I do not have a son named Joshua.

When President Obama said, "I have talked to enough doctors to know that defensive medicine may be contributing to unnecessary costs" in his speech last week, I was flooded with emotions. It reminded me of my family's own experience with "defensive medicine" and a completely unnecessary and risky procedure that is routinely recommended by obstetricians -amniocentesis.

My wife was thirty-nine years old and pregnant with what we thought was a little boy. We were going to name him Joshua. Our obstetrician suggested that because of my wife's age, we should consider doing "genetic testing." Without hesitation we told her we did not want to do this because we would not use the information. For us, terminating the pregnancy was simply not an option.

Undeterred, she continued, saying when the risk of an adverse pregnancy was greater than the risk of testing, she recommended people consider genetic testing. The risk of testing she was referring to is the risk that you lose the pregnancy. Experts estimate that between 1 in 200 and 1 in 400 women will spontaneously abort as a result of having an amniocenteses. These are women who would have delivered healthy babies in most cases but instead have miscarriages. So the risk of the procedure is not insignificant.

Since we were not willing to do an amniocentesis, she suggested we might want to do a test referred to as a "triple screen" test. In this case, the pregnant woman's blood is tested, and from these tests, doctors are able to more accurately estimate the chances of having a baby with Down Syndrome. (Click here for more information on the triple screen and genetic testing for Down Syndrome.) We saw no harm in this simple blood test and consented. When the results came back, we learned that according to the triple screen, the chances of us having a child with Down Syndrome were something like 1 in 1600. This confirmed our earlier decision not to do an amniocentesis.

It did not deter our obstetrician though. She persisted in recommending we at least discuss the procedure with another doctor who would have actually performed the test. Slightly confused, we trusted our obstetrician and were lead to the other doctor's office. When I spoke with this doctor I explained we had the results of the "triple screen" and were confident there was no need to do the amniocentesis.

"The triple screen is not a diagnostic test," she protested.

"Are you saying that the triple screen is not valid?" I asked.

Again she asserted the screen was not a diagnostic test. At this point, Su and I were feeling confused. I explained to the doctor I had a degree in applied mathematics and in my profession, I worked with risk and uncertainty all the time.

"Doctor, we can make a good decision about this if you will just give me the data," I assured her.

I think the assertion that I understood mathematics and statistics made her very uncomfortable. She knew I wasn't going to just cave to her white coat. She suggested we talk to the genetic counselors. We agreed and were sent to another room where two young women joined us and explained everything about genetic testing.

Suddenly I had a horrible thought. Had the doctor seen something on the ultrasound that caused her to think our baby had Down Syndrome? Well yes, the genetic counselors said. She had noticed a "marker." Markers are associated with Down Syndrome, the genetic counselors explained. Of course, the counselors went on, many perfectly healthy babies without Down Syndrome also had these markers.

"How will this change the probability that my baby will be born with Down Syndrome?" I asked. "We don't know," said the genetic counselors. After more frustrating, unanswered questions, the genetic counselors were still unable to convince us to consent to testing. So they asked us to sign a release saying we had declined on the procedures. This whole unpleasant experience left Su and me feeling frustrated and angry.

There is a lot of really sloppy thinking going on with regard to this test. Amazingly, the American College of Obstetrics and Gynecology began recommending that all women, regardless of age, be offered an amniocentesis in 2007. This is a really bad idea.

An amniocentesis does not guarantee you a healthy baby. It just gives you a piece of information you are going to get anyway in about five months. If you intend to act on the information however, it may be worth considering the test. But if you are not going to terminate the pregnancy should you learn your baby has the extra chromosome that causes Down Syndrome, it is irresponsible to expose the fetus to such risk.

When our obstetrician said she recommended the procedure when the risk of testing was less than the risk of an adverse pregnancy, she exercised faulty logic. Down Syndrome is a risk you take when you choose to get pregnant. Having a miscarriage as a result of the procedure is a new and additional risk that you assume when you consent to the test. Shockingly, the genetic counselors told us that some people who had no intention of terminating the pregnancy regardless of the result wanted to take the test just to know their baby was healthy. This is really bad risk management.

I do not have a son named Joshua. This is because when my wife gave birth, he was a she and we named her Hannah. She is six years old now, in the first grade, and perfectly healthy. She plays soccer, dances ballet, and sings the most beautiful rendition of "Jesus Loves Me" you ever heard. I am her dad and I protect her. I make sure she buckles herself into her car seat and wears a helmet when she rides her bike. And I am so happy that six years ago I did not let some lunatic doctor stick a needle in my wife's belly just to see if my child would be born mentally retarded. Sure, it was only a 1 in 300 chance that I would have lost her as a result, but she is exposed to far less risk each time she gets in a car or gets on her bicycle, and I would not think of letting her ride a bike without a helmet or not buckle her in when she gets in the car.

Decision-Making Best Practice #19: Obtaining additional information can expose you to new risks and costs. If you are not going to use the information, do not expose yourself to the additional risks.

Labels: amniocentesis, data, defensive medicine, jobs, risk, risk management

This blog, like my book The Naked Portfolio Manager, is designed to help readers think better and make better decisions. I thought to myself "What could be a better blog topic than to study the first great decision that mankind ever made?"

I am referring, of course, to the decision Eve made in the Garden of Eden when she chose to eat the forbidden fruit. When Eve ate the fruit she disobeyed God. We have been taught this was the original sign and was the cause of all of mankind's hardships. Having read the story many times, let me say I believe almost every biblical scholar has interpreted this event incorrectly and the original sin was not Eve's disobedience to God. Her act of sharing the fruit with Adam was the original sin. Examining the story critically without the constraints of religious dogma yields a much different interpretation of the acts in the garden than we have been taught. And it can lead us to important lessons and decision-making rules we can apply today.

Consider that Eve may have lived in the garden for a relatively short time when she encountered the talking serpent. The Bible tells us that Eve was very beautiful and she and Adam wore no clothes and Adam loved Eve very much. The implication is that Adam and Eve were having normal marital relations, but she had not yet had time to conceive a child when she encountered the serpent. So perhaps she was only a few months old when this occurred. The Bible does not make it clear how old Eve was, but it is clear that the serpent had been in the garden longer since God had created the animals before he had created Eve. So Eve encounters a talking serpent; this must have been an extraordinary event since other than God, Eve, and Adam, no other personages speak in the garden. The talking serpent suggests she eat from the tree of life. Eve says no, since God has told her she will die if she eats from the tree. The serpent says God is not correct and she will be omnipotent if she eats from the tree. Eve now becomes the first human to make a decision under uncertainty. Clearly, both God and the serpent cannot be correct. She must decide if she should risk death in order to have the chance to become omnipotent.

Eve, carried away by the dream of becoming God-like, ignores the risk and eats the forbidden fruit. We know the rest of the story.

Many scholars, parents, and school children have been critical of Eve's decision, but I think they are unfair to her. The normal ways that people make decisions under uncertainty today were not available to her then. Let's remember, Eve never took a course on logic. Neither probability theory nor utility theory had been developed yet either so there was no way to analyze the risk/reward relationship. She could not consult her Bible to see what had happened to people in the past who had disobeyed God. It simply hadn't been written yet. How was she to make this decision?

What is more, it seems almost impossible to believe she fully understood the risks, since no one had ever died in the Garden of Eden. Eve's concept of death had to be fairly abstract. I have asked Biblical scholars this question and I always get the same answer: Eve should have known to obey God. But how was she to know this? She really had no basis for making this decision.

Eve's decision had bad consequences for her as it meant she had to leave the garden and ultimately die, but we cannot call it a bad decision. Rather it was a decision with bad results. Given what she knew at the time, she simply gambled and lost. The original sin was to give the fruit to her husband. She gave it to him knowing full well it would cause his death and she did this because she did not want to face this by herself.

So what are the lessons from this story for today's decision-makers? Decision-Making Best Practices #11-15:
#11 - Challenge dogma. We are told thousands of things in life and many of them prove to be untrue.
#12 - Assign appropriate weight to obscure or poorly understood risks. Eve, like many decision-makers today, clearly underweighed the risks of dying when she made her choice.
#13 - Be careful when criticizing the decision-making of others, especially if you have the benefit of information that those people did not have at the time they made their decision.
#14 - Remember the difference between decisions and results and evaluate decisions on the quality of the thinking employed rather than the result of the decision.
#15 - Delay a critical decision if you can, especially if you will likely be able to get more information later that will allow you to make a better choice.

Labels: Adam, Eve, God, logic, results, risk, sin

Labels: choices, frames, illusion, risk