Rational decision making in medicine: 'Personal decisions are the leading cause of death'

5 September, 2019

Dear HIFA colleagues,

I was interested to learn about this paper thanks to Benjamin Djulbegovic, a member of the Evidence-Based Health forum, which is currently having an interestinng discussion on the impact of evidence-based medicine. https://www.jiscmail.ac.uk/cgi-bin/webadmin?A0=EVIDENCE-BASED-HEALTH

In the introduction to the paper the authors note: 'It has been contended that personal decisions are the leading cause of death and that physicians' decisions are responsible for 80% of health care expenditures.' A previous paper Personal Decisions Are the Leading Cause of Death (2008) argues this case: https://pdfs.semanticscholar.org/375e/8c9e3df49a7962d12bb186a4ec7dc7d2b3... The paper looks especially at personal decisions by the general public, and especially lifestyle decisions. But it would be interesting to assess the contribution of decisions by individuals/families not only in relation to lifestyle decisions, but also in response to illness and injury (leading, for example, to delayed seeking of health care for a sick child). A further are of inquiry would eb to ask: what is the contribution of decisions by health workers (including decisions on diagnosis and treatment) to avoidable death and suffering? Is anyone familiar with any research on this topic?

Citation and abstract and a comment from me below.

CITATION: J Eval Clin Pract. 2018 Jun; 24(3): 655–665.

Published online 2017 Dec 1. doi: 10.1111/jep.12851

PMCID: PMC6001794

PMID: 29194876

Rational decision making in medicine: Implications for overuse and underuse

Benjamin Djulbegovic, MD, PhD, Professor,corresponding author 1 , 2 Shira Elqayam, MA, BA, PhD, Professor, 3 and William Dale, MD, PhD, Clinical Professor and Arthur M. Coppola Family Chair, Associate Director for Social Sciences, Center for Cancer and Aging 1


In spite of substantial spending and resource utilization, today's health care remains characterized by poor outcomes, largely due to overuse (overtesting/overtreatment) or underuse (undertesting/undertreatment) of health services. To a significant extent, this is a consequence of low-quality decision making that appears to violate various rationality criteria. Such suboptimal decision making is considered a leading cause of death and is responsible for more than 80% of health expenses. In this paper, we address the issue of overuse or underuse of health care interventions from the perspective of rational choice theory. We show that what is considered rational under one decision theory may not be considered rational under a different theory. We posit that the questions and concerns regarding both underuse and overuse have to be addressed within a specific theoretical framework. The applicable rationality criterion, and thus the “appropriateness” of health care delivery choices, depends on theory selection that is appropriate to specific clinical situations. We provide a number of illustrations showing how the choice of theoretical framework influences both our policy and individual decision making. We also highlight the practical implications of our analysis for the current efforts to measure the quality of care and link such measurements to the financing of health care services.

COMMENT (NPW): If personal decisions (whether by individuals or by health workers) are the leading cause of death, how might such decisions be improved? In low-resource settings, where reliable and relevant healthcare information may not be available (or where misinformation prevails), empowering individuals with such information would be a key enabler of rational decision-making and positive health outcomes.

Best wishes, Neil

Coordinator, HIFA Project on Evidence-Informed Policy and Practice


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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - www.hifa.org ), a global community with more than 19,000 members in 177 countries, interacting on six global forums in four languages. Twitter: @hifa_org FB: facebook.com/HIFAdotORG neil@hifa.org