Five Steps for Making Difficult Decisions

COVID reminds us that life—and health—is a series of tradeoffs.

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• YOUR GUIDE TO FALL/WINTER VIRUSES & VACCINES

• What’s next with COVID: My conversation with public health expert Monica Gandhi, MD, MPH

• FIVE Things to Do When You Get COVID

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The pandemic laid bare one of the trickiest aspects of being human: assessing risk. Take, for example, this question I received from a reader last week: 

How do my family members live their lives and also protect those in the family who ARE vulnerable/higher risk for Covid complications? Some of the elder's physicians have said they should simply stay home. Yet for the elders, they want to be involved and social.

-Beth

Beth’s question gets at a central tension: balancing the risk of getting COVID with the risk of engaging in regular life.

Photo by Nathan Dumlao on Unsplash

The intrinsic challenge is that COVID isn’t going away. It is an endemic virus that has been woven into the fabric of society. Limiting potential exposures to COVID means restricting our interactions indoors and with other people, which itself has emotional, physical, and mental health costs. Avoiding COVID in perpetuity is like maintaining a urine-free zone of a swimming pool. 

So, I suggested to Beth that she might reframe her question from “How restrictive should a household with high-risk family members be?” to “How much risk are various family members willing to tolerate in order to do something that matters to them, and how can they mitigate that risk without doing more total harm than good?”

The answer to her question lies somewhere in the middle between constant COVID vigilance and complete COVID nonchalance. It requires breaking down the decision-making process into its core elements:

STEP 1: What are the risks and benefits of doing X? 

STEP 2: What are the risks and benefits of NOT doing X? 

STEP 3: Can you mitigate those risks without doing more harm than good?

Let’s take an example. Say that Beth wants to treat a high-risk family member out to dinner at their favorite pizzeria. It’s cold outside and leftovers aren’t doing the trick. But dining indoors means undertaking some risk, such as the risk of getting infected with COVID and the risk of transmitting the virus to other people. 

(Note that there are myriad other risks involved with leaving the house—from getting into a car accident to tripping and falling on the sidewalk—some of which we undertake without thinking twice. But I digress.)

Beth and her loved one are vaccinated, had COVID in August, and currently feel well. They know the facts about COVID (they read my newsletter 😉):

• The COVID vaccine no longer efficiently blocks the risk of infection or the risk of transmitting the virus to other people (that ship sailed after the Delta variant in 2021).

• The COVID vaccine’s superpower is its ability to reduce the risk of getting seriously ill from COVID.

• Getting another booster shot today might temporarily and modestly reduce the risk of infection but it wouldn’t take effect for two weeks and there are downsides of taking a shot too soon after a COVID infection. (Here is an excellent review of booster shot by public health experts Shira Doron and Monica Gandhi.)

• Masks have not been shown to significantly reduce COVID transmission, particularly in people without symptoms. The best way to reduce the risk of transmitting COVID to other people is to stay home when we are sick. 

• Masks can protect the wearer from infection but imperfectly so, and only if they are high-grade, well-fitted and worn consistently (e.g., not when taken on and off at a restaurant!)

• The best way to reduce the risk of getting COVID is not to be up close with a COVID-sick person in a poorly ventilated, indoor space. 

The benefits of dining out are clear. What about the risks of NOT going out? There’s the risk of convincing ourselves that there’s a better, lower-risk time to dine out—when, in reality, COVID is here in perpetuity and we’re only getting older with every postponed social event.

On the other hand, Beth could pick up takeout and set a festive table at home. She could relish the cost savings and enjoy the company of her loved one without worrying so much about COVID. 

The next steps?

STEP 4: Make an informed decision.

STEP 5: Live with the consequences. 

The “right” decision for Beth and her loved ones is about recognizing that risk is everywhere. We can’t eliminate risk; we can only mitigate it. Health—and life—is a series of tradeoffs. Making difficult decisions requires understanding the facts, defining our goals, and balancing the risk of doing with the risk of not doing.

At its core, decision-making about our health requires defining what matters to us most. For some of us, it’s pizza at our favorite place. For others, it’s lightening the mental load of worry. Regardless of what it is that gives us meaning, it’s important to define it first—and to use it as our North Star.

Decisions are made easier when we know why we’re alive in the first place.

For me, one of the silver linings of the pandemic was that it forced me to define what matters most. When your North Star is clear, the path is a little brighter. 💫

What’s yours?

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Disclaimer: The views expressed here are entirely my own. They do not reflect those of my employer, nor are they a substitute for advice from your personal physician.

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