Patients as Rational Traders: Response to Stewart and DeMarco

Abstract

Stewart and DeMarco's economic theory of patient decision-making applied to the case of diabetes is flawed by clinical inaccuracies and an unrealistic depiction of patients as rational traders. The theory incorrectly represents patients' struggles to optimize their management as calculated trade-offs against the costs of care, and gives an unrealistic, inflexible account of such costs. It imputes to physicians the view that their patients' lack of compliance is unreasonable, but physicians are accustomed to the variety of human factors which contribute to suboptimal compliance, and work with patients to minimize their influence. By depicting patients as rational traders rather than human beings with a range of motivations and burdens, the economic theory distorts the proper function of informed consent.

Rejoinder

“…According to him, our lack of care is reflected, first, in our failure to distinguish between the level of blood sugar diagnostic for diabetes and the blood sugar level considered ideal for health and, second, in "... an ambiguity which pervades the paper, viz. between symptoms and damage" [4]. We believe his criticism reveals an unwillingness to acknowledge what a theory is and the role of assumptions in a theory.…”

“…He characterizes the economic theory as "essentially a consumerist idea" [4] that he aligns with the "effete contractual ethics of the shopping mall" [4]. His response to our theory reflects a fear that the economic theory "lends support to the ... trend in reversing traditional 'doctor knows best'" [4]. "Doctor knows best paternalism" is inconsistent with the notion of informed consent.…”

“…Parker takes issue with our starting point when he states without evidence that the majority of diabetic patients do attempt to reduce their level of blood glucose to the medically ideal level [4]. Although we did not cite it in our original article, there is a substantial literature devoted to quantifying the high degree of patient noncompliance and improving compliance [2,3,5,7].…”

“…Further, Parker states that we "...have not taken sufficient care in consulting our clinical colleagues" [4]. According to him, our lack of care is reflected, first, in our failure to distinguish between the level of blood sugar diagnostic for diabetes and the blood sugar level considered ideal for health and, second, in "... an ambiguity which pervades the paper, viz.…”

“…Additionally in his response, Parker shows a lack of respect for patients by stating that patient trade-offs of costs and benefits of treatment are the unintentional results of "apathy, weakness of will and conflicting life requirements" [4]. Do these terms convey anything but a negative attitude and lack of respect towards patients?…”