Life Cannot Be Reduced To Numbers
Janice, a 43-year-old woman who religiously has a mammogram every year, heads to the doctor for her annual physical. As always, Janice asks the physician for a mammogram order so she can make her screening appointment. But this year, Janice is met with resistance. "Haven't you heard about the new recommendations?" her doctor inquires. "Mammograms for women in their 40s bring no benefit that outweighs the harm that can occur from false positives." Janice is stunned. "But what if I'm willing to take the chance that harm will occur in order to possibly detect something real?" Janice feels unheard and disrespected in her ability to make her own health care choices.
Who is right in this situation? Does the doctor know best? Is the doctor conducting ethical practice by following the recommendations of expert groups about when to recommend mammograms? Or does Janice have the right to request a mammogram even if it goes against best practice recommendations?
Situations like this one will only become more common as several expert groups have put forth more conservative recommendations regarding the administration of tests such as colonoscopies, electrocardiograms, and even routine physicals. And this will make the delivery of health care even more complex and challenging as group sanctions are balanced with individual values and needs.
Interestingly, the process of medical decision making first began with an 18th century mathematician, Daniel Bernoulli, who came up with a formula to determine a "best choice" in a situation. The formula entailed multiplying the probability of an outcome by the outcome's impact, or utility. For instance, the probability of a mammogram detecting a tumor multiplied by the usefulness, or impact, of finding the tumor, would result in what Bernoulli called "expected utility."
For a long time, Bernoulli's formula was mainly used to make economic decisions. Little did he know that it would be imported into the medical field to make decisions about life and death.
While decision analysis is an important part of medical care, there are a couple of problems with quantifying monumental health care decisions such as whether or not to undergo a cancer screening. While the application of broad mathematical brush strokes may be needed to generate societal standards, the individual often gets lost in the process.
Take the example above, in which Janice wants a mammogram. Isn't Janice really the only one who knows whether, for Janice, the possibility of detecting a treatable cancer early is worth more than the anxiety and anguish of going through a biopsy because of a false positive result? For a man at risk of prostate cancer, which is worse (or better) - the pain and severe urinary complications that result from advanced prostate cancer, or the impotence and related symptoms that accompany the treatment of this cancer in its early stages? Again, only that man can answer such a question - not a mathematical formula.
Numbers can be beautiful, and they clearly have their place in modern medicine. But constructs like pain, dignity, comfort, fear, and peace of mind cannot be reduced to algorithms, nor should they be. Each patient sitting in a doctor's office must be considered distinctive, with his or her individual characteristics shining in the foreground, with the numbers and their implications serving as a helpful backdrop.
Hartzband, P., & Groopman, J. (2012). There is more to life than death. New England Journal of Medicine, 367, 987-989.