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Disclosure and rationality: Comparative risk information and decision-making about prevention

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Abstract

With the growing focus on prevention in medicine, studies of how to describe risk have become increasing important. Recently, some researchers have argued against giving patients “comparative risk information,” such as data about whether their baseline risk of developing a particular disease is above or below average. The concern is that giving patients this information will interfere with their consideration of more relevant data, such as the specific chance of getting the disease (the “personal risk”), the risk reduction the treatment provides, and any possible side effects. I explore this view and the theories of rationality that ground it, and I argue instead that comparative risk information can play a positive role in decision-making. The criticism of disclosing this sort of information to patients, I conclude, rests on a mistakenly narrow account of the goals of prevention and the nature of rational choice in medicine.

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Notes

  1. There are various terms used for the two kinds of information discussed here. “Personal risk” [4] information is sometimes labeled “absolute risk” [2] or “objective risk” [1] information. “Comparative risk” [5] information is sometimes called “social comparison risk” [1, 4] or “relative risk” [2] information.

  2. QALYs and utilities may be more easily measured for a group, such as a population, rather than for individuals. But many normative accounts of decision-making assign utilities to outcomes for specific individuals as well [12], as I will do here.

  3. Here, I will assume that “maximizing” involves simply choosing the action with the largest expected utility. Assuming a different way of comparing outcomes, such as satisficing, fails to support the argument against comparative risk information, as discussed in Section “Conclusion: The purpose of disclosure.”

  4. These possibilities are listed as the outcomes of having the disease or not, rather than the event of getting the disease or not, since utilities are attached to outcomes rather than events.

  5. To be precise, the utility of an outcome is also best estimated for a specific time period, but I will ignore this complication in this discussion.

  6. I have assigned the utilities to the two women for the purpose of illustration, so these values should not be assumed to be accurate for any actual people.

  7. I am thankful to an anonymous reviewer for suggesting the following case, where comparative risk information may also improve decision-making. Consider a woman with above average risk who is reluctant to undergo treatment with tamoxifen since she doesn’t know anybody else who is taking the medication. In this case, telling her that her risk is above average may help counteract her reluctance—which is irrational on the basis of expected utility theory—by explaining why she is different from other women she knows.

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Acknowledgments

The author wishes to thank Erik Angner, Aaron Carroll, Meg Gaffney, Fred Gifford, Harold Kincaid, William Stempsey, John Tilley, and, especially, Eric Meslin for comments and encouragement. Thanks also to two anonymous reviewers for Theoretical Medicine and Bioethics and to an audience at a conference on Philosophy of Medicine at the University of Alabama, Birmingham, in April 2008. This work was partially supported by a grant to the Indiana University Center for Bioethics from the Richard M. Fairbanks Foundation.

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  1. Indiana University Center for Bioethics, Indiana University School of Medicine, Indiana University – Purdue University, Indianapolis (IUPUI), 410 W. 10th St., Suite 3100, Indianapolis, IN, 46202, USA

    Peter H. Schwartz

  2. Indiana University Center for Bioethics, Indiana University School of Liberal Arts, Indiana University – Purdue University, Indianapolis (IUPUI), 410 W. 10th St., Suite 3100, Indianapolis, IN, 46202, USA

    Peter H. Schwartz

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Schwartz, P.H. Disclosure and rationality: Comparative risk information and decision-making about prevention. Theor Med Bioeth 30, 199–213 (2009). https://doi.org/10.1007/s11017-009-9111-7

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