CAERS SUBSTACK ARTICLE #33
CAERS SUBSTACK ARTICLE #33
Everyday each of us makes countless decisions; some are very important (should I ask this person to marry me?) and some are less important (should I have toast or cereal for breakfast this morning?). By definition a decision involves freely choosing between at least two options, and most of the time the options are not exactly identical. Each choice will differ from the others in both the degree of benefit as well as the degree of cost or harm. We may prefer a fancy car but of course it is likely to cost more. Although we may find skydiving more exhilarating than watching a good movie, the potential for harm is greater with the former than the latter.
To complicate matters, not infrequently we do not know the exact likelihood of the ensuing benefit or harm. The various outcomes, good and bad, all have mere probabilities of occurring, and we do not always know for certain what the odds are in advance. In other words, because every decision we make requires weighing incompletely-known probabilities of benefit and harm, every decision involves taking risks.
That means that we cannot avoid risk, we can only manage it. Beware of promises of outcomes that seem ‘too good to be true’ because such promises often minimize the reality that all decisions involve a non-zero level of risk. We all have varying comfort levels for risk depending on the circumstances; sometimes we are very risk-averse, and other times we are more risk- tolerant. We are more likely to make decisions with which we are satisfied if we take the time to reflect more deeply on the potential for benefit and harm by being more discerning, and by balancing the likelihoods carefully.
Of course, there are usually time limitations in most cases of decision-making; someone proposing marriage usually develops reservations the longer their significant other takes to respond. As they say, waiting for the perfect mousetrap means you might get overrun by the mice.
Risk is important to consider when it comes to health care. Every medical decision made by a patient requires that they carefully weigh and balance the degrees of benefit and harm, as well as the likelihoods of both. When using the process of consent (capacity, disclosure, voluntariness), the better we disclose relevant information to the patient, the better they can weigh all of the relevant factors to find their comfort level for risk. In addition, we assume, unless proven otherwise, that each individual has the capacity to choose, and we try to guarantee voluntariness so that every decision is one that is truly freely chosen (a choice forced on someone is not really a decision for them).
In other words, each patient, provided that they demonstrate the ability to understand and appreciate the clinical situation (capacity), has the right to accept whatever risk they desire in any particular medical scenario. They will live with the outcomes, good and bad, not us. This is true even if we disagree with their decision; even if we think they are being foolish. There is no ideal level of risk by which we all must abide.
There is, of course, one caveat: all individuals living within a society must consider how the risks they are willing to take might impact others. Equally, the collective must factor in the consequences of their decisions on each individual within the collective. This is the essence of rights and obligations as discussed in Article #30 (‘Rights and Obligations’). Such a balance often requires much sober discernment; it is not something that should be based purely on emotion. That’s where ethics enters the picture: in light of the risks that each of us takes many times a day, how do we balance the rights and obligations of any individual and those of the collective? (In particular see Article # 2, ‘Medical Mandates,’ and Article #7, ‘Freedom, Democracy and Ethics’.)
This issue of risk has been of central importance during the pandemic. Have we understood that risk is unavoidable with every decision we make? That risk involves a spectrum from very low to very high? How do we manage risk individually and as a collective? How do we know that we are making the best decisions?
An obvious question might be, when we say that we ‘know’, what does that mean? That’s the topic of my next article.
J. Barry Engelhardt MD (retired)
MHSc (bioethics) CAERS Health Intake Facilitator
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