All medical decisionmaking (as most other decisionmaking) is an application of values to given sets of facts. Sometimes the facts are so overwhelming that almost any logically-consistent set of values would point to just one conclusion; other times different people with different sets of values react differently to the same facts. But no decision is dictated by clinical facts alone: any clinical decision can only be right when it matches the goals and values the patient brings to the treatment context. The fact that some decisions are slam-dunk obvious (a cast for a broken arm; surgery for appendicitis) does not mean that the patient’s values are not implicated in the decision - only that they are so in an obvious way. When the patient’s values do not match the “obvious” expectations regarding people’s goals and desires, the right decision is similarly non-obvious.

Sue Trinidad, at the Women’s Bioethics Project, raises the issue of prophylactic mastectomy in response to diagnosis with BrCa1/BrCa2 genes, indicating a familial tendency to breast cancer. She asks:

Are there circumstances under which we could all agree that prophylactic mastectomy/oophorectomy makes sense? Would we base our decisions on clinical criteria, or other reasons?

This is asking whether there is any set of facts regarding predictions of breast-cancer susceptibility in which either every rational person would opt for prophylactic mastectomy, or at least no rational person could object to another person’s choice of prophylactic mastectomy.

Taking the latter case first, obviously, we would almost undoubtedly agree that the procedure makes sense under the (not unrealistic) scenario that: a screening procedure was developed that predicted with 100% certainty that Breast-Ca would develop, but could not predict when. Under that scenario, waiting too long would certainly give rise to a cancer that could metastasize before it was detected, while acting ahead of time could certainly prevent both the cancer and its sequellae. It’s hard to imagine that anyone would object to prophylactic surgery in that circumstance (and hard to imagine that the vast majority of women faced with such a diagnosis would not opt for it). Objecting would mean arguing that it was irrational for someone to choose an outcome of certain health over an outcome of certain cancer - which seems an unattractive position no matter what the downside (early mastectomy) may be. Given the assumption that most people value avoiding serious illness much more highly than they do their appearance or their fear of surgery, no one would be surprised at a choice in favor of surgery in this scenario. But notice that this evaluation is not our own opinion regarding the advisability of the surgery; it is merely our factual prediction regarding others’ likely opinions about its advisability - which we know from our familiarity with their psychology.

However, to the more stringent interpretation of the question: is there any set of circumstances in which it would be rationally impossible to refuse an early mastectomy no matter what your personal values may be? - the answer must be “No.” This is for the familiar reason that we cannot subject values themselves to rational analysis. There are certainly sets of facts under which most people would choose a certain thing (as I’ve argued above), because most people have at least roughly similar values, but there are none under which all people have to choose the same thing, because no one has to have any particular set of values, and there are those who do have values that are divergent or even perverse.

No matter how dire the prognosis, or how obviously imbalanced the goods and harms attending the various treatment options seem to be from our perspective, we can only react to the decision made by the affected person from their perspective, which is to say in judging whether they have made the “right” clinical decision we can only judge whether they have applied the “right” values to the facts of the case. And this we cannot do, if we believe values are a matter of personal taste. As examples, we may have a women with a morbid fear of surgery, who is willing to take her chances with chemotherapy and radiation for her eventual cancer but will not consent to mastectomy under any circumstances. We may deplore her choice of a factually much-higher-risk path, but we may not tell her whether she is “right” to be more afraid of cancer than of surgery or vice versa. (If her fear results from a mistaken appreciation of the odds of survival of each treatment, we should certainly point that out, but if it is a true personal preference, there is nothing we can say, and possibly nothing we should say, to change that.) We may even have a woman who is so concerned with her appearance she will not sacrifice her natural breast until absolutely forced to do so by disease, and hence chooses certain disease over prophylactic treatment. We may regard those values as shallow, but again have no rational grounds for opposing them. (And it would be particularly heartless to do so, given the immense social pressures that bear upon women in respect of their appearance, especially of the breasts. To force women to live in a context in which they are judged on their breasts, and then condemn them for valuing the thing by which they are judged, would be a cynicism of a kind which is hardly unknown in medicine, but no less harsh.)

This seems very obvious, and hardly worth pointing out. But it is striking how often we are tempted to ask questions like that above: “Would we base our decisions on clinical criteria [alone]?”. We never base any decisions on clinical criteria alone. But we often pretend to be surprised by patients who have “different” values when they in fact act on them.