounds and tastes seems similarly unlikely. As much as inequality may be a problem, no real solution is in sight.

OMG, if the only alternatives are freezing technological progress or making people marry random partners (on second thought, this is the best explanation for my first marriage, and the kids turned out great anyway), then I guess there really is nothing to be done.

Or maybe we could try the following:

• We could give every mother good prenatal care, and institute programs to reduce premature delivery. 
• We could provide every child with universal, high-quality preschool education. Please, read Heckman for yourself. He isn't saying that early interventions "show promise." He's saying that "Early interventions promote schooling, reduce crime, foster workplace productivity, and reduce teenage pregnancy." 
• We could reform our criminal justice system. The US has 751 persons in prison per 100,000 population. Canada has 117. England's rate is 151; Germany's is 88; and Japan's is 63. Mexico has 204. The global median is 125. Are Americans really six times as violent and criminal as the rest of the world? The burden of US incarceration falls on the poor and above all on people of color. It destroys families. But it could be fixed.

America could do these things and it would still have considerable inequality. But these are solutions that would help and, contrary to Kling and Schulz, they are in plain sight.

The epigenetic lottery

post by Bill Gardner

Tyler Cowen discusses the (possibly diminished) US social mobility, and asks

How much of [social] immobility is due to “inherited talent plus diminishing role for random circumstance”?  Is not this cause of immobility very different — both practically and morally — from such factors as discrimination, bad schools, occupational licensing, etc.?  What are you supposed to get when you combine genetics with meritocracy?  I do not know how much of current American (or other) immobility is due to this factor, but I find it discomforting that complaints about mobility are so infrequently accompanied by an analysis of this topic.

So, the idea is that nature roles the dice and gives each child a set of genetic endowments. Families will also invest their resources in cultivating the children's talents. Then, as we become adults, 'society' (meaning the schools, job markets, etc.) places each of us in the social hierarchies of wealth, income, and power (the figure to the right is from Catherine Mulbrandon [@visualecon], and shows the 2005 income distribution among the bottom 98% -- adding the next 2% takes you way off the page). If societies are increasingly meritocratic, those outcomes will mirror the individual distribution of genetic talent and family resources to an increasing degree. So it could be that reduced mobility and increasing social inequality of outcomes reflects increasingly accurate meritocratic selection processes. And many would argue that such processes are not inherently unjust, so maybe we should just get over being upset about the worsening inequality of outcomes. If you add the ideas that genetic endowments are exogenous, and that trying to compensate for the inequality of family resources is either wrong or futile, then you have even stronger justifications for current inequality.

I don't buy these conclusions, for lots of reasons, but this post is not the place to provide the discussion that Cowen is calling for.

I want to raise just one objection here: The story about the genetic lottery is too simple. Our biology is less exogenous than most theorists believe. Michael Rutter explains that genes do not give us talents:

...although the DNA is what a person inherits, the effects of that DNA are dependent on a chain reaction that ends up with the expression of the products of the DNA in the structure and function of individual cells that is how environments alter genes (emphasis added).

Referring to this account of the interaction of nature and nurture, James Heckman writes

The field of epigenetics surveyed in Rutter (2006) demonstrates how genetic expression is strongly influenced by environmental influences and that environmental effects on gene expression can be inherited (emphasis added).

He then argues that there is evidence

that high quality early childhood interventions foster abilities and that inequality can be attacked at its source.  

and we are therefore not absolved from responsibility for the inequitable distribution of adult talent visible in infancy and early childhood.

The problem I'm pointing to in the meritocratic argument is that there isn't really a genetic lottery  in the way we imagine: and to the degree there is, the dice are loaded in the womb. If Heckman is right, there is much more we can do about inequality than most of us are willing to acknowledge.

However, if Heckman is right, it is also the case that much if not most of what we can do is equalize the epigenetic and child developmental lotteries that will govern inequality among future generations. And we have to decide whether we are motivated to struggle for equality in that future, a promised land that we will not see.

In which I am chastised for arrogance

post by Bill Gardner

Here is a tweet from @jacobgrier in response to my condemnation of smoking that was quoted by Andrew Sullivan:

"Smoking is a vice that benefits no one." -- @Bill_Gardner Oh please. I like it. It benefits me! Arrogant assumption. bit.ly/A07L3a

It's a great tweet: names a culprit, cites a source, states the writer's opinion, gives a cogent reason, and links to a source, all in 140 characters. 

Jacob is a "Mixologist, writer, barista, magician, libertarian." The odd picture to the right is from his blog. It depicts some men consuming drinks through a bone luge -- a drink is being poured down through a hollowed-out bone -- possibly where Jacob tends bar. Kind of like a bong for cocktails. It has an arresting paganism, which I expect is a component of the pleasure. Anyway, Jacob is right, it would be absurd for my to deny that his subjective pleasure in consuming alcohol through an animal (I HOPE) femur can raise his subjective well-being.

I get it about being young, reckless (and male?). I participated in several high risk outdoor sports before I had children, and my life is much richer for it. However, the 'luge' trope is absurd: Binge consumption of alcohol or drugs is at best a degenerate form of adventure; at least in my view, but as Jacob correctly notes, I am arrogant.

But what about liberty? I am not arguing that government should ban bone lugers from employment. My point is that I do not see a compelling argument against employers choosing not to hire them. By extension, we should have no public policies protecting access to employment for smokers (or bone lugers). This is, I believe, consistent with Mill's view that

The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not sufficient warrant.

I do want to see smoking go away, and I think social pressure is what makes that happen. ("Social pressure" is not, I think what Mill means by "exercising power".) To that end, I think it is legitimate to ban smoking in public places, and for employers to refuse to hire smokers if they judge that to be in the interest of their firms. 

Having conceded that smoking may benefit Jacob's subjective well-being, can I still say that "smoking is a vice that benefits no one"? I certainly can, if it's understood that benefit refers to the long-term well-being of smokers, and those who depend upon them, rather than immediate subjective well-being. In that sense of benefit, there is nothing to be said for smoking or binge drinking. 

Thinking, Fast and Slow about Informed Patient Choice

The following is an invited post from Thom Walsh PhD, MSPT, OCS, Diplomat MDT (@thomwalsh on twitter).  Thom very recently completed his doctorate in health policy at The Dartmouth Institute for Health Policy and Clinical Practice.  He is currently on faculty as a curriculum specialist in The Dartmouth Center's Health Care Delivery Science program.

Nobel-Prize winning economist Daniel Kahneman has made it his life’s work to scrutinize the many ways in which human beings fail to behave rationally.  His most recent book, “Thinking, Fast and Slow” summarizes the 40 years of research conducted by him and his colleague Amos Tversky on the topic.

Kahneman categorizes human thinking into two systems: 1) fast and 2) slow.  The fast system (System-1) represents rapid decision making based on assumptions, prior personal experience, and neurologic short cuts that have proven advantageous to survival.  System I “prepares us to perceive the world around us, recognize objects, orient attention, avoid losses, and fear spiders,” using subconscious actions and reactions that are unavoidable.  One cannot unlearn the simple mathematical formula 2+2=4 any more than they can stop themselves from flinching when surprised by the sudden bark from an angry dog.  To work at such instantaneous speed, System-I thinking relies on biases and heuristics.  Kahneman explains the “hindsight bias,” the “optimistic bias,” the “availability heuristic” and the “fast and frugal heuristic,” along with many others.  These multiple biases and heuristics detail the seemingly infinite ways in which humans divert from the utility maximization path laid out by econometrics and utility theory.  See here for a basic overview of decision theory in econometrics

By contrast, the slow system (System-2) is lazy and laborious.  Activating System-2 thinking requires us to pay attention and allows us to follow complex directions, compare choices, reflect on the past and project into the future.  Activities that rely on System-2 thinking require self-control and sustained effort.  In short, engaging System-2 is oftentimes depleting and unpleasant. 

Difficulties arise when we are presented with a situation that intuitively engages System-1 thinking, but actually requires System-2 thinking.  For example, if I told you the price of my son’s new ball and bat was $1.10, and the bat cost $1.00 more than the ball, your brain would likely switch into System-1 thinking by immediately concluding that the ball cost 10¢.  And, you would be wrong.  If the ball were 10¢, the bat would be $1.10 and our total would be $1.20.  By engaging System-2, we find the actual cost of the ball is 5¢.

Kahneman’s brilliant studies also demonstrate that humans are risk-averse when there is hope for a gain, yet risk-seeking when faced with a decision between certain losses.  He goes on to explain that we tend to rely heavily on System-I thinking when faced with uncertainty, trade-offs, or long-term horizons.

Uncertainty, novel situations, trade-offs, hopes, certain and long- term horizons are common features of many health care decisions.

The surprising truth is that medical providers seldom have solid evidence of superior treatment effectiveness.  More frequently, the clinical context is a choice between treatments with outcomes that differ depending on the option chosen without clear evidence to tell the patient or provider which is the superior choice.  Trade-offs exist with probabilities of good and bad outcomes over various time horizons.

For example, a patient suffering from 6 weeks of uncomplicated low back and leg pain from a herniated disc could chose surgical or non-surgical treatment.  Surgical care holds the promise of relieving the leg pain more quickly than non-surgical care but at the added risk of the surgical procedure itself.  Non-surgical care holds the promise of relief over a longer period of time and without the surgical risks.  Existing evidence suggests the long-term outcomes are equivalent.  (See here, here, & here for supporting evidence.) For this reason the patient’s preferences should determine the treatment pathway.  More commonly, however, it is the provider’s opinion that determines the patient’s treatment destiny.

Following this thought process further leads to the uncomfortable realization of a seldom discussed medical error, operating on the wrong patient.  I do not mean operating on patient A instead of patient B.  By “wrong patient,” I mean one who would have, had she been fully informed of the risks and benefits of all treatment options, chosen non-surgical care.  Evidence of the over-use of surgical interventions in this manner is detailed in Dartmouth Professor Jack Wennberg’s latest book, “Tracking Medicine.”

Patient preference-sensitive clinical situations are best addressed by aligning the fully informed patient’s preferences with the care she receives.  Doing so requires System-2 thinking by both the clinician and the patient.  This is not easy and there are legitimate reasons for both the clinician and the patient to be unhappy.

The situation is difficult for clinicians because System-2 thinking is laborious, but not reimbursed.  There are no evaluations or procedures to order.  Further, medical school does not provide the skills required to elicit a patient’s preferences, fears, and risk-tolerance, let alone their numeracy.  This final aspect is especially important because medical decisions frequently involve very small numbers that are difficult to place in context.

Patient preference-sensitive clinical situations are difficult for patients because they may not want to be so involved.  Patients engage the health care system at their most vulnerable times.  They reveal secrets to us their spouses may not know.  They disrobe in front of us and we peer inside of them with our technology or surgical technique.  Despite all this, patients reveal their anxieties and hopes to us, after the briefest of interactions, in the hopes of receiving information, wisdom, and care that can prevent or ease pain and dysfunction.

In return, they should receive our best information and judgment.  Past attempts to involve the patient in sharing the medical decision have, in my opinion, come up short.  They have relied on econometric utility-maximizing theory, weighting each of the probabilities in a decision tree and then mathematically folding branches back to reveal the most rational choices with the highest probability of producing the most utility for the patient.  This process has always struck me as an unusual because, in over 15 years of clinical work, I have never met a truly rational patient.  Nor for that matter, have I encountered a fully rational and unbiased clinician.

The work done by Kahneman and Tversky debunks utility theory and replaces it with “prospect theory.”  Kahneman describe this well in his book.  It is incumbent on us to find ways to design the delivery of care in ways that incorporate the insights gained from prospect theory and employs methods that lead to fully informed patient choice.  I think you’ll agree and look forward to your comments.