Willingness to assume vaccination risk

[Guest guest]

Article discusses a paper that surveyed the general public regarding its

opinions about

uptake of a controversial vaccine. Willingness to assume risk depended on

whether the

survey respondent was considering the choice from the perspective of a patient

(48%

would take vaccine) or as a physician (73% would recommend that others take the

vaccine).

Vicky

http://www.nytimes.com/2006/06/20/health/20docs.html?

ex=1151640000 & en=6a762c52e2ce1fea & ei=5070

June 20, 2006

In Medicine, Acceptable Risk Is in the Eye of the Beholder

By NICHOLAS BAKALAR

The situation is imaginary, but the dilemma it illustrates is quite real. A

deadly influenza

moves across the world from Asia, finally arriving on our shores.

There is no cure, and your doctor tells you that you have a 10 percent chance of

dying

from it. An effective vaccine is widely available, made from a weakened form of

the virus.

But it has an unfortunate side effect: there is a 5 percent chance that a

patient will die

from the less serious form of the flu it can cause.

Would you take the vaccine, or take your chances? What would you have your

children do?

If you were a doctor, would you tell a patient to get the shot? If you were the

head of a

large hospital, would you order the vaccine for all patients?

Judging by the numbers alone, there is a clear answer to this hypothetical

problem: a

person is much better off taking the vaccine. But people do not always arrive at

health

decisions by applying mathematical models, and in some cases the numbers may be

less

important than other considerations.

In a new study published in the June issue of the Journal of General Internal

Medicine,

researchers found that the answer depended on which role the person was asked to

assume. Only 48 percent of the participants said they would take the vaccine

themselves.

But 57 percent said they would give it to their children; 63 percent said that

if they were

doctors they would give it to patients; and 73 percent said that if they were

the medical

director of a hospital they would recommend the vaccine for all patients.

The risks were the same for everyone, so there was no logical reason to

recommend the

vaccine in some situations but not in others. Yet the more distant the patient,

the more

likely people were to recommend the vaccine.

" Researchers have found these biases before, " said Dr. A. Ubel, the

study's senior

author and a professor of medicine at the University of Michigan.

" People hate the risk of bringing bad things on themselves, " Dr. Ubel said, " but

a sense of

responsibility makes them overcome these instincts to think about what's best

for others. "

He added, " That may be what makes doctors feel so strongly about recommending to

patients what they ought to do. "

Dr. A. Redelmeier, a professor of medicine at the University of Toronto

who was

not involved in the study, said, " What's intriguing is that these people are

sometimes

unaware of the extent to which their opinions can be changed by the way the

question is

posed. "

Doctors and their patients face choices much more confusing than the fictional

vaccine

problem described in Dr. Ubel's study. Determining the risks and benefits of

prostate

cancer diagnosis and treatment, for example, presents a series of decisions that

must be

made with only partial information. A positive result on the P.S.A. screening

test does not

distinguish between a fatal cancer and one that will be asymptomatic, so the

patient is left

to choose either no treatment or any of a number of different procedures that

have varying

degrees of effectiveness and unpleasant side effects.

Should a patient get the P.S.A. screening test in the first place? If the

screening test is

positive, should he get a treatment that may or may not be effective, or even

necessary,

and that may or may not have serious side effects, like incontinence and

impotence?

Even a fairly sophisticated patient with an understanding of all the risks and

benefits

would be hard put to reach a satisfactory answer.

In a paper published in the June issue of PLoS Medicine, Dr. Jerome R. Hoffman

says using

illustrations is helpful. Pie charts, dartboards and, best of all, roulette

wheels, he suggests,

communicate the complex information about the probability of a good outcome more

understandably.

Most doctors want patients to be fully informed and then to make their own

decisions —

the paternalistic " doctor knows best " model no longer predominates.

Yet, said Dr. Appelbaum, a professor of psychiatry at Columbia, doctors may

be going

too far in their zeal to present only the facts.

" Physicians who place emphasis on informed consent have mistakenly come to see

this as

a process in which they play only a neutral role, " Dr. Appelbaum said, " and not

the role of

someone who gives advice as well. Yet patients who value the information often

value the

advice, too, and that seems to me a very proper role for a physician to play. "

http://www.blackwell-synergy.com/doi/abs/10.1111/j.1525-1497.2006.00410.x

Journal of General Internal Medicine

Volume 21 Page 618 - June 2006

doi:10.1111/j.1525-1497.2006.00410.x

Volume 21 Issue 6

A Matter of Perspective: Choosing for Others Differs from Choosing for Yourself

in Making

Treatment Decisions

J. Zikmund-Fisher, PhD1,2,3, na Sarr, BS2,3, Fagerlin,

PhD1,2,3, A.

Ubel, MD1

BACKGROUND: Many people display omission bias in medical decision making,

accepting

the risk of passive nonintervention rather than actively choosing interventions

(such as

vaccinations) that result in lower levels of risk.

OBJECTIVE: Testing whether people's preferences for active interventions would

increase

when deciding for others versus for themselves.

RESEARCH DESIGN: Survey participants imagined themselves in 1 of 4 roles:

patient,

physician treating a single patient, medical director creating treatment

guidelines, or

parent deciding for a child. All read 2 short scenarios about vaccinations for a

deadly flu

and treatments for a slow-growing cancer.

PARTICIPANTS: Two thousand three hundred and ninety-nine people drawn from a

demographically stratified internet sample.

MEASURES: Chosen or recommended treatments. We also measured participants'

emotional response to our task.

RESULTS: Preferences for risk-reducing active treatments were significantly

stronger for

participants imagining themselves as medical professionals than for those

imagining

themselves as patients (vaccination: 73% [physician] & 63% [medical director] vs

48%

[patient], Ps<.001; chemotherapy: 68% & 68% vs 60%, Ps<.012). Similar results

were

observed for the parental role (vaccination: 57% vs 48%, P=.003; chemotherapy:

72% vs

60%, P<.001). Reported emotional reactions were stronger in the responsible

medical

professional and parental roles yet were also independently associated with

treatment

choice, with higher scores associated with reduced omission tendencies (OR=1.15

for both

regressions, Ps<.01).

CONCLUSIONS: Treatment preferences may be substantially influenced by a

decision-

making role. As certain roles appear to reinforce " big picture " thinking about

difficult risk

tradeoffs, physicians and patients should consider re-framing treatment

decisions to gain

new, and hopefully beneficial, perspectives.