Understanding Dax Cowart’s Case and the Limitations of Snap Judgements Regarding Quality of Life

CE Binkley et al. NEJM 2022; 387: 1325-1328. From the Eyeball Test to the Algorithm — Quality of Life, Disability Status, and Clinical Decision Making in Surgery

“Good surgeons know how to operate; better surgeons know when to operate. But only the wisest surgeons know when not to operate.”

Key points:

  • “Qualitative evidence concerning the relationship between QoL and a wide range of disabilities suggests that subjective judgments regarding other people’s QoL are wrong more often than not1,2 and that such judgments by medical practitioners in particular can be biased.3,4
  • “Physicians had treated the severely burned patient Dax Cowart against his express and capacitated refusal of treatment.8 Cowart’s refusal was based in part on his judgment that if he survived, his QoL would be such that death was preferable. His physicians, on the other hand, believed it was their ethical duty to preserve his life regardless of his assessment of its quality. Cowart’s case was one of the first to highlight the importance — ethically, not just medically — of letting the patient’s own QoL valuation guide surgical decision making.”
  • When physicians do not offer a treatment due to concerns about potential QoL concerns, the “patient may never know that surgery was a possibility because the surgeon dismissed it as not indicated and never offered it.”
  • “In a recent survey of practicing physicians in the United States, 82.4% of 714 physicians indicated their belief that people with significant disability (as defined by the study) have worse QoL than people without disabilities.3 Yet this judgment directly conflicts with a large body of social science research spanning decades suggesting that people with significant disability, like those with less severe disability, experience QoL that is similar to that of people without disabilities.1,14-17
  • “We are not advocating that surgical interventions should be offered indiscriminately. Rather, we believe that a patient’s candidacy for a proposed treatment should be based on an objective assessment of the likely outcome of the treatment and the value that the patient, rather than the physician, places on that outcome, rather than on a flawed intuitive assessment.”

My take: The authors make a compelling argument that treatment recommendations need to be based on more than a physician’s subjective assessment of a patient’s quality of life.

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