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Table 3 Scenario 5: Influence of response shift on guidelines (macro level)

From: Influence of response shift and disposition on patient-reported outcomes may lead to suboptimal medical decisions: a medical ethics perspective

Scenario 5 Ethical analysis: Utilitarianism Ethical analysis: Fair equality of opportunity
An RCT is conducted to compare the effects of bypass surgery (open heart surgery) and angioplasty (catheter intervention) on frail patients. In the longer term, both treatments produced the same health status. However, as bypass surgery requires several months of recovery and thus adaptation, it may induce a greater response shift than angioplasty. As a result, after 6 months the bypass group reports higher levels of HRQoL than the angioplasty group, even though their health states are similar. This shows that the guidelines may be suboptimal, with an unwarranted preference for bypass surgery, leading to suboptimal care: unneeded treatment with unnecessary medical risks. Since utility should be maximized, influences of response shifts or dispositions on self-evaluations are not an issue as such. The situation is problematic because bypass surgery is more expensive than angioplasty and has more medical risks, in this case without greater health benefits. However, the higher HRQoL scores due to response shift may justify the preference for bypass surgery, despite the medical risks. Nonetheless, especially when the costs and risks of bypass surgery are substantially higher, one might question whether these ‘extra’ resources would not be better spent on other healthcare or even services other than healthcare. Indeed, this may yield a larger increase of total utility in the broad sense, i.e. the wellbeing of the population. The situation is problematic. The guideline may lead to medical risks of unneeded bypass surgery, which could cause a loss in the range of capabilities and opportunities of this patient group.