Article Text

Download PDFPDF
21 OverDiagnosis and unshared decision making as paradigm-constructed Anomalies
  1. Jack Dowie1,2,
  2. Mette Kjer Kaltoft2
  1. 1London School of Hygiene and Tropical Medicine, London, UK
  2. 2University of Southern Denmark, Odense, Denmark


We suggest that ‘OverDiagnosis’ (OD) and ‘Shared Decision Making’ (SDM) can be interpreted as ‘anomalies’, self-detected in the dominant practice paradigm within which healthcare legislators legislate, regulators regulate, administrators administer, researchers research, and practitioners practice. We ask why these two anomalies are not seen as of such irreparability as to necessitate a paradigmatic modification of ‘normal practice’, in both the Kuhnian and medical senses. The basic answer is that no alternative paradigm is worth considering or, for most, exists. On the contrary, we argue that there is a serious alternative to the Verbal Deliberative Reasoning (VDR) paradigm/doxa that dominates professional practice – and hence relevant legislation, regulation, administration and research - in healthcare. That alternative is Numerical Analytical Calculation (NAC), most effectively and practically implemented in some version of (Bayesian) Multi-Criteria Decision Analysis (MCDA). This offers the prospect of reducing, or avoiding, by their de-construction, anomalies such as overdiagnosis (and underdiagnosis) and the lack of appropriately allocated responsibilities in decision making. The failure to accept it as an alternative – and of peacefully co-existing paradigms – is explicable in two mutually supportive ways. The motivated explanation is that it would massively reduce the return on the accumulated human and social capital assets (financial, material, and symbolic) of all those operating in the VDR paradigm. The cognitive explanation brings in some version of the Dunning-Kruger Effect, where those who believe they know enough about the NAC/MCDA alternative to reject it, overestimate their ability to make such an assessment because of their lack of competence in it; a lack assured by training curricula and professional socialisation that leave many innocent of anything but pejorative stereotyping of it as a ‘cold and calculating’, logos-dominated, pathos-deficient, ethos-questionable approach. From a sociological point of view, OD and SDM are ‘boundary objects’ which form the unifying constructs of successful ‘boundary organisations/infrastructures’ (Preventing OverDiagnosis and the International SDM Society), each made up of organisations and individuals pursuing what is, at the ill-defined level of a successful boundary object, a common external goal; but also pursuing their own diverse internal interests. The furthering of interests - research grants, academic positions, conferences, publications, simply having power – sets the ontological direction of travel for most ‘boundary working’ towards monopolistic essentialism, and the universal standards, regulations and laws which can follow, and away from pluralist constructivism, which would undermine the possibility of these. However, in these two cases the movement is restrained by the overwhelming interest of all parties in preserving the interpretive flexibility inherent in the VDR paradigmatic hegemony. Why not simply conduct a ‘trial’ of the two paradigms? Because the key characteristic of alternative paradigms is that they are incommensurable. While they can be compared, this can only be done on the basis of some form of weighted multi-criterial analysis. This will be sensitive to the preferences entered and hence the interests with which these preferences are aligned. Given the need for preference transparency, enthusiasm for open ‘comparative evaluation’ is not to be expected.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.