Monday, July 17, 2006

Rational Choice in Medical Treatment

Last week, while I was in the middle of wish week, I read a story about a 16-year-old cancer patient suing for the right to choose his own medical care.

Last year, the teen acquired Hodgkin's Disease. He went through three months of chemotherapy that he found unpleasant. This year, his cancer became active again and he was advised to undergo another round of chemotherapy. The patient instead decided that he would prefer a less harsh treatment from a Mexican clinic that involved a sugar-free organic diet and herbs called the Hoxsey’s Method. His parents are supporting him in his decision. However, social workers are arguing that the minor be forced back into conventional treatment.

Encountering this issue caused me to think back to when I was 16 years old. One of the things that struck me is that I do not recall anybody ever . . . ever . . . explaining to me how medical research works, or how to use medical research to make rational decisions.

Nobody ever said to me as a child growing up, "Here's how the science of medicine works.

"Let's assume that you have come down with the dread disease known as Mung. You want to get better. In order to get better, you have three options available to you.

"Option 1 is to do nothing. Research shows that 90% of those who do nothing will die of the disease. The other 10% will recover.

"Option 2 is to use Treatment A. In our studies of those who use Treatment A, we discover that 90% of them will die as well. The other 10% will recover.

"Option 3 is to use Treatment B. Treatment B has a mortality rate of 15%. However, Treatment B comes with a bunch of unpleasant side effects -- vomiting, hair loss, weight loss, muscle cramps, fatigue, and hiccups.

"Option 4 is to use Treatment C. Treatment C has a 55% mortality rate without all of the side effects."

“Option 5 involves using Treatment D, which has never been tested.”

“Option 6 is to use Treatment E. Those who use Treatment E actually have a 97% mortality rate.”

Please note, with the introduction of Option 5, that anecdotal evidence is worthless. This is the type of evidence that one finds on television commercials where those who made the commercial find a small number of people willing to claim that they have used a product successfully. Even Option 5, in this example, gives a 3% success rate. If 100 people try Option 5, the people creating the commercials will be able to find three people willing to swear by the product on camera to tell you how essential it was to their success.

The other 97 are dead.

Given these options, which do you choose?

The problem with this situation is that scientists speak in a language that many people do not understand. Because people are not taught the language, they find it difficult to use scientific findings to make rational decisions.

Specifically, when it comes to Treatment A, scientists do not say, "We have proved that it does not work." Scientists cannot say that; it would be dishonest. The scientists say, "We have no evidence that it works."

Now, to the average person on the street, there is a whole lot of different between, "We know that it does not work," and "We have no knowledge that it does work." The latter option is consistent with the claim that it does work in ways that we do not know about. Indeed, that is true. The scientists are keeping open the possibility that there are things going on in the universe that they do not know.

In short, scientists have this bad habit of being both honest and humble. So, they say, "We have no evidence that this works."

Way too many people hear this and think, "You don't know whether it works or not. It's a coin toss. This is my life I am talking about. I am willing to gamble for my life. Heck, a coin toss is better than no toss at all, right? Maybe I'll lose; but, at least I will have a chance."

Actually, in Scienceese, "No evidence that Treatment A is effective" means that you have no reason to choose Treatment A. This whole reaction assumes that Treatment A improves the odds of survival. In fact, Treatment A, ex hypothesi, leaves those odds exactly what they were. Objectively, scientifically, no reason exists for choosing Treatment A. If the agent chooses Treatment A, and he claims to have a reason to do so (to increase his chance of survival), then he is mistaken.

To this, the desperate individual might respond, "There is no reason to believe that Treatment A will help, but there is no reason to believe that Treatment A hurts either. You say that I have no reason to take Treatment A. I have no reason NOT to take Treatment A either."

Well, if Treatment A is completely free (if you are not paying somebody $150 for a bottle of pills), and completely easy (you are not spending an hour each day preparing special foods or performing special rituals), and Treatment A does not prevent you from looking for treatments that are actually effective, then this is true. There is no reason NOT to take Treatment A.

Yet, this is almost never true.

In most circumstances, the reason NOT to take Treatment A can be found in the waste of money and time that goes into that which one has no reason to do. If money is involved, there are other possible uses for that money. Even if the agent has no options available to him, a contribution to research so that future generations have more options than those who live at present counts as a reason NOT to take Treatment A.

Another reason NOT to pursue Treatment A is that it promotes a snake-oil industry that draws countless individuals each day down a road that will bring them to an avoidable death or suffering. If these industries were not profitable – as they would not be if individuals paid attention to evidence of usefulness and sound reason – people would make less of an investment in them, and less harm would be done. For a person of good moral character, these would be important considerations.

Now, I have assumed so far that we are talking about an option that has been studied and found no more useful than no treatment at all. What about an option that has not been subject to medical studies?

For any and all afflictions, there are an infinite number of untried cures available. Here are a few:

(1) Holding your breath for one minute 10 times between noon and 1:00 pm may cure your affliction.

(2) Eat 12 raw eggs, one at the top of each hour, throughout the day.

(3) Hang upside down for 15 minutes per day.

(4) Wrap copper wire completely around your body and run through the house with all of the lights on.

If a person is truly desperate for a cure for his illness, and has taken the position that, “If nobody has proved that it does not work, then it is worth trying,” then that is going to be one very busy person. There are always an infinite number of options that have not yet been proved ineffective. Sitting at this computer, I could come up with thousands before the evening is done.

One thing that I can say about all of these untested options is that, if you pick any one, it will tend to have a 10% chance of success – the same odds that you have if you do not treat the illness at all.

Somehow, an individual has to make a choice among the infinite number of options available. A prudent person will look for options that there is actually some reason to accept. The best some reason available is empirical evidence showing that those who use a particular option actually do have a better chance of survival.

Why is it that in this society we do not spend an important part of time in school teaching children these very simple rules for making rational decisions? It is almost as if we do not care whether they live or die; whether they live well or in misery.

3 comments:

Eric said...

And people ask me what harm there is in religion. The harm comes from a lack of basic logic and reason that allow faith to blind otherwise intelligent people to the truth before them. This lack of logic and reason is a breeding ground for not only "good" religion, but the unsavory people as well preying on the weak and the desperate.

This kid should be allowed to refuse treatment if he truly understands what he is doing. If he is doing this because some charlaton has convinced him that this will be a less painful cure than he should be forced to take the chemo.

Martin said...

Alonzo, you never said whether this 16-year-old should be allowed to make his own decision on this matter. Should the government really intervene to keep him from hurting himself? At what age *should* a person be allowed to choose their own medical care? I don't think you're actually saying that people shouldn't be allowed to make stupid decisions, and that seems to be the key point in this news item.

Alonzo Fyfe said...

Martin

You are correct, I did not address that issue. The reason is because I did not want to distract attention from a point that I think is more important. The issue of teaching people how to rationally assess options and make intelligent choices.

I think that answering the question of whether a 16 year old in these circumstances should have the option of choosing his own treatment will have limited social value.

On the other hand, a policy of teaching people (in Junior High and High School) how to intelligently handle issues of risk and uncertainty could have a tremendous social benefit.

So, I sought to argue for a higher standard of education, where training in how to intelligently handle risk and uncertainty is mandatory.

(It would be a fitting topic for the Logic Circles that I wrote about earlier.)

However, I will answer your question this evening (Wednesday, July 19th).

Chris

I hate to say it, but I have seen a great deal of "lack of logic and reason" among atheists as well. I find this among Ayn Rand Objectivists, common subjectivists, and evolutionary moralists.

Now, either these atheists in any one of these camps lack a capacity to see the fundamental logical flaws in their own system, or I and others fail to see the fundamental soundness of their system. Either way, we draw the conclusion that a society full of atheists will also have reason to complain about each other's poor use of reason.