Preferences: Cleaning up the concept and its use

This post is a preview of a presentation for the Baruch A. Brody Lecture in Bioethics. Want to learn more about this topic? Tune into the lecture Feb. 26 at noon CT.  Register Today!

What does it really mean when physicians say patient preferences should be “respected” and should guide clinical decisions? Is this always true? For example, physicians are not obligated to prescribe ivermectin to COVID patients who prefer it to Paxlovid. A better understanding of preferences helps clarify the issues.

In the view of economists, preferences rank states of affairs – but not in terms of any specific criterion, such as their cost or happiness. Preferences depend instead on every aspect of states of affairs that people take to be relevant to their choices. Preference rankings also depend on beliefs about the properties and consequences of alternatives, and when individuals have false beliefs, preferences and values may diverge. For example, those who refuse to be vaccinated against COVID-19 because they believe that the vaccines are dangerous may have the same values as those who are eager to be vaccinated.

How can clinicians tell whether certain patient preferences derive from idiosyncratic values or mistaken beliefs? The short answer (which is long in its demands on caregivers) is that conversations are needed to isolate patients’ misconceptions and clarify their specific motivations. Thinking in terms of “respecting preferences” misdescribes the consideration that may be owed to the patient’s values that can be teased out of an attentive dialogue.

Having these conversations can be challenging, especially in cases where treatment decisions must be made in just hours. There’s no magic bullet, but “the customer knows best” is not the right slogan for caregivers. Even when they must ultimately accede to the patients’ wishes, clinicians have an obligation to challenge false beliefs when they lead patients to make harmful decisions that are inconsistent with the patient’s values.

Preferences are important to healthcare in another, very different way. To distribute resources to improve health as much as possible, health economists must be able to say which health problems are worse and by how much. For example, is incontinence worse than losing a leg, and if so, how much worse?

Faced with hard questions, health economists answer by eliciting the populace’s preferences among health states. In doing so, they delegate the task of assigning values to health states to survey respondents, who typically have not previously thought about the problem and know little about health states and their consequences. A further problem with measuring health by measuring preferences is that the method cannot be used with children, whose preferences among health states (if they have any) are not a reliable guide to their health.

At this point, health professionals may ask, how else can health be measured? My lecture will offer some answers.

By Dr. Daniel M. Hausman,  research professor in the Center for Population–Level Bioethics (CPLB), Department of Health Behavior, Society and Policy at Rutgers University and a faculty member within the Rutgers Department of Philosophy. He is the recipient of the 2023-2024 Baruch A. Brody Award & Lecture in Bioethics sponsored by the Baylor College of Medicine Center for Medical Ethics and Health Policy, Houston Methodist and the Rice University Department of Philosophy.