Tuesday, December 20, 2005

Caught on the Horns of a Prisoner's Dilemma

I'm from a family of doctors - father, grandfather and a sister. My other sister is a physical therapist. Much of my work has been in and around hospitals from nursing to IT to research. I was raised to believe that lawyer jokes were the only acceptable form of vicious ethnic humor. I'm still pretty much that way. Most doctors are hardworking and knowledgeable. It is impossible to guarantee a good result, just good treatment. As Hippocrates said "Life is short and the art long, the occasion instant, experiment perilous, decision difficult." Besides, I owe my life to an exceptional team of physicians at the local medical school. They did a superb job with an advanced condition from a torturous operation through excellent followup care. I'm probably going to live out my normal span, G-d willing, which wasn't at all a sure bet two years ago.

So why am I irritated with some of my team? To put it bluntly, they gave me a bad answer to a direct question, and it may have life-altering consequences. Actually, it already has. I won't bore you with the organ recital. Suffice it to say, my fertility was impaired by the treatment. At my wife's age a temporary problem could put our last chance at children out of reach. I asked several members of the department about banking sperm. They said there was no cause for concern, that it wouldn't be an issue.

They were wrong. It was. And I'm out of pocket a fair amount of money trying to kick start my gonads into action. The doctors are stonewalling, telling the Patients' Advocate office that there is "no science" to support my concerns. This in the face of many peer-reviewed articles in the medical literature backing up the claim. All I'm looking for is a tiny change in the procedures and some help on the portion of my iatrogenic expenses that aren't covered by insurance, the ones which could have been avoided with better advice. Quite reasonable all things considered.

Why is this happening? It's very simple, really. We have entered the age of mistrust between doctor and patient. The fear of litigation on one hand and the loss of trust in the medical profession on the other have made it difficult to work things out amicably. The moment there is a complaint the medical-legal immune system activates. Any doctor or department knows it is a target for lawsuits. The best means of reducing that risk is to say nothing that could be taken wrong in court. This works well as a defensive tactic most of the time. The problem arises when a patient with a grievance does not want to get into a legal battle and is not looking for a payday but wants his concerns addressed. The strength of the defense does not easily allow lesser means.

Enter the Prisoner's Dilemma.

In 1984 Axelrod came up with a very insightful way of looking at decisions involving trust by using non-zero-sum game theory. Two parties can choose to cooperate or "defect". If both cooperate they get a good result. If both defect they both get a bad result. If one cooperates and the other defects the defector gets a good result, and the defector gets a bad result. It has been applied to everything from nuclear war policy to prisoner interrogations.

The classic best strategy is what they call "tit for tat". You start off by trusting the other player and cooperating. After that you react according to his last move. If he cooperates, you cooperate. If he defects, you defect.

What we have here is a case where one player has decided that the patients as a class have already defected. As the other player I have to choose a strategy, preferably one that will allow both of us to cooperate and thus ensure a good mutual outcome.

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