Medical Decision Making and the Counting of Uncertainty

In economic theory, homo economicus is a concept used to explain decision making as a rational exercise.1 The “economic man,” to use the term often associated with the work of the utilitarian philosopher John Stuart Mills, is someone who makes decisions by carefully weighing the benefits and costs of his or her options and then deciding on a course of action that maximizes his or her utility. Although now considered overly simplistic, this idea is often implicit in how we as clinicians have traditionally approached medical decision making. In the case of statins for the primary prevention of cardiovascular diseases, the choice is frequently framed in terms of the tradeoff between the potential benefit of preventing a future heart attack or stroke (ie, utility) and the side effects and inconveniences of taking a medication (ie, disutility). Thus, the recently released 2013 American Heart Association/American College of Cardiology guideline on the treatment of blood cholesterol reminds us that, in addition to calculating estimated atherosclerotic cardiovascular disease risk to determine statin eligibility, we should engage with patients “in a discussion…to consider the potential for ASCVD [atherosclerotic cardiovascular disease] benefit and for adverse effects, for drug-drug interactions, and patient preferences for treatment.”2 However, although much of the debate over the current guidelines has focused on the accuracy of risk estimation,3,4 the evidence base is limited for how to engage with patients during the decision-making process to assess their disutility for taking statin therapy.Article see p 2539The reason is in part that, although the proportion of patients who report side effects can be measured, it is difficult to assign a numeric value to the aspect of disutility resulting from having to take a medication daily. In this issue of Circulation , Fontana and …