Decision Making in Everyday Life: A Theory-Based Approach

Journal of Family Practice, Dec, 1998 by Barry G. Saver

It was breakfast time. Once again, I faced the dilemma of what to offer our 4- and 6-year-old boys to eat. Keith, the 4-year-old, wanted a waffle, but I didn't know whether the waffles in our freezer had pecan bits, and Keith hates nuts. Thinking quickly, I whipped out our bright light to check the waffle and, not seeing any densities, popped it into the toaster. Unfortunately, it turned out that some lesions, er, nuts, had been missed on the initial reading. Keith protested until the offending waffle was removed and an acceptable substitute was found. As I sat there eating the discarded waffle, it occurred to me that if our toaster had been equipped with a built-in MRI scanner, this problem and the associated loss of 120[ or -]9 QACS (Quality-Adjusted Child Seconds, pronounced "quacks") could have been avoided. I wondered, though, whether this would have been a cost-effective use of technology.

After mulling this over for a few days, I began to sec domestic responsibilities in a whole new light. It turns out that most household activities suffer from the lack of careful application of decision-theoretical methods and the determination of family member preferences. Why not apply this maturing technology to daily life? QALYs (Quality-Adjusted Life Years) are the standard outcome measure used in many cost-benefit and cost-effectiveness studies. With little or no modification, this approach should be usable in nonmedical decisions as well.

For example, last night we faced a decision about where to go for dinner. We debated the type of food (pizza, Mexican, Chinese, or the new vegan/anarchist restaurant in the neighborhood), how far we wanted to drive (traded-off against how hungry we were), and how child-friendly the choices might be. It was difficult to reach a consensus. Keith threatened to throw up all over the vegetarian restaurant if we even stepped through the door and Mark, the 6-year-old, reminded me that I had to have my gallbladder removed after our last outing to Fat Yung Boy. Had we constructed a decision tree and come up with a valuation for each node in QUAALUDEs (QUAlity-Adjusted LUnch or Dinner Events), the correct choice would have been obvious.

Of course, there are a few methodologic issues that need to be ironed out before we can entirely switch over to this new, evidence- and preference-based method of family decision making. For example, the appropriate trade-off of QASIs (Quality-Adjusted Spouse Instants, pronounced "quasies"(1)) with QACS has not been thoroughly investigated. There does appear to be a direct: relationship between the ages of the involved parties and, for comestible-related decisions, time since last intake.(2) Time-dependent utilities, of course, require complex dynamic modeling. Catastrophe theory(3) suggests that time can reach a critical value at which point the utilities become unstable, leading to the "water under the (nasal) bridge" phenomenon in Age-Adjusted Quality Assessment (AQUA).

Weighting of competing individual utilities has produced inconsistent results in some trials.(4-6) Use of a VETO (Victory Every Time, Or else ...) strategy by one participant can result in choices with marked disutilities for others and progressive utility polarization. Consistent use of a VETO strategy in household decision making (aka radical decision-tree priming) can lead not to a solution, but to (marital) dissolution.

The application of decision theory to daily household activities promises to bring new clarity, validity, and reproducibility to family decision making. As soon as I get the funding approved, I will be able to decide whether to replace our current toaster with a combined toaster-MRI unit. In the meantime, I should have a preliminary model ready by next fall to help me decide whether I need to rake the leaves off the lawn. I can hardly wait to decide what we'll do with all the money save on marriage-counseling fees.

REFERENCES AND NOTES

(1.) For unmarried couples, use QESIs (Quality-Adjusted Equivalent-to-Spouse Instants), pronounced "queasies."

(2.) Rogers F. A cookie in time, saves my mind. J Parental Bribery 1998; 23:89-97.

(3.) Catastrophe theory is used to describe sudden, discontinuous transitions, eg, the sudden change from the "not fighting" to the "fighting" state among siblings. For a general overview, see: Simon, P. Bridge over troubled water: catastrophe theory and "Galloping Gertie." Tacoma, Wash: Columbia Press, 1970.

(4.) Logic NO. Who's taking out the garbage? A time-motion study on the lack of transitivity in interpersonal utilities. Quantitative Fam Dec Making 1983; 3:206-315.

(5.) Certain T Some couples really can't decide--a new instance of the Heisenberg uncertainty principle. J Quantum Interpersonal Dynamics 1987; 43:1395-8, more or less.

(6.) Goodenough RU. A randomized, controlled trial of family therapy, electroconvulsive therapy, and decision trees. J Experimental Counsel 1996; 7:16-25.

Correspondence should be addressed to Barry G. Saver, MD, MPH. Bar 354696, University of Washington, Seattle, WA 98195-4696. E-mail: saver@u.washington.edu