The place of prudence in medical decision making

In the world of practical affairs in general, no less than in the matter of medicalethical decision making, there is place for the possession of the classical virtue of prudence. Most persons involved in making such decisions are interested exclusively in solving a case, and ignore the importance of growing in virtue and character at the same time while having their decision reflect prudential reasoning. A study of the virtue of prudence shows that it is a much misunderstood virtue, and requires deeper penetration into its meaning to grasp its place in humanizing medical decisions.     

An outcomes model of medical decision making

In the traditional fix-it model of medical decision making, the identified problem is typically characterized by a diagnosis that indicates a deviation from normalcy. When a medical problem is multifaceted and the available interventions are only partially effective, a broader vision of the health care endeavor is needed. What matters to the patient, and what should matter to the practitioner, is the patient's future possibilities. More specifically, what is important is the character of the alternative futures that the patient could have and choosing among them so as to achieve the best future possible, with the ranking of outcomes determined by the patient's preferences. This paper describes the fix-it model, presents and defends the outcomes-based model, and demonstrates that the latter is useful in developing normative conceptions of informed consent and decision making and in establishing a basis for societal involvement in the decision making process. Finally, several shortcomings of the model will be acknowledged.     

The current environment for medical decision making: Alternative efficiency concepts and decision motivation

Health services delivery is rapidly changing in the U.S. and along with it the incentives and motives for making decisions about the use of services. This paper discusses the economic criteria for making good decisions from both individual and social perspectives. The position is taken that individual criteria for decision-making efficiency in health services is quite different from social efficiency criteria but the two perspectives can be viewed as complementary. These criteria are used to examine current developments in health services, including aggressively competitive managed care. The analysis concludes that current directions may be in conflict with both social and individual efficiency. Alternative public policies are required to alter motives and incentives such that decisions better meet the complementary efficiency criteria.Originally prepared for presentation at the Annual Meeting of the American Association for the Advancement of Science, Atlanta, Georgia, February 17, 1995, as part of the symposium Cognitive Interpersonal, and Societal Influences on Medical Decision Making (A. M. Isen and B. S. Moore, Chairs).     

Subjective decision making in medical school admissions: Potentials for discrimination

Medical schools place considerable emphasis on admissions interviews in the selection of students. Interviews, with unwritten performance criteria and subjective evaluation, contain the potential for unconscious discrimination against certain groups of applicants. This study investigates the contribution of interview scores to the total evaluation of male and female applicants for admission to one medical school in the United States. Findings reveal that interveiw scores are counted more heavily for females than males in arriving at a final ranking for admission. Further, females were rated lower in general than males on interview evaluations. While the magnitude of the associations is small, the combined effect points to a potential for discrimination, however unintended, against women applicants in the present case study.The authors appreciate the valuable criticisms of and comments on an earlier draft from Drs. Sidney Fleming, Dorothy Brinsfiled, Glenn Clark, Maurice Jurkiewicz, and Michael Kutner, some of whom may still take exception to parts of this article.     

Knowledge management in decision making and decision support

A knowledge-oriented view of decisions and decision making is introduced, as a complement to classical perspectives and as a contribution of under-standing computer-based possibilities for relaxing strains on decision makers. This perspective includes a model of knowledge management activities performed by a decision maker and a taxonomy of knowledge types. It leads to a characterization of decision-support-system purpose, traits, and potentials that offers a basis for new research into computer-based possibilities for knowledge management. Clyde W. Holsapple holds the Rosenthal Endowed Chair in Management Information Systems and is Professor of Decision Science and Information Systems at the College of Business and Economics, University of Kentucky.     

Preferences for involvement in medical decision making: comparing British and German views

Despite beneficial outcomes of patients' involvement in medical decision processes, it has been claimed that patients are generally not interested in medical decision making (MDM). Whereas current research focuses on actual MDM, this research explored the impact of nationality and perceptual processes of MDM. Preferences for involvement in decision making were examined in a sample of 204 German and 143 British university students. Hierarchical multiple regressions were employed to explore the link between socio-demographic information, individuals' perceived relationship with their GP, Health Locus of Control - Powerful Others, perceptions regarding the frequency and sufficiency of information provision and involvement in MDM, and individuals' preferred level of involvement and information. A significant amount of the variance in individuals preferences for involvement could be explained (Adjusted R2 = .59, p < .001). Independent t-test analyses showed that British and German perceptions of care differed significantly on a variety of different measures. Separate analyses for the German and British group highlighted cross-national differences in care and preferences for involvement. The study suggests that preferences to become involved might depend more on perceptual processes than actual involvement in decision making, and that communication and national health policy could play an important role.     

Numeracy and decision making

A series of four studies explored how the ability to comprehend and transform probability numbers relates to performance on judgment and decision tasks. On the surface, the tasks in the four studies appear to be widely different; at a conceptual level, however, they all involve processing numbers and the potential to show an influence of affect. Findings were consistent with highly numerate individuals being more likely to retrieve and use appropriate numerical principles, thus making themselves less susceptible to framing effects, compared with less numerate individuals. In addition, the highly numerate tended to draw different (generally stronger or more precise) affective meaning from numbers and numerical comparisons, and their affective responses were more precise. Although generally helpful, this tendency may sometimes lead to worse decisions. The less numerate were influenced more by competing, irrelevant affective considerations. Analyses showed that the effect of numeracy was not due to general intelligence. Numerical ability appears to matter to judgments and decisions in important ways.     

Decision making styles and progress in occupational decision making

This study provides a reexamination of the role of different decisional strategies in facilitating progress in occupational decision making. Although the assumptions that a rational decision making style is the preferred mode of vocational functioning has been endorsed in a variety of career theories and interventions, there has been conflicting evidence about the validity of this assumption. To examine the role of different decisional approaches in the progress of making an occupational decision, the rational, intuitive, and dependent decision making style scores of 71 undergraduate students were used to predict progress in occupational decision making. The results of the regression analyses failed to provide support for the assumption that a rational style is the most effective in accomplishing this careerrelated task, but indicated strong support for the conclusion that the use of dependent decisional strategies is damaging, particularly in early stages of the decisional process.     

Group decision process and incrementalism in organizational decision making

In two studies examining resource allocation, support is found for the notion that group decisions are affected in systematic ways depending on whether or not there was individual consideration of the problem before meeting as a group. Specifically, compared to no prior consideration groups, prior consideration groups (1) escalate their commitment more in progress (i.e., ongoing) decisions, and (2) are less willing to concentrate resources on a single project in adoption (i.e., resource utilization) decisions. The findings challenge the blanket assertion that promoting divergent views in a group decision context is always related to better decisions.     

Computer-augmented decision making

The principal judgmental components of multiattribute decision making are examined here with specific reference to how these components can be captured electronically. Once captured, a function, rule, or algorithm may be executed for the integration of this information and the selection of the optimal alternative(s). Two kinds of algorithms are discussed: one based on linear models, the other on fuzzy-set theory and ratio scaling. With on-line support and certain assumptions about human biases (which lead to nonoptimal decisions), the quality of decisions can be enhanced considerably. The principal concerns are with end-user acceptance of computer augmented decisions.     

Time and decision making in humans

Decision making requires evaluating alternatives that differ on a number of attributes. During this evaluation process, selection of options depends on the duration of the options, the duration of the expected delay for realizing the options, and the time available to reach a decision. This article reviews the relationship between time and decision making in humans with respect to this evaluation process. Moreover, the role of psychological time, as compared with physical time, is accentuated. Five topics have been selected that illustrate how time and mental representations of time affect decision making. These are (1) the duration of options, (2) temporal decision making, (3) the time between having made a decision and experiencing the consequences of that decision, (4) the temporal perspective of decision makers, and (5) the duration of the decision process. The discussion of each topic is supplemented by suggestions for further research. It is shown that psychological time is often neglected in human decision making but seems to play an important role in the making of choices.     

Counterfactual thinking and decision making

Recent research on counterfactual thinking is discussed in terms of its implications for decision making. Against a backdrop of the functional benefits of counterfactual thinking, two distinct types of bias, one liberal and one conservative, are discussed. Counterfactuals may cause decision makers to become liberally biased (i.e., capricious) in terms of tactics, but conservatively biased (i.e., rigid) in terms of long-term strategy. That is, counterfactuals may lead to short-term corrective changes that are needless and costly, but they may also lead to long-term overconfidence, blinding the decision maker to possible beneficial strategic adjustments. Recent research on counterfactual thinking, which is inherently multidisciplinary, is reviewed in light of a theoretical structure that posits two mechanisms by which counterfactual effects occur: contrast effects and causal inferences.