There Is More to Life Than Death — NEJM

A good piece by Pamela Hartzband and Jerome Groopman, and medical decision-making, risk, and choice, the related uncertainties related to quality of life, and that quantification has its limits. Quote:

Daniel Kahneman, the cognitive psychologist and Nobel laureate, in addressing a meeting of medical decision analysts, likened efforts to quantify the experience of illness using these methods to the attempts of 19th-century physicists to measure the viscosity of the ether, which of course did not exist.1 Yet these methods, though flawed, are widely used. In Britain, the National Institute for Health and Clinical Excellence (NICE) asks healthy British citizens to use such methods to assess what their lives would be like were they to become sick. NICE then uses the information to set priorities about screening tests and treatments for the National Health Service. In the United States, in the wake of health care reform, the same methods are being proposed as ways to calculate the cost-effectiveness of various treatments and decide what is worth paying for. For example, an expert committee of the American College of Physicians recently issued a position paper based on the use of the time-tradeoff method for calculating quality-adjusted life-years (QALYs) and recommended a price of $65,000 per QALY as the cutoff for reimbursement.

Paul Slovic, a leading researcher of risk, has pointed out that “when experts judge risk, their responses correlate highly with technical estimates of annual fatalities.” He adds, however, that risk means much more to most people than simply numbers of deaths. “Their conceptualization of risk is much richer than that of the experts and reflects legitimate concerns that are typically omitted from expert risk assessments.”

Basing decisions on the outcome of death ignores vital dimensions of life that are not easily quantified. There are real complexities and uncertainties that we all, patients and physicians alike, confront in weighing risk and benefit. Wrestling with these uncertainties requires nuanced and individualized judgment. It is neither ignorant nor irrational to question the wisdom of expert recommendations that are sweeping and generic. There is more to life than death.

There Is More to Life Than Death — NEJM.


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