33 Acceptance after analysis

The Peacock and the Crane: A peacock showed off his brilliant plumage and taunted a crane, "Poor dear! How dull are your feathers.” The crane replied, "No doubt, your plumage is glamorous. But my feathers help me to soar into the clouds while yourplumage confines you to the ground like any dung hill rooster."

Dr Singhal, a university professor, had angina (chest pain) on walking twenty steps at a normal pace. Adequate medical treatment gave only partial relief and he was advised to undergo coronary bypass surgery. He learnt that the risk of dying of the surgery was about 2%. He decided to postpone his surgery. "But you can't go on living like this - like a cripple," chided his close friend Mr Moorthy, "Look at me. I got the bypass done. I am fine."

Dr Singhal replied, "You are right, Moorthy. But my daughter Pooja is doing her MBA. I want to be around to ensure that she gets a good job and a good husband. I have lived with angina for the last six years. A few more months of the same are acceptable to me than the risk of surgery.” He continued to be on drug treatment for two more years. He was fortunate in not getting any worse. Meanwhile her daughter got employed and got married. Then he underwent a successful bypass surgery.

Comments

Any health care option can be analysed in terms of benefits, risks and cost. The benefits have to be weighed against the risks and against the cost. An enlightened health care seeker like Dr Singhal can cope with a difficult decision making process through

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analysis. Any professional should encourage such patients to take decisions instead of being paternalistic and talking down to them.

Cost-benefit and risk-benefit can be simplified into four categories (see box).

HIGH ↑ 2 3 │ │ Benefit │ │ │ 1 4 LOW └──────────→ HIGH

Risk / Cost

Category 1: A) Low risk - Low benefit

B) Low cost - Low benefit

These are mostly rituals in health care that are routinely done. "Why not try it? After all there is no harm" or, "It does not cost much and may do some good" are the arguments put forth to promote these options. These are acceptable options but may not be of much use.

Category 2: A) Low risk - High benefit

B) Low cost - High benefit

These are ideal options to be avidly accepted. "It is safe and dramatically improves the outcome" or, "You can't get a more affordable option. It is a steal" are the arguments put forth to promote these options.

Category 3: A) High risk - High benefit

B) High cost - High benefit

Many modern miracles of health care belong to this category. Some examples are 101

transplantation, assisted reproduction, foetal surgery and cancer chemotherapy. No doubt, the benefits are great, but one has to accept considerable risks and be prepared for short term and long term expenditure. Quite often, health care providers and the media highlight the benefits and understate the risks/costs. Care seekers may mistake these options to be of low risk or low cost. If they burn their fingers due to unaffordable costs or an adverse outcome, they may react badly and seek redressal.

Many health care litigations in court arise from mistaking a category 3-A option as a category 2-A option. Proper pre-treatment counselling is the only effective way of preventing such mistakes.

Category 4: A) High risk - Low benefit

B) High cost - Low benefit

Some researchers wanting to be the first to prove a point may actively pursue high risk-low benefit options. High cost-low benefit options are promoted by the health industry that looks for newer ways of making profits. We should weed out such options from health care.

A desperate care seeker is often asked, "What other chance do you have" to justify a category-4 option. Such pursuit of the margin of the impossible is an example of technological brinkmanship in health care (Silverman WA, 1995).

TS Eliot has warned us against action taken "not for the good it will do but that nothing be left undone.” Empower yourself to cope with health problems by a careful analysis. Consider the benefit, risk and cost before making a decision. Help your doctor to help you better. In short, be smart.

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