Peter Schwartz, MD PhD, director of the IU Center for Bioethics and Professor of Medicine and Bioethics at IU School of Medicine, presented at Bioethics Grand Rounds last week. He focused on how to evaluate patient decision-making and the somewhat elusive measurement of decision quality. Find the recording of the talk here. Schwartz’s talk not only informed but also gave some philosophical questions about the epistemological nature of decision-making. The following is my summary of his talk and some of my reflections.
Schwartz began by describing the emergence of medical decision-making in light of the development of Modern Bioethics in the 1960s. As anti-paternalism sentiment emerged alongside the framework of respect for persons and autonomy, one area of major study was medical decision-making. Original models focused on a two-actor setting: the clinician, who brings technical expertise and can convey key information, and the patient, who brings values and then chooses one optimal option.
Considering the many limitations of this model, including limited time for patient visits and the complexity of the decision, work has been done to create decision aids to help physicians and patients partner in this process. The question then arises: how can we know and measure the success of these interventions? Or, as Dr. Schwartz questions, is it reasonable to think we can develop a measure to assess decision quality?
He highlights that the three main measurement types for decision quality – subjective, observational, and concordance – all have their uses and, more importantly, their limitations. For example, points may be attributed to the length of a visit and merit longer conversations. However, a good decision may be made quickly if there is a good relationship between the physician and the patient. Some scales give points for lowering the uncertainty of a decision which may be a poor measure of difficult decisions where a hard choice is not necessarily a bad choice.
He concludes that no measurement, or combination of measurement tools, of decision quality is sufficient to assess decisions. Comparable to assessing quality of life, it seems unfair to think of quality as a single entity. Rather, it may make more sense to think of buckets of quality – such as good, satisfactory, or bad – rather than attempt to quantify the quality itself.
Schwartz indicates that the focus should shift from attempting to quantify decision quality to identifying and addressing problematic decision-making. In other words, we should focus on finding problems and addressing them rather than seeking to score everything empirically. Bringing the discussion back to classical bioethics, he ends by arguing that justice cannot and should not be understood through an overall justice value. Rather, we should try to reduce conditions that contribute to injustice in decision-making.
As I reflect on his talk and think about my future career in medicine, I begin to think of how I can apply this framework from a provider standpoint. Medicine is not an objective practice no matter how often standardized exams may make it feel this way. When there is no clear best choice, when shared decision-making should shine, a physician must truly turn his or her full attention to the patient before them. Rather than serving as a repository of information alone, physicians should seek to understand patient’s values and share information in that light.
This is not an easy task to accomplish, especially considering the business-minded healthcare practices we live in. But it is what physicians owe to their patients. Just as Schwartz argues that decision quality must be understood by looking at individual conditions that contribute to injustice, physicians must train to see these barriers themselves.
This is a lofty goal and one that in many ways requires a shift in the philosophy of medicine. While this change should happen on institutional levels, individual physicians can impact value in this space in each decision they share with their patients. Check out Schwartz’s thought-provoking talk here and check back to this blog and the IU Center for Bioethics for more!
