DISCUSSION OUTLINE: DESCRIPTIVE/PRESCRIPTIVE/NORMATIVE INTERACTIONS IN MEDICAL DECISION MAKING

Issues relating to values and preferences

Valued consequences that are typically reflected in formal models of medical decision making include the following:

• survival (length of life)

• quality of life

• symptoms

• physical function

• social function

1. Are preferences regarding these attributes fixed or labile? How do they change with age, physical status, mental status, interactions with physicians? Prescriptively or normatively, how does one deal with the existence of “multiple selves”? Is the prescriptive solution more complicated than just trying to assess the uncertainty about future preferences, and then take expectations across all possible future utility functions? If perfectly or imperfectly knowable, should future preferences substitute for present preferences in decisions with future consequences?

Examples: labor and anesthesia (Christensen–Szalanski)

smoking and addictive behaviors

myopia, ignorance, or uncertainty about old age

euthanasia (Schelling)

1. Are some preference functions normatively “better” than others? When is it appropriate for the physician to intervene to try to change patients' preferences?

2. What are the ethical implications for informed consent?

Example: a couple's desire to have a baby at home, under the care of a midwife

1. Issues in assessing utilities for health outcomes: Assuming that preferences are stable and measurable, what is the best way to measure them? While proper von Neumann–Morgenstern utility functions may be the prescriptive goal, are there other means to that end that are more reliable or acceptable than using lottery techniques, e.g., category scaling, magnitude estimation? […]