Djulbegovic Benjamin, Elqayam Shira
Program for Comparative Effectiveness Research, University of South Florida, Tampa, FL, USA.
Department of Internal Medicine, Division of Evidence-based Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
J Eval Clin Pract. 2017 Oct;23(5):915-922. doi: 10.1111/jep.12788. Epub 2017 Jul 20.
Given that more than 30% of healthcare costs are wasted on inappropriate care, suboptimal care is increasingly connected to the quality of medical decisions. It has been argued that personal decisions are the leading cause of death, and 80% of healthcare expenditures result from physicians' decisions. Therefore, improving healthcare necessitates improving medical decisions, ie, making decisions (more) rational. Drawing on writings from The Great Rationality Debate from the fields of philosophy, economics, and psychology, we identify core ingredients of rationality commonly encountered across various theoretical models. Rationality is typically classified under umbrella of normative (addressing the question how people "should" or "ought to" make their decisions) and descriptive theories of decision-making (which portray how people actually make their decisions). Normative theories of rational thought of relevance to medicine include epistemic theories that direct practice of evidence-based medicine and expected utility theory, which provides the basis for widely used clinical decision analyses. Descriptive theories of rationality of direct relevance to medical decision-making include bounded rationality, argumentative theory of reasoning, adaptive rationality, dual processing model of rationality, regret-based rationality, pragmatic/substantive rationality, and meta-rationality. For the first time, we provide a review of wide range of theories and models of rationality. We showed that what is "rational" behaviour under one rationality theory may be irrational under the other theory. We also showed that context is of paramount importance to rationality and that no one model of rationality can possibly fit all contexts. We suggest that in context-poor situations, such as policy decision-making, normative theories based on expected utility informed by best research evidence may provide the optimal approach to medical decision-making, whereas in the context-rich circumstances other types of rationality, informed by human cognitive architecture and driven by intuition and emotions such as the aim to minimize regret, may provide better solution to the problem at hand. The choice of theory under which we operate is important as it determines both policy and our individual decision-making.
鉴于超过30%的医疗保健成本被浪费在不适当的护理上，次优护理与医疗决策质量的联系日益紧密。有人认为个人决策是主要死因，且80%的医疗保健支出源于医生的决策。因此，改善医疗保健需要改善医疗决策，即让决策（更）合理。借鉴哲学、经济学和心理学领域的《大理性辩论》中的著作，我们确定了各种理论模型中常见的理性核心要素。理性通常分为规范性（解决人们“应该”或“应当”如何做出决策的问题）和决策描述性理论（描绘人们实际如何做出决策）。与医学相关的规范性理性思维理论包括指导循证医学实践的认知理论和为广泛使用的临床决策分析提供基础的预期效用理论。与医疗决策直接相关的理性描述性理论包括有限理性、推理论证理论、适应性理性、理性的双加工模型、基于遗憾的理性、实用/实质理性和元理性。我们首次对广泛的理性理论和模型进行了综述。我们表明，在一种理性理论下的“理性”行为在另一种理论下可能是非理性的。我们还表明，情境对理性至关重要，没有一种理性模型能适用于所有情境。我们建议，在情境匮乏的情况下，如政策决策，基于最佳研究证据的预期效用的规范性理论可能为医疗决策提供最佳方法，而在情境丰富的情况下，由人类认知结构提供信息并由直觉和情感驱动（如将遗憾最小化的目标）的其他类型的理性可能为手头问题提供更好的解决方案。我们所依据的理论选择很重要，因为它决定了政策和我们的个人决策。
