Many faces of rationality: Implications of the great rationality debate for clinical decision‐making

Abstract

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.

Reasoning, evidence, and clinical decision‐making: The great debate moves forward

“…It is of course not clear that Djulbegovic and Elqayam would disagree, as the “policy contexts” they identified where the “expected‐utility informed by best research evidence” model was appropriate were identified precisely because of the lack of rich, context‐specific knowledge. The discussion does, nonetheless, raise important issues about the role of guidelines in clinical decision‐making, and a common conception of “practical wisdom” (as Djulbegovic and Elqayam note) does indeed suggest that a key component of such wisdom is knowing “when not to” follow guidelines based on expected general utility.…”

“…Our first paper in this edition is an attempt by two very important contributors to the development of EBM over many years to draw together a broad range of literature on the concept of rationality and to bring out its implications for clinical practice. With a very practical focus on reducing the waste of health resources on inappropriate care, Ben Djulbegovic and Shira Elqayam examine “The Great Rationality Debate,” considering models of reasoning developed by philosophers, economists, and psychologists, in an attempt to identify core ingredients of rationality commonly encountered across various theoretical models. Their survey reinforces a point made by several other contributors to this edition, that no one model can fit all contexts, such that “context is of paramount importance to rationality.” They begin to identify different types of context in which different identified models may be more appropriate, from policy contexts in which “expected‐utility informed by best research evidence” might be the basis for the optimal approach, to what they describe as more “context‐rich circumstances,” where such concepts as intuition and emotion form essential components of the “cognitive architecture” providing the basis for practical reasoning.…”

“…The first contribution to this section comes from Rani Anjum and Stephen Mumford. Focussing on the relationship between research evidence and decision‐making, the authors note that EBM has “two components,” a methodological one concerning RCTs and their systematic review, which embodies a “difference‐making conception of cause,” and a “policy component.” We have seen that Djulbegovic and Elqayam identified “policy contexts” in which the best model for practical reasoning was based on “expected‐utility informed by best research evidence.” Anjum and Mumford agree that this model is utilitarian in nature, noting that utilitarianism is a normative (moral) theory which identifies “the good” with that which produces “the greatest happiness of the greatest number.” They further note that, in ethical debate, there are two forms of utilitarian theory, “act utilitarianism” and “rule utilitarianism,” and they characterize “evidence‐based policy” as a form of rule utilitarianism.…”

“…Just as many authors in our collection emphasize the social nature of knowledge and the centrality of context to practical reasoning, so many challenge, implicitly or explicitly, other modern dichotomies. The strict dichotomy between evidence and value—the former concerned with objective fact and the latter invariably reduced to matters of subjective “preference”—suggests a clear philosophical dividing line between epistemic questions (concerning knowledge, empirical data, and reason) and questions of an evaluative or moral nature (concerning what should be the case, what is preferable, matters of emotion and personal commitment).…”

“…In this edition, we present an array of up‐to‐date analyses of the problems of reason in practice, addressing a diverse range of healthcare contexts and methods, considering policy decisions as well as specific instances of clinical reasoning . Contributors discuss the nature of practical wisdom, the relationship between reasoning, emotion, intuition, and evidence, and the sense in which EBM is (or is not) a “modern” scientific enterprise, in the light of considerations of the relationship between science, context, and culture . The edition includes important sections on mental health, where questions ranging from epistemic injustice to psychiatric nosology and validity are analysed—discussions given both specificity and depth via a range of papers from a significant conference on how we conceptualize a number of psychiatric disorders .…”