I recently woke up on a Sunday morning to a flat tire. Although I was able to install the spare tire (were the lugnuts this tight when I was younger?) and plan to have the flat fixed at the service station in town during the work week, we had some decisions to make about using the car without a spare tire. When my spouse asked if the car was OK to drive to get groceries in town a mile away, I said there was no problem. Later in the day when we wanted to visit some friends 45 minutes away, we decided we should not use the car for that. Our decision lay in our personal tolerance for risk and reminded me of the ever-present similar calculations we and our patients have been making about COVID-19.
Let’s break down the flat tire problem and then I’ll apply it to risk assessment in disease. Risk of harm is never taken in isolation but rather as a larger assessment in the context of a benefit. With our flat tire, the primary risk was that if we got another flat tire (albeit a low probability event), we wouldn’t have a spare to get us back on the road. A trip to a nearby grocery store probably wouldn’t leave us stranded, but for a flat 25 miles from our house, the consequences would be more significant. We would likely have to have the car towed to a service station where on a Sunday we may not be able to have the tire fixed or replaced. At the same time, the benefits of getting groceries were significant – we had nothing for lunch or dinner for the week. Seeing friends, while lovely, was lower down on our Maslow’s hierarchy of needs. For us at that particular time, the harms to benefits ratio clearly favored feeding our family but not for seeing far-away friends.
Harms vs Benefits
The key to understanding our decision (which may have been different than yours) was by recognizing the ratio of the potential harms and benefits, not simply thinking of them in isolation.
Changing some of the conditions also could have changed the calculus of the relative harms and benefits and therefore our decision. What if the spare tire I had installed had no tread left and it was snowing out? What if we decided that the probability of getting another flat was remote? What if rather than visiting friends, we wanted to see a family member we had not seen in 2 years because of COVID-19? Our dynamic appreciation of those harms and benefits affects our willingness to use the car without a spare.
This is where the ethical principle of proportionality can help us understand both how to make hard decisions as well as how our patients make them. People weigh not just the absolute risks of harm or benefit, but whether or not they are proportional. Large risks of harm are generally balanced by large potential benefits. The risks of dialysis are acceptable to patients because of the tremendous benefit of life-saving treatment. The risks of a ureteroscopy for a patient with significant pain from a ureteral stone are often acceptable to both patient and surgeon if it promotes the promise of better and faster pain control.
At the time of this writing, both the new case and death rate from COVID-19 are rising, likely from the Omicron variant, the holiday season, and persistent lower vaccination rates in some communities. Your patients might be asking if they should get vaccinated now. From a medical perspective, the answer has always been an unqualified yes, but if we try to understand the patient’s appreciation of the harms and benefits (and their ratio to one another), it might become easier to understand why they have previously chosen not to get vaccinated. When patients decline vaccination, they may have a different appreciation of what is considered a harm or a benefit. They may not believe reducing their risk of hospitalization or death from COVID-19 or that contributing to reducing the risk of hospitals becoming overwhelmed are significant benefits, especially in light of their appreciation of the risks of vaccination. When the proportionality condition is not met for them, they may be less likely to be vaccinated. How do we manage this problem?
Ultimately, patients’ health care decisions stem from their appreciation of harms and benefits and their relationship to one another, even if they have not considered or articulated them explicitly. The clinician can help by eliciting the patient’s understanding of both the harms and benefits and how they relate to one another. Asking how the risks and benefits could change based on new information can help to isolate the inflection point in their decision-making. “OK, so you’re saying that if the risk of serious bleeding were lower, you would be willing to consider the operation?”
Help Patients Articulate Thoughts and Beliefs
Although it may be difficult to change the mind of patients with firmly held beliefs, at least helping them to articulate their thoughts and beliefs can open the door to more effective counseling. When patients are able to articulate their beliefs, it can help them move from making what may have been an unconscious choice into a conscious one: Clinicians can work with conscious choices much more easily. In the best-case scenario, this might help them change their mind. In other situations, simply improving the transparency of the decision provides a roadmap for future discussions and reduces clinicians’ distress when patients make choices that don’t necessarily promote their health.
David J. Alfandre, MD, MSPH, is a health care ethicist and an associate professor in the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the VA National Center for Ethics in Health Care or the US Department of Veterans Affairs.