A Game Theory Application The Interaction Between Physicians and Patients Dissertation

Politecnico di Milano
Scuola di Ingegneria Industriale e dell’Informazione

Corso di Laurea in Ingegneria Matematica
A Game Theory application:

the interaction between physicians and
patients
Relatore: Prof. Roberto LUCCHETTI
Tesi di Laurea Magistrale di:

Margherita VIGORELLI
Matr. 804337
Anno Accademico 2014-2015

Abstract
The purpose of this work is to describe and analyse a typical clinical interaction
between a doctor and a patient, via Game Theory. The conceptual tools provided
by Game Theory can be used, in medical consultation, to analyse optimal deci-
sions and to highlight the dynamics of the doctor-patient interaction.
After a brief review of the basic concepts of Game Theory, the Prisoners’ Dilemma
game is applied to different situations in the medical consultation field. Later,
since every clinical encounter is fundamentally based on trust, the Prisoners’
Dilemma game is modified into a trust version of it (incorporating regret, guilt and
frustration) to make it relevant to describe a typical clinical interaction. There-
fore, it is employed to analyse the participation of a patient to a randomized
controlled trial.
Moreover, two simultaneous games by B. Djulbegovic are used to describe the
simplest clinical interaction: a doctor has to decide whether or not to prescribe a
treatment and a patient has to decide whether or not to accept it, in conditions of
diagnostic uncertainty. After a deep analysis of the models, two sequential games
are suggested, in order to describe a more realistic situation. The analysis shows
that the solutions of the games strictly depend on the probability of disease of
the patient, which is assessed and known by both the patient and the doctor. It
appears clear that the most reasonable model to describe an everyday interaction
between a patient and a doctor is a sequential game: the doctor chooses whether
or not to treat a patient and, later, in both circumstances, the patient chooses
whether or not to trust him.
I
Sommario
L’obiettivo di questa tesi è quello di descrivere e analizzare, attraverso la Teoria

dei Giochi, l’interazione tra un medico ed il suo paziente. I modelli offerti dalla
Teoria dei Giochi permettono di analizzare le strategie ottimali degli agenti e os-
servare le dinamiche alla base della relazione medico-paziente.
Dopo una breve introduzione alla Teoria dei Giochi, sono presentate alcune ap-
plicazioni del Dilemma del Prigioniero in campo medico. Dal momento che ogni
interazione tra medico e paziente si basa sulla fiducia, il Dilemma del Prigioniero
è successivamente modificato e riproposto in una versione che integra i concetti di
pentimento, frustrazione e colpa, strettamente legati alla fiducia. Questo nuovo
modello descrive meglio l’interazione clinica ed è mostrata una sua applicazione
alla scelta di un paziente di partecipare a un esperimento clinico.
Successivamente, è presa in considerazione una semplice ma interessante inte-
razione clinica, in cui un medico, in caso di diagnosi incerta, deve valutare se
prescrivere o non prescrivere un trattamento a un paziente, che a sua volta può
decidere se fidarsi del medico oppure no. Dopo una dettagliata analisi di due
giochi simultanei, proposti da B. Djulbegovic, sono suggeriti due giochi sequen-
ziali, per descrivere in modo più realistico un incontro clinico. L’analisi mostra
che le soluzioni dei giochi dipendono strettamente dalla probabilità che il paziente
sia malato, nota ad entrambi gli agenti. Risulta che il modello più ragionevole per
descrivere una tipica interazione tra medico e paziente è un modello sequenziale:
il medico decide se prescrivere un trattamento oppure no e, dopo aver osservato
la scelta del medico, il paziente, in entrambi i casi, decide se fidarsi.
II
Contents
Introduction 1
1 Introduction to Game Theory 4

1.1 Non Cooperative Games . . . . . . . . . . . . . . . . . . . . . . . 5
1.1.1 Games in strategic form . . . . . . . . . . . . . . . . . . . 6
1.1.2 Games in extensive form . . . . . . . . . . . . . . . . . . . 8
1.2 A strategic game: the Prisoners’ Dilemma . . . . . . . . . . . . . 11
2 A doctor-patient interaction 14
2.1 The Prisoners’ Dilemma in a doctor-patient encounter . . . . . . . 15
2.2 The trust version of the Prisoners’ Dilemma game . . . . . . . . . 19
3 The participation of a patient to a Randomized Controlled Trial 21

3.1 A sequential game with perfect information . . . . . . . . . . . . . 23
3.2 Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.2.1 Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
4 Game Theory models for healthcare decisions 38

4.1 Simultaneous games for healthcare decisions . . . . . . . . . . . . 39
4.1.1 Simultaneous game, model A: the patient demands treat-
ment and he does not get it . . . . . . . . . . . . . . . . . 40
4.1.2 Simultaneous game, model B: the patient demands treat-
ment and he gets it . . . . . . . . . . . . . . . . . . . . . . 54
III
4.2 Sequential games for healthcare decisions . . . . . . . . . . . . . . 61
4.2.1 Sequential game, model A: the patient demands treatment
but does not get it . . . . . . . . . . . . . . . . . . . . . . 63
4.2.2 Sequential game, model B: the patient demands treatment
and gets it . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
4.3 Comments on the models . . . . . . . . . . . . . . . . . . . . . . . 77
4.3.1 Simultaneous game - Model A . . . . . . . . . . . . . . . . 78
4.3.2 Simultaneous game - Model B . . . . . . . . . . . . . . . . 80
4.3.3 Sequential game - Model A . . . . . . . . . . . . . . . . . . 82
4.3.4 Sequential game - Model B . . . . . . . . . . . . . . . . . . 84
4.4 Data simulations . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Conclusion 91
List of Figures 93
List of Tables 94
Bibliography 95
IV
Introduction
A clinical encounter, between physicians and patients, is a two-way social inter-

action. Typically, the physician gets information from the patient, provides a
diagnosis and, if needed, prescribes a treatment [15]. However, the physician is
not the only agent in the decision analysis, since the patient can choose what infor-
mation to tell the doctor (influencing the diagnosis) and even more importantly,
can choose to reject the physician’s advice or treatment. Hence, the outcome of
the consultation depends on the choice of both the patient and the doctor.
Game Theory provides conceptual tools to describe and analyse optimal decisions,
in situations in which the outcome depends on more interactive individual with
common and divergent interests, as in medical consultations [1].
Game Theory first applications have been to economics, to work out how events
occur when agents (business leaders, organisations, companies) behave in what
they think is their best interests. Later, it has found applications to various dis-
ciplines as psychology, political science, computer science and biology and, today,
it applies to a wide range of human behaviours.
In the medical field, Game Theory has already been employed in several settings.
For example, it has been used to study the evolution of tumours (carcinogenesis),
to predict under which conditions cancer cells have a better chance of emerging
[11]. Even in medical imaging, image segmentation, which is the process of de-
composing an image into homogeneous regions to delineate anatomical structures
for medical analysis and intervention, can be formulated as a game [7]. More-
over, Game Theory is used in the field of kidney transplantation to determine a
1
Introduction 2
systematic way of selecting, for each incompatible patient-donor pairs, a set of

compatible transplants [14].
One interesting application to Game Theory is the interaction between physicians
and patients: Game Theory models can be used to understand health care deci-
sions, highlighting the doctor-patient dynamics.
In recent years, several studies have been presented in this field. In particular, in
this work, we analyse three Game Theory models, presented by Benjamin Djul-
begovic et al. in their articles [3, 4].
The purpose of the following work is to present some models describing the in-
teraction between physicians and patients, to suggest modified models and to
compare the solutions.
In Chapter 1, we provide the basic concepts of Game Theory, useful in the fol-
lowing analysis. Specifically, non cooperative games are described. In Chapter 2,
the most known strategic game, the Prisoners’ Dilemma, is applied to different
situations in the medical consultation field. Since trust is fundamental in every
clinical encounter, the Prisoners’ Dilemma game is modified to make it relevant
to describe a typical clinical interaction: specifically, trust, regret, guilt and frus-
tration are integrated in the pay-off function of the players. Therefore, in Chapter
3, we describe an application of the trust version of the Prisoners’ Dilemma game
to a specific clinical interaction: the participation of a patient to a randomized
controlled trial (RCT) [3]. Then, in Chapter 4, firstly, we present two simulta-
neous games describing a clinical encounter [4], where the doctor has to decide
whether or not to prescribe a treatment and a patient has to decide whether or
not to accept it, in conditions of diagnostic uncertainty. Since the aim of the
models is to analyse a typical clinical interaction, the simultaneous approach does
not seem the most suitable (even if it is applicable to specific situations). For this
reason, we introduce and analyse, in this thesis, two sequential games, describing
the same situation, but with a radically different assumption, that the patient
Introduction 3
is aware of the decision of the doctor. The analysis shows that the solutions of
the games strictly depend on the probability of disease of the patient, which is
assessed and known by both the patient and the doctor. In the simultaneous
games, the solution is a pure or mixed strategies for both the players, while in
the sequential games, the doctor’s optimal choice is a pure strategy, while for the
patient, it is a couple of pure strategies. The solution concept is what makes the
models essentially different.
From the analysis, it appears clear that the most reasonable model to describe
an everyday interaction between a patient and a doctor is a sequential game: the
doctor chooses whether or not to treat a patient and, later, the patient chooses
whether or not to trust him, in both circumstances.
Chapter 1
Introduction to Game Theory
Game Theory is a branch of mathematics that deals with the study of models
of conflict and cooperation, between several decision-makers. The concepts of
Game Theory provide a language to formulate, analyse and understand strategic
scenarios. The object of the study is the game, which is a formal model of an
interactive situation with two or more players: thus, a game is a simplified, yet
efficient, representation of real life situations.
The formal definition of a game lays out the players, their preferences, their
knowledge about each other choices, the strategic actions available to them, and
how these influence the outcome.
In a game, each player has some alternatives to choose from and the combination
of choices of each player leads to a possible outcome of the game. Each player
has preferences on the outcomes and this is expressed by means of a pay-off (or
utility): the pay-off associated to a particular outcome is the payout a player
receives, by getting there.
A central assumption, in Game Theory, is that players are rational: a rational
player always chooses the action that gives him the outcome he most prefers,
given what he expects his opponents to do.
Thus, Game Theory is the study of taking optimal decisions in presence of multiple
players.
There are, roughly speaking, two categories of games: the cooperative games and
4
Chapter 1, Introduction to Game Theory 5
the non cooperative games.

In cooperative games, the players have the possibility to form coalitions: for
each potential coalition, we specify the pay-off that the coalition can obtain if
its members cooperate. Thus, the game is played between coalitions of players,
rather than between individual players, even if what analysis provides is always
the utility for the single players.
In contrast, in non cooperative games, players cannot form binding commitments
and they act strategically to get the best for themself.
1.1 Non Cooperative Games

A non cooperative game can be represented in two different forms: the strategic
form and the extensive form.
A game in strategic form (or normal form) lists each player’s strategies and the
outcomes that result from each possible combination of choices.
In a two player game, let X and Y be the sets of strategies for the players and
let f, g : X × Y → R be the pay-off functions of the players. Thus, a two player
game in strategic form is a quadruplet (X, Y, f : X × Y → R, g : X × Y → R).
In case the strategy sets are finite, the game can be efficiently represented by a
bimatrix which shows players, strategies, and pay-offs.
 
(a11 , b11 ) ... (a1m , b1m )
 ... ... ... 
(an1 , bn1 ) ... (anm , bnm )
The first player and the second player have n (rows) and m (columns) possible
strategies, respectively. When the first player chooses the i -th row and the second
one chooses the j -th column, they produce the outcome assigning utility aij to
the first player and bij to the second one.
When a game is presented in normal form, it is presumed that each player acts
simultaneously or, at least, without knowing the actions of the other. If players
have some information about the choices of other players, the game is usually
presented in extensive form.

The extensive form of a game is a complete description of all relevant information
about the game and of how the game is played over time (in sequential games).
Therefore, we specify the initial setting, all possible evolutions, all final outcomes
of the game (and relative pay-offs), the order in which players take actions and
the information that players have at the time they are called to take those actions.
Usually, this is made by constructing the tree of the game.
I
p q
II II
r s t u
(apr , bpr ) (aps , bps ) (aqt , bqt ) (aqu , bqu )
Figure 1.1: Example: an extensive game with two players
The game in Fig.1.1 consists of two players (I, II). Each node represents a point
of choice for one of the players and each branch out of the node represents an
available action for that player. The combination of players’ choices leads to all
the available outcomes of the game, whose pay-offs are specified at the bottom of
the tree.
A game in extensive form may be analysed directly, or can be converted into an
equivalent strategic form.
1.1.1 Games in strategic form
Strictly dominated strategies The strategic form of a game is useful to anal-

yse strictly dominated strategies. Since all players are assumed to be rational,
they make choices which result in the outcome they prefer most, given what their
opponents do. Thus, the following assumption is quite natural:
A player does not choose X, if it is available to him Z allowing to

him to get strictly more, no matter which choice will make the other
players.
Then strategy Z is said to strictly dominate strategy X and a rational player will
never choose to play a dominated strategy. In some games, elimination of strictly
dominated strategies results in a unique rational outcome of the game.
Nash equilibria In many games, however, the rational outcome cannot be

singled out by means of the procedure of eliminating dominated strategies.
Nash equilibrium is a more general concept of solution, which includes dominant
strategy equilibria as special cases of it.
Definition 1.1. Let (X, Y, f : X × Y → R, g : X × Y → R) be a two player non

cooperative game in strategic form. A Nash equilibrium for the game is a pair
(x, y) ∈ X × Y such that:
f (x, y) ≥ f (x, y) for all x ∈ X
g(x, y) ≥ g(x, y) for all y ∈ Y.
A Nash equilibrium recommends a strategy to each player, which any player can-
not improve upon unilaterally: each player, taking for granted that the other one
will play what he is recommended to play, has no incentive to deviate from the
proposed strategy.
Since the other players are also rational, it is reasonable for each player to expect
his opponents to follow the recommendation as well.
Let BR1 (best response) be the following multifunction:
BR1 : Y → X : BR1 (y) = max {f (·, y)} .
In order to maximize his utility, the first player, once he knows that the second
player plays a given strategy y, will choose a strategy x, belonging to
max {f (·, y)} = {x ∈ X : f (x, y) ≥ f (u, y) ∀u ∈ X}

The same argument follows for the second player best response BR2 . Let BR be
such that
BR : X × Y → X × Y : BR(x, y) = (BR1 (y), BR2 (x)).
Thus, (x, y) is a Nash equilibrium for the game if and only if (x, y) ∈ BR(x, y).
Pure and mixed strategies A game in strategic form does not always have
a Nash equilibrium that allows each player to deterministically choose one of his
strategies (the players play pure strategies). Players may instead randomly select
from among these pure strategies with certain probabilities and, thus, play a mixed
strategy.
Definition 1.2. A mixed strategy is a probability distribution over the set of the
pure strategies.
A mixed strategy assigns a probability to each pure strategy and randomizes play-
ers’ choices. Thus, we need to consider expected pay-offs.
A Nash equilibrium in mixed strategy recommends a mixed strategy for each
player, where any players cannot gain on average, by unilateral deviation. More-
over, it always exists.
Theorem 1.3. If mixed strategies are allowed, then every game with a finite num-
ber of players, in which each player can choose from finitely many pure strategies,
has at least one Nash equilibrium.
1.1.2 Games in extensive form
While, in a game in strategic form, the players act simultaneously and do not
know others’ choices (there is not a temporal component), the extensive form of
a game allows to formalize also interactions where the players are informed about
the actions of others (sequential games).
A strategy is a complete algorithm for playing the game: it specifies player’s moves
for every possible situation throughout the game, even those not reached by the
actual play of the game because of a former choice specified by the strategies itself.
A game is called of complete information if the features of the players (strategies
and utility functions) are common knowledge.
Perfect information games and backward induction A game may be of

perfect information: every player knows at any time what is the current situation,
the past history and all possible future evolutions. Every player is at any point
aware of the previous choices of all other players and only one player moves at a
time.
Extensive games with perfect information can be analysed by backward induction,
in order to understand how rational players will play. This technique solves the
game by first considering the last possible choices in the game: it analyses what
happens at every terminal node, i.e. a node such that all branches, going out from
it, lead to a final situation. Every player knows what to do at every node he is
called to make a decision, and the other players know what he will do (they are all
rational players and they act in their own self-interest). Once the last moves have
been decided, backward induction proceeds to the players making the next-to-last
moves (and then continues in this manner).
Usually, backward induction provides a unique outcome of the game. The only
exception is if a player is indifferent among several alternatives.
Backward induction solution specifies the way the game will be played, starting
from the root of the tree and proceeding along a path to an outcome. Because
backward induction looks at every node in the tree, it specifies for every player
a strategy, a complete plan of what to do at every node in the game where the
player can make a move, even though that node may never be reached in the
course of play. Thus, an extensive game can be described by his strategic form.
Backward induction may not always find all Nash equilibria of a game of perfect
information, described in strategic form.
Imperfect information games The extensive form can also describe games
with simultaneous moves. These games are called of imperfect information, since a
player does not know the decision of the others, once is called to decide. However
they know who the other players are, what their possible actions are and the
preferences of these other players (the information is complete). Thus, a player
knows to be in one of possible nodes, but not in which one. To represent it, a
dotted line connects these nodes and the set of nodes is called information set.
I
p q
II II
r s t u
(apr , bpr ) (aps , bps ) (aqt , bqt ) (aqu , bqu )
Figure 1.2: Example: an extensive game with an information set for the second
player
A strategy specifies the choice of the player at each information set, labelled by
the name of the player (in games of perfect information, the information sets are
singletons).
Uncertainty Extensive games may include states where neither player makes a
choice: a random decision is made by a player (the chance) who has no strategic
interests in the outcome. For rationality, the players will evaluate their utility
functions in terms of expected values. This allows players having no uncertainty
about past moves and possible evolutions: the presence of the chance, once its
moves are observed by all the players, does not imply that the information is
imperfect. Rather, pay-offs will be evaluated using expected values.
1.2 A strategic game: the Prisoners’ Dilemma

As described in the previous sections, Game Theory provides a means of abstract-
ing the fundamental structure of an interaction and representing it in terms of a
strategic game.
The most famous of all strategic games with two players, in an interaction in-
volving cooperation and competition, is the Prisoners’ Dilemma game. It is a
standard example of game of complete and imperfect information: the structure
of the game and the pay-off functions of the players are common knowledge, but
each player has to choose strategically without knowing the other player’s choice.
The Prisoners’ Dilemma shows why two rational players might not cooperate,
even if cooperation would be in their best interests.
The concept of this game was originally developed by Merrill Flood and Melvin
Dresher working at RAND Corporation in 1950 and later formalized, with pay-
offs as prison sentence rewards, by Albert W. Tucker (that is the reason why it is
called Prisoners’ Dilemma).
In the standard formulation of the dilemma, two people are suspected of being
responsible of a serious crime. They are arrested and kept in solitary cell, there-
fore they cannot communicate (what is important is that they cannot make a
binding commitment to play in a certain way). The judge lacks enough evidence
to convict the pair on the principal charge, but he can prove that they are guilty
of a lesser crime. Each prisoner has two possible strategies: to confess the crime
(specifically, he confesses the responsibility of both) or to remain silent. Seven
years in jail is the punishment for the crime they are suspected of. The judge
offers each prisoner a bargain:
• if one confesses and the other does not, the collaborator will be set free and
the other one will be sentenced to 7 years in jail
• if they both confessed, they both will be sentenced to 5 years in jail (reduced
sentence: collaboration is appreciated)
• if no one confesses, they both will be sentenced to 1 year in jail (they are
guilty of a lesser crime)
The Prisoners’ Dilemma is a non cooperative game. It is useful to present the

game in strategic form, by means of a bimatrix, showing players’ strategies and
pay-offs. Each element of the matrix stands for the pay-off, obtained by the
players for a specific outcome of the game: in this particular situation they define
the number of years prisoners are sentenced to.
Given the game, the goal is to define, for each player, the optimal strategy, that
is the one minimizing the pay-offs (pay-offs are years in jail).
The available strategies for each players are ”to confess” (C) and ”not to confess”
(NC).
C NC
C (5,5) (0,7)
NC (7,0) (1,1)
Table 1.1: Prisoners’ Dilemma Bimatrix
I
C NC
II II
C NC C NC
(5,5) (0,7) (7,0) (1,1)
Figure 1.3: Prisoners’ Dilemma Tree
Eliminating all dominated strategies can solve this game: each prisoner analyses
his best strategy given the other prisoner’s possible strategies.
Specifically, if a player confesses, it is in the best interest of the other player to
confess too, in order to avoid the worst punishment (7 years). Otherwise if a
player decides not to confess, the other one, confessing, can be free.
It results that to confess is a dominant strategy for both players (it is better than
another one for a player, no matter how the opponent may play): this way, both
prisoners are sentenced to 5 years (C-C). This is the unique Nash equilibrium of
the game.
Clearly (NC-NC) would lead to a better outcome for both the players than (C-C)
(only 1 year in jail instead of 5) but it is not in equilibrium: this is because the
best replay to NC is to confess (a prisoner who discloses information, while the
other conceals it, is rewarded) and, by choosing NC, a prisoners exposes himself to
the worst possible outcome for himself. Because confessing offers a greater reward
than keeping silent, all rational self-interested prisoners would confess, and so the
only possible outcome for two purely rational prisoners is for both of them to
confess.
The interesting part of this result is that pursuing individual reward leads both
of the prisoners to confess, when they would get a better reward if they both
kept silent: the rational solution of the game does not lead to the best possible
outcome. The dilemma is that picking the best individual choice precludes the
group from achieving the best common outcome.
Chapter 2
A doctor-patient interaction
Modern clinical practice is founded on doctor-patient relationship: through this

interaction, doctors gather information and data, make diagnoses and therapeutic
decisions, treat the patient and help preventing illness, using clinical judgement.
Usually, a doctor checks the health condition of a patient, through a medical
examination and through a discussion about symptoms: therefore, the doctor-
patient relationship directly determines the quality of information gathered and
the care provided, since the more the patient trusts his doctor, the more he will
disclose complete information. Once the doctor has all the data, he has to decide
whether or not it is necessary to do something and, specifically what to do, in the
patient’s best interest: therefore, he presents findings and options to the patient.
The patient, deciding to consult a doctor, relies on him but he may expect his
needs to be met in the way himself defines. Usually, he has his own treatment
preferences or expectations (for example, among different treatment options, he
would prefer a specific one) [6].
Often, interests of doctors and patients partly diverge and it may happen that a
patient does not get the treatment he wants. As we have seen in Chapter 1, in
this specific situation, Game Theory allows to analyse the strategic behaviour of
a patient and a doctor, interacting in a clinical encounter. This analysis underline
the doctor-patient dynamics and it can guide decision making in health care.
Firstly, we present two applications of the most known strategic game, the pris-
14
Chapter 2, A doctor-patient interaction 15
oner’s dilemma game, described in Section 1.2. In his famous formulation, it may
seem contrived, but there are in fact many examples in human interaction as well
as interactions in nature that have the same pay-off matrix. Actually, it can be
used as a model for many real situations involving cooperative behaviour and is
therefore of interest to the social sciences such as economics, politics, and sociol-
ogy, as well as to the biological sciences.
With some simplifications, medical consultations in primary care may have an
underlying structure corresponding to the Prisoners’ Dilemma game.
2.1 The Prisoners’ Dilemma in a doctor-patient

encounter
Prisoners’ Dilemma and consultation A first possible hypothetical scenario
can be constructed with a busy doctor and his patient [15, 3].
Suppose that the doctor is consulted by a patient with a sore problem. After a
brief examination, the doctor has two options: on one hand, he can prescribes
antibiotics, hence dealing with the patient in less than 5 minutes, even if he is
not sure it is the best option for the patient, or, on the other, he can undertake
a full assessment of life style and other contributing factors and give the patient
a prescription and self-management advise after a detailed discussion of benefit
and risk of treatment, which would prolong the consultation to over 10 minutes.
The patient can choose to follow the advise and the prescription or to ignore the
prescribed treatment and seek a second opinion (consulting another doctor).
There are four possible outcomes:
• (C,C) the doctor spends times giving advice, the patient follows the advice;
• (C,D) the doctor spends times giving advice, the patient does not follow the
advice;
• (D,C) the doctor prescribes briefly a treatment, the patient follows the ad-
vice;
• (D,D) the doctor prescribes briefly a treatment, the patient does not follow
the advice.
In this example, the best collective outcome is (C,C): the doctor acts in the
patient’s best interest and the patient follows his advice without taking up valuable
time of other doctors. But this is not a Nash equilibrium.
Individually, the patient prefers seeking a second opinion (D) to avoid possible
medical errors, therefore the doctor’s best option is to spend little time on the
patient (D). On the other hand, if the doctor chooses to deal with the patient
quickly (D), than the patient prefers not to follow the treatment and to get a
second opinion.
Therefore, the patient obtains antibiotics for his sore problem and the doctor can
move on to the next patient. Both the patient and the doctor, by choosing D,
avoid the worst possible outcome for themself, but their choices lead to (D,D),
which is a negative outcome in good quality care.
Prisoners’ Dilemma for prescribing opioids to potentially drug-seeking

patients Another paradigmatic situation, that can be described through the
Prisoners’ Dilemma game is the description and analysis of a clinical encounter,
where a doctor prescribes opioids to potentially drug-seeking patients [8, 4].
I am addicted to [opioids], and it is doctors’ fault

because they prescribed them.
But, I will sue them if they leave me in pain.
Opioids are synthetic narcotics that affect on the brain to decrease the sensation
of pain. They are typically used in medicine as analgesics (painkillers) with severe
restrictions on their use, as most of them are extremely addictive.
In the United States, in 2010, there were reported as many as 2.4 million opioid
abusers and it results that sixty percent of the abused opioids have been obtained
directly through a physician’s prescription. In many instances, doctors are fully
aware that their patients are abusing these medications or diverting them to oth-
ers for non-medical use, but they prescribe them anyway. Prisoners’ Dilemma
models this paradigmatic situation.
Until the 19th century, pain was considered a sign of physical vitality, important
to the healing process. Nowadays, as the availability of painkillers increases, re-
lieving pain and suffering seems to be what the doctors are trained and almost
obliged to do: society expects them to treat pain and it seems that the patients’
subjective experience of pain prevails other considerations.
Recently, the importance of the subjective experience of pain has increased by the
practice of assessing patient satisfaction after the medical attention: patients have
to fill out surveys about the care they received, which include specific questions
about how their physicians have behaved in regard of their pain. In some institu-
tions, physicians’ compensation may depend on patients’ satisfaction scores and
this score can affect even the physician’s reputation. Obviously, doctors achieve
great satisfaction and professional gratification in relieving patients’ pain.
Thus, doctors are pushed on treating pain. However, when a patient asks for
opioids to alleviate suffering, the doctor has to evaluate whether the patient is in
real pain or he is pretending to be, in order to avoid prescription to patients who
ask for opioids for non-medical uses (for example, illegal uses or addiction habits).
If the patient has real pain, the rational choice for the doctor is to treat him. If
he fakes pain and the doctor suspects it, prescribing opioids is inappropriate as
it would continue to feed addiction or illegal uses: the professionally right choice
would be to diagnose and treat addiction. Besides having disastrous consequences
for patient with addiction, prescribing opioids when there is no need represents
also squandering resources for the health system.
Nevertheless, doctors who refuse to prescribe opioids to patients who demand it,
are likely to get a poor satisfaction score from those patients (which eventually
means poor reimbursement and bad reputation for the doctor). Moreover, the
professionally right choice not to prescribe pain medication to those who are not
in pain will not improve doctors’ satisfaction score. Therefore, it seems that it is
in doctor’s best interest to treat the pain, may it be real or fake.
This particular situation can be described by the following game tree.
Doctor
Prescribe Do Not Prescribe
N N
Real Fake Real Fake
S/R S/NR D D/R
Figure 2.1: S satisfied, D dissatisfied, R professionally rewarding, NR profes-

sionally less rewarding
Specifically, in Figure 2.1 the first player is the doctor, who decides whether or
not to prescribe opioids, while at the nodes, labelled by N, Nature chooses: the
patient may be in real or fake pain.
The patient, asking for opioids, is assumed to be more satisfied if he gets opioids
rather than if does not get them, no matter what his state of health is.
Moreover, the pay-offs in figure refer to the doctor:
Doctor : S/R indicates that the doctor gets high satisfaction score and he is pro-
fessionally rewarded (he prescribed opioids to a patient in real pain), D
indicates that the doctor gets poor satisfaction score from the patient (he
did not prescribe opioids to a patient in real pain), S/NR indicates that
the doctor receives a high satisfaction score but he is not professionally re-
warded (he prescribed opioids to a patient faking pain), D/R indicates that
the doctor gets a poor satisfaction score but he is professionally rewarded
(he did not prescribe opioids to a patient faking pain).
S/R > S/N R > D/R > D
It results that, for the doctor, Prescribe is a dominant strategy.

This is a classical Prisoners’ Dilemma: the best strategic move for individual (to
prescribe opioids, no matter the state of health of the patient) is not good for the
society, which actually is damaged.
2.2 The trust version of the Prisoners’ Dilemma

game
The Prisoners’ Dilemma game has been applied to two different situations but it
cannot be assumed as an appropriate model of doctor-patient interactions. For
example, the pain example, just considered, is a simplification of a typical interac-
tion between physicians and patients, because it neglects doctors’ professionalism
and ethical obligations [4]. Moreover, Prisoners’ Dilemma does not take into ac-
count trust, which is essential in every clinical encounter: without it, patients
would not commit to doctors in the first place.
In both the considered situation, lack of trust intensifies the Prisoners’ Dilemma,
while considering trust may help avoiding it.
Thus, Prisoners’ Dilemma can be modified, adding trust (this way, the pay-offs
change), in order to overcome paradoxical outcomes and to be a more realistic
description of a clinical interaction.
Trust is important because it allows agents to form relationship with others and
to depend on others in order to get something, yet it is risky because trusting
someone does not guarantee to actually obtain what needed [12].
Clearly, every clinical encounter is asymmetrical: patients have to expose themself
in a position of vulnerability and their trust can be abused. Sometimes it hap-
pens that patients’ interests may diverge, partially or completely, from doctors’
interests. Moreover, facing with decisions involving uncertain outcomes, only in
retrospect it is possible to see whether a decision proves right or wrong: doctors
cannot guarantee a priori that the therapy chosen for the patients will be effective
(in diagnostic uncertainty, he can make mistakes).
Therefore both patient and doctor may regret their choices: after making a de-
cisions under uncertainty, they can discover that another alternative would have
been better, for example, it happens when the doctor does not prescribe a treat-
ment to a patient needing it.
Moreover, the doctor feels guilty when he abuses patient’s trust, for example when
he gives unnecessary treatment to a patient who trusted him.
Eventually, both patients and doctors, can experience frustration when they are
not able to do something, because of other’s resistance. For example it occurs
when the patient refuses a treatment (frustration for the doctor) or when the
doctor refuses to prescribe a treatment to a patient that demands it (frustration
for the patient).
These concepts can be formalized in Game Theory models: regret, guilt and frus-
tration lead to smaller utilities and satisfaction for patients and doctors.
Chapter 3
The participation of a patient to

a Randomized Controlled Trial
The article When is it rational to participate in a clinical trial? A game theory ap-
proach incorporating trust, regret and guilt by Djulbegovic and Hozo [3], provides
a game theoretic analysis of a dilemma researchers and patients face, whether to
test new medical treatments on humans, through Randomized Controlled Trials.
Randomized Controlled Trials (RCTs) are the standard form of clinical trials: they
are scientific experiments, done in clinical research, to discover new treatments
and test standard ones. Specifically, they are used to test the efficacy of various
types of medical interventions, i.e. experimental treatments, standard treatments
or placebo: people, participating in a trial, are randomly allocated one or other of
the different treatments under study, and through human experimentations, they
generate data on safety and efficacy.
A patient can participate to a Randomized Controlled Trial only if the principle
of clinical equipoise is verified, that is to say that there is genuine uncertainty
about the preferred treatment. This principle provides the ethical basis for med-
ical research that involves assigning patients to different treatments.
RCTs have always raised ethical concerns whether a researcher risks putting clin-
ical research ahead of his patients’ best interests.
In clinical research that uses Randomized Controlled Trial, there is an interaction
21
Chapter 3, The participation of a patient to a RCT 22
between two agents, a patient and a clinical researcher, with common and con-
flicting interests. If a patient provides informed consent for their participation in
an RCT, he is not certain to receive treatment that is best for him personally, but
he prides himself in his contribution to clinical research. Obviously, he also hopes
to improve his own health conditions. Similarly, a clinical researcher is motivated
to help his own patient, through RCT, even if the main purpose of the RCT is to
potentially improve healthcare for the good of future patient.
Thus, the matter of patients’ participation to RCTs can be formulated as a Game
Theory game with two players that act strategically to advance their interests, in
conflict and cooperation situations.
In a model describing a RCT situation, trust has to be taken into account, since
every clinical encounter is based on it and specifically, trust is essential for the
participation of patients in experimental clinical trials.
A patient, by trusting the researcher and by participating to a RCT, accepts some
level of risk and vulnerability. Once enrolled in the trial, the patient may discover
that his trust has been abused (for the sake of research) and therefore, regret his
choice to participate. In the same way, the researcher may feel guilty because he
did not honour his patient’s trust.
Concepts of regret and guilt are formalized in Game Theory models, to under-
stand when it is rational to participate in a Randomized Controlled Trial, from
the point of view of patients and researchers. We will see that the analysis leads
to the same conclusions of the Prisoners’ Dilemma game.
3.1 A sequential game with perfect information

The model used to describe the participation of a patient to a Randomized Con-
trolled Trial is a sequential game with perfect information: the patient first has to
decide whether or not to trust the researcher and once the researcher is trusted,
he has to decide whether to honour the patient’s trust or to abuse it.
It is considered a Randomized Controlled Trial, used to test a new experimen-
tal treatment, by comparing it to a standard one. In the RCT, the patient is
randomly assigned to the experimental treatment or to the standard one, with
probability of randomization r, associated to the experimental treatment.
Since no treatment is always successful, it is assumed that there is a certain prob-
ability of success of experimental and standard treatment, respectively e and s.
e (U1 , V1 )
EXP
r (U2 , V2 )
1-e
1-r RCT
o ur s (U3 , V3 )
Hon
STD
Researcher 1-s (U4 , V4 )
Ab
use (U1 , V1 )
e
st
u
Tr
EXP
1-e (U2 − R(U3 − U2 ), V2 − G(V2 − U2 ))
Patient
N
o
(U3 , N A)
Tr
s
us
t
STD
1-s
(U4 − R(U1 − U4 ), N A)
Figure 3.1: A sequential game with perfect information to model a RCT clinical
research - Tree structure
Firstly, the patient decides whether or not to trust the researcher: if he trusts
him, he accepts to get the new, unproven, experimental treatment (EXP) within
the context of the trial, otherwise, if he does not trust the researcher he chooses to
directly get the standard treatment (STD). Once the patient trusts the researcher
and decides to participate in the RCT, the researcher has to decide whether to
offer the experimental treatment only within the context of the RCT (honour-
ing patient’s trust) or to offer it outside the trial (abusing trust). The last case
happens if the researcher believes that the new treatment is superior or if they
invested considerably effort in developing it.
Available strategies for the patient are Trust and No Trust, while, for the re-
searcher, they are Abuse and Honour.
At every possible outcome of the game, each player associates a pay-off, which
represents his preference on the outcome of the game. Patient and researcher’s
utilities are denoted by U and V, respectively.
Specifically:
V1 , U1 are the pay-offs associated with the success of experimental treatment
V2 , U2 are the pay-offs associated with the failure of experimental treatment
V3 , U3 are the pay-offs associated with the success of standard treatment
V4 , U4 are the pay-offs associated with the failure of standard treatment
If the patient chooses No Trust, he gets the standard treatment, directly: the
researcher is not called to decide, therefore his utility is not defined (NA).
It is assumed that the patient favours success over failure of a treatment and he
gets more satisfaction in the experimental success rather than in the standard
one, since, this way, he feels to contribute to clinical research on new treatments.
U1 ≥ U3 ≥ U2
U1 ≥ U3 ≥ U4
The researcher favours success over failure of a treatment, but does not prefer a
treatment success over the other: data on experimental treatment are significant,
even in case of unsuccessful testing. Thus, researcher’s pay-off, associated with
the failure of experimental treatment is greater than analogous patient’s.
V1 ≥ V2 V3 ≥ V4 V2 ≥ U2
Since in clinical experiments patients cannot be guaranteed successful outcomes

with any treatment, clinical trials, as any other clinical encounter, are based on
trust. Thus, concepts of regret and guilt have been integrated in the model: they
all lead to smaller utilities and satisfaction for the players.
Specifically, after a patient has volunteered participation in the trial, he may
discover that his trust has been abused and, therefore, he will regret his choice:
regret (R) is defined as a fraction of the difference between the utility of the taken
action and the utility of the best action he should have taken, a posteriori. For the
sake of simplicity, R is the same in all possible scenarios (No Trust and Abuse).
Similarly, a researcher may feel guilty when he abuses the patient’s trust. Guilt
(G) diminishes the researcher’s utility by a fraction of the difference between his
and the patient’s utility corresponding with the same outcome, but obtained in
the RCT scenario.
For example, the path Trust - Abuse - Failure is considered: the patient trusts the
researcher, who abuses his trust and offers the experimental treatment outside the
RCT, without success.
P atient : U2 − R(U3 − U2 )
Researcher : V2 − G(V2 − U2 )
The patient:
1. gets the experimental treatment without success → U2
2. regrets his choice to trust the researcher: his utility diminishes by a fraction
of the difference between the utility he gets and the utility he should have
achieved, a posteriori → R(U3 − U2 )
The researcher:
1. gives the patient the experimental treatment without success → V2
2. feels guilty: his utility diminishes by a fraction of the difference between his
and the patient’s utility corresponding with the same outcome (unsuccessful
experimental treatment), but obtained in the RCT scenario. → G(V2 − U2 )
3.2 Analysis
Success of experimental treatment, success of standard treatment and randomiza-
tion in RCT introduce uncertainty in the model. Once probability of randomiza-
tion is fixed, e and s will be the key parameters to determine optimal strategies.
In order to solve the game, the model is reduced by evaluating the utility functions
of the players in terms of expected utilities.
Specifically, the expected values of all possible scenarios are calculated, denoted
by P and R, for patient and researcher respectively: P1 and R1 are the expected
values of scenario Honour (they are randomization-weighted averages), P2 and R2
are the expected values of scenario Abuse, P3 and R3 are the expected values of
scenario No Trust.
P1 = r · [e · U1 + (1 − e)U2 ] + (1 − r) · [s · U3 + (1 − s) · U4 ]
R1 = r · [e · V1 + (1 − e) · V2 ] + (1 − r) · [s · V3 + (1 − s) · V4 ]
P2 = e · U1 + (1 − e) · U2 − (1 − e) · R · (U3 − U2 )
R2 = e · V1 + (1 − e) · V2 − (1 − e) · G · (V2 − U2 )
P3 = s · U3 + (1 − s) · U4 − (1 − s) · R · (U1 − U4 )
R3 = N A
our RCT (P1 , R1 )

Hon
Researcher A
st buse
T r u
EXP (P2 , R2 )
Patient N
oT
rust
STD (P3 , R3 )
Figure 3.2: A sequential game with perfect information to model a RCT clinical
research - Reduced tree structure
Solving the game means to determine patient’s and researcher’s optimal strategies.
Let p be a variable such as
(
1 if the researcher honours trust
p=
0 if the researcher abuses trust
and let τ be a variable such as

(
1 if the patient trusts the researcher
τ=
0 if the patient does not trust the researcher
Since it is a perfect information game, the method used to solve the game is
backward induction. This technique starts from the terminal nodes of the tree
structure and proceeds up to the root.
Researcher The unique terminal node is the one associated to the researcher:
his choice depends on which expected utility is greater, R1 or R2 .
Specifically, the researcher honours patient’s trust (p = 1) if R1 > R2 .
Let
EV [Exp] = e · V1 + (1 − e) · V2 EV [Std] = s · V3 + (1 − s) · V4
be the researcher’s expected utilities of experimental and standard treatment,

respectively.
Using the expressions of utilities, the researcher honours patient’s trust (p = 1) if
r · (EV [Exp] − EV [Std]) ≥ EV [Exp] − EV [Std] − (1 − e) · G · (V2 − U2 )

If EV [Exp] > EV [Std], i.e. the researcher prefers the experimental treatment over
the standard one, he will choose to honour patient’s trust if
(1 − e) · G · (V2 − U2 )
r >1−
EV [Exp] − EV [Std]
Otherwise, if EV [Exp] < EV [Std], the researcher will choose to honour patient’s
trust if
(1 − e) · G · (V2 − U2 )
r <1−
Let
(1 − e) · G · (V2 − U2 )
r∗ = 1 −
be the randomization probability, that makes the researcher indifferent between
choosing to honour or abuse trust.
Thus, the researcher’s best reply is
> r∗


 p = 1 if r ∧ EV [Exp] > EV [Std]
< r∗

p = 0 if r ∧ EV [Exp] > EV [Std]
BRr =


 p = 1 if r < r∗ ∧ EV [Exp] < EV [Std]
> r∗ ∧

p = 0 if r EV [Exp] < EV [Std]
The researcher’s best strategy is defined, once all parameters are fixed.
Patient To conclude the analysis, root node is analysed: the patient is called
to move. Since it is a game of perfect information, the patient knows what is the
researcher’s rational choice.
Let
EU [Exp] = e · U1 + (1 − e) · U2 EU [Std] = s · U3 + (1 − s) · U4
be the patient’s expected utilities of experimental and standard treatment, re-

spectively.
In order to choose, the patient has to compare the expected utility of No Trust
(P3 ) with the expected utility of Trust, which depends on the researcher’s choice.
Thus, to derive the patient’s best reply, it is necessary to distinguish five cases:
1. if r > r∗ ∧ EV [Exp] > EV [Std] the researcher honours trust (p = 1).

Therefore, the patient’s decision depends on the sign of P1 − P3 .
Specifically, he trusts the researcher (τ = 1) if P1 > P3
r · EU [Exp] + (1 − r) · EU [Std] > EU [Std] − (1 − s) · R · (U1 − U4 )
2. if r < r∗ ∧ EV [Exp] > EV [Std] the researcher abuses trust (p = 0).

EU [Exp] − (1 − e) · R · (U3 − U2 ) > EU [Std] − (1 − s) · R · (U1 − U4 )
3. if r < r∗ ∧ EV [Exp] < EV [Std] the researcher honours trust (p = 1).

4. if r > r∗ ∧ EV [Exp] < EV [Std] the researcher abuses trust (p = 0).

5. if r = r∗ , the researcher is indifferent between choosing Honour or Abuse.

In this situation, backward induction does not provide a unique outcome of
the game.
3.2.1 Data
To compute the solution, it is necessary to estimate variables in the game: players’

utilities, trust variables such as regret and guilt and the randomization probabil-
ity. Once they are fixed, best strategies for the players depend on values of the
variables e and s, the probability of success of the experimental and standard
treatment, respectively.
There are not empirical data that can precisely inform the values of each of the
utilities of the model: usually they are obtained by surveying a sample of ex-
perienced clinical investigators, asking them to provide the values of each of the
utilities in the model, first from a patient and then from a researcher point of
view. Regret and guilt are quantified using psychometric measurement approach.
Djulbegovic and Hozo, in their article [3], provide values for utilities and trust
variables, which satisfy the conditions
U1 ≥ U3 ≥ U2 U1 ≥ U3 ≥ U4
V1 ≥ V2 V3 ≥ V4 V2 ≥ U2
Specifically,
Researcher Patient
V1 =95 U1 =90
V2 =54 U2 =16.3
V3 =70 U3 =84
V4 =44 U4 =16.9
G=0.2 R=0.2
Moreover, let r = 0.5: it is assumed equal probability of being assigned to the
standard or to the experimental procedure.
Using data, it results that
26 10
EV [Exp] − EV [Std] > 0 ⇔ e> s−
41 41
(1 − e) · G · (V2 − U2 ) 26 5.08
r > r∗ =: 1 − ⇔ e< s+
EV [Exp] − EV [Std] 56.08 56.08
Thus, all the results are rewritten, highlighting the dependence on e and s. Figures
are used to display the results of the patient’s and the researcher’s best strategy
over all possible values of the success of experimental and standard treatment.
Researcher Firstly, the researcher’s best reply is analysed.

It results that
26 5.08 26 10
e> s+ ∧ e< s−
56.08 56.08 41 41
are incompatible. It corresponds with conditions r < r∗ ∧ EV [Exp] < EV [Std]: it
is not possible that, under the condition that the researcher prefers the standard
treatment over the experimental one (EV [Exp] < EV [Std]), his best strategy is to
honour trust (p = 1).
Thus, the researcher’s best reply is
 26 5.08 26 10

 p=1 if e < 56.08
s + 56.08
∧ e> 41
s − 41
(3.1a)


26 5.08 26 10
BRr = p = 0 if e > 56.08
s + 56.08
∧ e> 41
s − 41
(3.1b)


26 5.08 26 10

p=0 if e < s + ∧ e< s − (3.1c)

56.08 56.08 41 41
1.0
0.8
0.6
p=1 Honour HaL

e
p=0 Abuse HbL

0.4 p=0 Abuse HcL
0.2
0.0
0.0 0.2 0.4 0.6 0.8 1.0
s
Figure 3.3: Researcher’s best reply

A researcher should enrol a patient in a RCT when there is genuine uncertainty

about the preferred treatment, i.e. the probability of success of the experimental
treatment is equal to the probability of success of the standard one. It means
that, in figure, for values of e and s close to the diagonal e = s, the researcher’s
best strategy should be to honour trust.
Instead, as shown, close to the diagonal, the researcher’s best strategy is to abuse
the patient’s trust and to give him the experimental treatment outside the RCT.
The researcher’s best strategy is to honour the patient’s trust (p = 1) if:
- both probabilities e and s are close to zero;
e
- ratio s
is close to 0.5: the probability of success of the standard treatment
is, at least, twice the probability of success of the experimental treatment.
For all other combination of e and s, the researcher abuses the patient’s trust
(p=0 ) and gives him the new experimental treatment outside the trial.
Specifically, it happens if:
- the probability of success associated to the experimental treatment is large,

let s be small or large;
- both probabilities are large (the higher the probability that the experimental
treatment will be successful, the more incentive the researcher has to abuse
the patient’s trust);
- the probability of success associated to the standard treatment is large and

the probability of success associated to the experimental one is close to zero.
Patient To derive the patient’s best reply, it is necessary to distinguish four

cases:
1. if the probabilities of success associated with experimental and standard

treatment, e and s, are such as
26 5.08 26 10
e< s+ ∧ e> s− , (a)
56.08 56.08 41 41
the researcher honours trust (p = 1) and enrols the patient in the RCT.
Thus, the patient trusts the researcher (τ = 1) if P1 > P3 .
Using data, it results that the patient trusts the researcher (τ = 1) if
96.34 28.64
e> s−
73.3 73.7
1.0
0.8
0.6
Τ=1, Trust
Τ=0, No Trust
0.4
0.2
0.0
0.0 0.2 0.4 0.6 0.8 1.0
Figure 3.4: Patient’s best reply if p = 1
Under the conditions that make Honour the researcher’s best choice, the
patient chooses to trust the researcher if both the probabilities of success of
the treatments, e and s, are close to zero. Otherwise, for high values of the
probability of success associated with the standard treatment, the patient’s
best choice is No Trust: he gets directly the standard treatment.

26 5.08 26 10
e> s+ ∧ e> s− (b)
56.08 56.08 41 41
the researcher abuses trust (p = 0) and directly offers the experimental

treatment to the patient.

81.72 0.48
e> s−
87.24 87.24
1.0
0.8
0.6
Τ=1, Trust
Τ=0, No Trust
0.4
0.2
0.0
0.0 0.2 0.4 0.6 0.8 1.0
Figure 3.5: Patient’s best reply if p = 0 (b)
Under the conditions r < r∗ ∧ EV [Exp] > EV [Std], that make Abuse the
researcher’s best choice, the patient chooses to trust the researcher and to
volunteer participation in the trial if the probability of success associated
with the experimental treatment is larger than the one associated with the
standard treatment.

26 5.08 26 10
e< s+ ∧ e< s− (c)
56.08 56.08 41 41
the researcher abuses trust (p = 0) and directly offers the experimental

treatment to the patient.
81.72 0.48
e> s−
87.24 87.24
81.72 0.48 26 10
However, e > 87.24
s − 87.24
and e < 41
s − 41
are incompatible, therefore
this is an empty region: it is not possible that, under the conditions that
the researcher prefers the standard treatment over the experimental one
(EV [Exp] < EV [Std]), the patient’s optimal choice is Trust.
Under these conditions, the patient chooses No Trust always.
1.0
0.8
0.6
Τ=0, No Trust
0.4
0.2
0.0
0.0 0.2 0.4 0.6 0.8 1.0
Figure 3.6: Patient’s best reply if p = 0 (c)
26 5.08
4. if e = 56.08
s + 56.08
, the researcher is indifferent between choosing Honour
or Abuse. In this situation, backward induction does not provide a unique
outcome of the game.
Once the players’ utilities, trust variables and the randomization probability are
fixed, players’ best strategies depend on the probabilities of success e and s.
The final situation is depicted in the following figure, which displays the results
of the patient’s and the researcher’s best strategy over all possible values of the
success of experimental and standard treatment.
1.0
0.8
0.6
Τ=1, p=0
Τ=0, p=0
Τ=1, p=1
0.4 Τ=0, p=1
0.2
0.0
0.0 0.2 0.4 0.6 0.8 1.0
Figure 3.7: Players’ best strategies, function of e and s. The dot shows the most
likely values of e and s
The best possible outcome would be for the patient to trust the researcher and
for the researcher to honour trust (τ = 1 and p = 1, yellow field in figure): it is
favourable both for the researcher to have people enrolling to clinical trial and for
the patient to be able to trust his own doctor.
It happens for values of e and s close to zero: the researcher honours the patient’s
trust if both treatments have little probability to be successful.
From RCTs performed over 50 years in the field of cancer, the most likely values
of the probability of success e and s are assessed to be (e, s) = (0.41, 0.59).
As shown, the most likely situation is such that neither the patient trusts the
researcher, nor the researcher honours trust (τ = 0 and p = 0, the dot in the
purple field in figure). Thus, under randomization of 50%, the most rational
strategy for the player is not to cooperate, which is a negative and very socially
inefficient outcome.
This situation describes a Prisoners’ Dilemma: the players’ optimal strategies are
Abuse and No Trust.
The results of this model may explain the low rate of patients enrolling to clinical
trials, because they believe the researcher will not honour their trust. Therefore,
the model highlights the necessity to find a way to induce an optimal behaviour
of the researcher, in order to lower abuses and increase participation to clinical
trials.
Chapter 4
Game Theory models for

healthcare decisions
It is now interesting to analyse Game Theory application in healthcare decisions,

specifically in a generic and common interaction between a patient and a doctor,
to analyse the strategic behaviour of the agents, interacting in a clinical encounter.
Therefore, we consider the easiest clinical encounter between a patient and a doc-
tor. The doctor faces the difficult choice of whether or not to administer a certain
treatment to a patient who may have a disease or not. It is supposed (and this
happens in the majority of clinical interactions) that there is uncertainty about
the presence of a given disease and no further diagnostic testing is available. Ad-
ministering a treatment, known to be effective for the disease under consideration,
is advantageous if the disease is actually present, otherwise it could be damaging
if the disease is absent. On the contrary, failing to prescribe the treatment is good
if there is not disease, but it may worsen the patient’s condition if the disease is
present [5].
The patient has to decide whether or not to trust the doctor. Moreover, he may
demand treatment when the doctor does not recommend it (and he may get it or
not).
In this chapter, several different models are presented, analysed and compared,
specifically simultaneous games and sequential games. Simultaneous games have
38
Chapter 4, Game Theory models for healthcare decisions 39
been provided by already existing studies [4], while sequential ones are new mod-
els. The choice of modifying models aims to create a more realistic game for
everyday clinical encounters.
Since every clinical interaction is fundamentally based on trust, concepts of regret,
guilt and frustration have to be integrated in Game Theory models.
4.1 Simultaneous games for healthcare decisions

The first models we consider are two simultaneous games with two players, the
doctor and the patient, as Djulbegovic, Hozo and Ioannidis present them in the
article Modern health care as a game theory problem [4].
They are games of complete and imperfect information: the structure of the game
and the pay-off functions of the players are commonly known, but the players do
not see all the moves made by others (they play simultaneously).
This is a strong hypothesis: it is assumed that the patient does not know if the
doctor prescribes the treatment or not. Even if it is realistic in some situation,
as in a surgical context, this hypothesis is not verified in everyday clinical inter-
actions, since usually, the doctor shares the diagnosis and the benefit and risk of
a treatment with the patient.
The situation is the following: a doctor sees a patient, there is uncertainty about
the presence of a certain disease and a specific treatment is known to be efficient
for that disease. It is not possible to obtain further information, as all diagnostic
testing is exhausted.
The doctor’s strategies are:
R: he recommends the treatment to the patient
No R: he does not recommend the treatment to the patient
Instead, the patient’s strategies are:
Trust: he accepts the doctor’s choice

No Trust: he does not agree with the doctor’s choice
In the specific situation when the doctor does not recommend the treatment and
the patient does not trust him (he disagrees with the doctor’s decision not to
recommend the treatment), the patient himself can ask for the treatment.
It leads to two slightly different models:
Model A : the patient asks for the treatment and he does not get it
Model B : the patient asks for the treatment and he gets it
4.1.1 Simultaneous game, model A: the patient demands

treatment and he does not get it
Firstly, we consider model A: the patient asks for the treatment that the doctor
does not recommend and he does not get it.
Since it s a simultaneous game, its extensive form has an information set for the
patient (dashed line in the tree structure): the first player is the doctor and the
second player, the patient, when called to decide knows to be in one of the two
nodes of the information set, but not in which one.
+
D (V1 , U1 )
s t
Tru D− (V2 − G(U4 − V2 ) − Rd (V4 − V2 ), U2 − Rp (U4 − U2 ))
Patient
+
R No D (V3 − Fd (V1 − V3 ), U3 − Rp (U1 − U3 ))
Tru
s t
D− (V4 , U4 )
Doctor
+
D (V3 − G(U1 − V3 ) − Rd (V1 − V3 ), U3 − Rp (U1 − U3 ))
No st
R Tru D− (V4 , U4 )
Patient
+
No D (V3 − G(U1 − V3 ) − Rd (V1 − V3 ), U3 − (Rp + Fp )(U1 − U3 ))
(De Trus
man t (V4 , U4 − Fp (U4 − U2 ))
dR D−
)
Figure 4.1: Simultaneous Model A tree structure

D+ states that the disease is present (the treatment is known to be effective),

while D− states that the disease is absent (the treatment may be harmful).
Each path of the tree (or course of action) is associated with the pay-offs, which
refer to how the players quantify various clinical outcomes such as life expectancy,
mortality rates, absence of pain, satisfaction with care and cost. Doctor and
patient’s utilities are denoted by V and U, respectively.
Specifically:
V1 , U1 are the pay-offs associated with the prescription of the treatment in presence
of the disease
V2 , U2 are the pay-offs associated with the prescription of the treatment in absence
of the disease
V3 , U3 are the pay-offs associated with the non-prescription of the treatment in

presence of the disease
V4 , U4 are the pay-offs associated with the non-prescription of the treatment in

absence of the disease
It is assumed that the doctor gets more satisfaction in treating a patient with
disease (V1 ) than in non-treating a patient without disease (V4 ): action is valued
better than no action and the patient expects the doctor to do something. The
administration of no treatment to a patient without disease (V4 ) is valued more
than the unnecessary administration of the treatment to someone without disease
(V2 ). The worst outcome, however, is associated with failing to administer treat-
ment to a patient with disease (V3 ). Similarly, patient’s outcomes are ordered in
the same way.
0 ≤ V3 < V2 < V4 < V1
0 ≤ U3 < U2 < U4 < U1

The patient’s utility of receiving the treatment in presence of disease (U1 ) is greater
than the doctor’s utility when he does not recommend the treatment to a patient
with disease (V3 ).
V3 ≤ U1
The patient’s utility of non-receiving the treatment when there is not disease (U4 )
is greater than the doctor’s utility when he recommends a treatment to a patient
without disease (V2 ).
V2 ≤ U4
This game models a clinical encounter and, since every doctor-patient interaction
is fundamentally based on trust, concepts of regret, guilt and frustration have been
integrated in the model: they all lead to smaller utilities and satisfaction for the
players.
+
D (V1 , U1 )
st
Tru D− (V2 − G(U4 − V2 ) − Rd (V4 − V2 ), U2 − Rp (U4 − U2 ))
Patient
+
R No D (V3 − Fd (V1 − V3 ), U3 − Rp (U1 − U3 ))
Tru
s t
D− (V4 , U4 )
Doctor
+
D (V3 − G(U1 − V3 ) − Rd (V1 − V3 ), U3 − Rp (U1 − U3 ))
No s t
R Tru D− (V4 , U4 )
Patient
+
No D (V3 − G(U1 − V3 ) − Rd (V1 − V3 ), U3 − (Rp + Fp )(U1 − U3 ))
(De Trus
man t (V4 , U4 − Fp (U4 − U2 ))
dR D−
)
Figure 4.2: Simultaneous Model A tree structure, highlighting regret, guilt and
frustration
When a player regrets his decision because he realizes that another course of action
would have been preferable, he has a loss of potential utility: R is defined as a
fraction of the difference between the utility of the taken action and the utility of
the best action he should have taken, a posteriori. For the sake of simplicity, R
is the same in all possible scenarios, but it may differ from doctor (Rd ) to patient
(Rp ).
Doctor may feel guilty when he abuses the patient’s trust: he fails to evaluate the
health condition and makes a mistake in the therapeutic decision. G diminishes
the doctor utility by a fraction of the difference between his and the patient’s
utility.
Eventually, frustration occurs when a player cannot do something because of the
resistance of the other player. Similarly to regret, F is defined as a fraction of the
difference between the utility of the taken action and the utility of the best action
he should have taken, a posteriori.
For example, we consider the path No R - No Trust - D+ in Fig. 4.2: in presence
of the disease, the doctor does not recommend the treatment to a patient, who
asks for it, without getting it.
Doctor : V3 − G(U1 − V3 ) − Rd (V1 − V3 )
P atient : U3 − (Rp + Fp )(U1 − U3 )
The doctor:
1. does not prescribe the treatment in presence of the disease → V3
2. feels guilty: his utility diminishes by a fraction of the utility that the patient
could have achieved and his utility → G(U1 − V3 )
3. regrets his decision (he should have chosen R): his utility diminishes by a
fraction of the difference between the utility he should have achieved and
the utility he gets → Rd (V1 − V3 )
The patient:
1. does not get the treatment in presence of the disease → U3

2. regrets his (forced) choice not to get the treatment: his utility diminishes
by a fraction of the difference between the utility he should have achieved
and the utility he gets → Rp (U1 − U3 )
3. is frustrated because the doctor refused to give him the demanded treatment:
his utility diminishes by a fraction of the difference between the utility he
should have achieved and the utility he gets → Fp (U1 − U3 )
The reduced model In order to solve the game, the model needs to be reduced.
The presence or absence of the disease (D+ or D− ) is a random event, which
introduces uncertainty in the model.
Let X be a random variable such as
(
1 if the disease is present (D+ )
X=
0 if the disease is absent (D− )
Let p be the probability, assessed by the doctor and known by the patient, that
the disease is present, P (X = 1) = p, and let 1 − p be the probability that the
disease is absent, P (X = 0) = 1 − p.
Thus, X is a random variable with Bernoulli distribution
X ∼ B(p)
which takes the value 1 with probability of disease p and the value 0 with proba-
bility 1 − p.
Let u(·) be the utility function, such that u(X = 1) is the player’s utility when
the disease is present and u(X = 0) the player’s utility when the disease is absent.
Thus, u(X) is a random variable with Bernoulli distribution
u(X) ∼ B(p)
since P (u(X) = u(i)) = P (X = i), i = 0, 1.

The model can be reduced: the utility functions of the players are evaluated in
terms of expected utilities. More specifically, the expected value of the random
variable u(X) is calculated as the probability-weighted average of all possible
values u(X) assumes.
X
E[u(X)] = P (X = i) · u(i) = p · u(1) + (1 − p) · u(0)
i
s t (D11 , P11 )
Tru
Patient
R No
Tru (D21 , P21 )
s t
Doctor
No s t (D12 , P12 )
R Tru
Patient
No
(De Trus (D22 , P22 )
man t
dR
)
Figure 4.3: Reduced simultaneous model A tree structure
Using the expressions of the pay-offs, it results that the expected pay-offs, denoted
by D and P for the doctor and the patient, respectively, are the following:
D11 = p · V1 + (1 − p) · (V2 − G · (U4 − V2 ) − Rd · (V4 − V2 ))
D21 = p · (V3 − Fd · (V1 − V3 )) + (1 − p) · V4
D12 = p · (V3 − G · (U1 − V3 ) − Rd · (V1 − V3 )) + (1 − p) · V4
D22 = p · (V3 − G · (U1 − V3 ) − Rd · (V1 − V3 )) + (1 − p) · V4
P11 = p · U1 + (1 − p) · (U2 − Rp (U4 − U2 ))
P21 = p · (U3 − Rp · (U1 − U3 )) + (1 − p) · U4
P12 = p · (U3 − Rp · (U1 − U3 )) + (1 − p) · U4
P22 = p · (U3 − (Rp + Fp ) · (U1 − U3 )) + (1 − p) · (U4 − Fp · (U4 − U2 ))

All the expected utilities depends on the parameter p, the probability of disease.
For example, D11 is the doctor’s utility when he recommends the treatment (R)
and the patient trusts him (Trust) and P12 is the patient’s utility when he agrees
(Trust) with the doctor’s decision not to prescribe the treatment (No R).
It is evident that D12 = D22 and P21 = P12 : when the doctor does not prescribe
the treatment, his utility does not depend on the patient’s choice (in any case
the patient does not get the treatment) and the patient’s utility, when he does
not get the treatment, does not depend on how he gets at this outcome (because
he refuses the recommended treatment or because he agrees with the doctor’s
decision not to prescribe the treatment).
Since this is a simultaneous game, it is useful to represent it into its strategic
form, by a 2x2 pay-offs bimatrix: the rows are doctor’s strategies (R, No R) and
the columns are patient’s strategies (Trust, No Trust).
Trust No Trust
R (D11 , P11 ) (D21 , P21 )
No R (D12 , P12 ) (D22 , P22 )
Table 4.1: Strategic form - Model A
Analysis Solving this game means to determine doctor and patient’s optimal
and rational strategies. Since all the expected utilities depends on p, also the
solution of the game will be a function of p.
First of all, it is interesting to determine under which circumstances a player has
a strictly dominant strategy, a strategy which is superior to all other strategies
regardless of what the other player does. Since there are two possible strategies,
usually, elimination of strictly dominated strategies results in a unique rational
outcome of the game: each player plays an optimal pure strategy, which define a
player’s choice at each information set. A dominant strategy equilibrium is a pure
strategy Nash equilibrium.
Otherwise, if conditions for pure strategies equilibria are not met, the best strategy
is a mixed strategy, a probability distribution over the set of pure strategies.

Equilibria in mixed strategies result in mixed strategy Nash’s equilibria, solutions
where no player has anything to gain by changing only his own strategy.
Trust No Trust
R (D11 , P11 ) (D21 , P21 )
No R (D12 , P12 ) (D22 , P22 )
Table 4.2: Strategic form - Model A, highlighting the utilities that are compared
in the analysis
Firstly, it is useful to compare the following utilities, since the existence of domi-
nated strategies depends on their signs.

p Bd U4 − V2 p U1 − V3
D11 − D12 ∝ − (1 + Rd ) 1 − +G −
1 − p Hd Hd 1 − p Hd
D22 − D21 ∝ − [(Rd − Fd )Bd + G(U1 − V3 )]

p Bp
P11 − P21 ∝ − 1 −
1 − p Hp
P22 − P12 < 0 always
We introduce the notations Benefit Bp = U1 − U3 for the patient, Bd = V1 − V3 for

the doctor and Harm Hp = U4 − U2 for the patient, Hd = V4 − V2 for the doctor.
Given the uncertainty of the disease, administrating a treatment, known to be
effective for the disease under consideration, will be beneficial if the disease is
actually present, but may be harmful if the disease is absent. So Bp is the benefit,
in term of utilities, that a sick patient (D+ ) achieves in receiving the treatment
against not receiving it. On the other hand Hp represents the risk of harmful
consequences for a patient without disease (D− ), when he receives a treatment
instead of not receiving it.
Similarly, Bd and Hd refer to benefit and harm, assessed by the doctor, adminis-
trating or not a treatment to a patient (sick or not).
We observe that the signs of P22 − P12 and D22 − D21 do not depend on the prob-
ability of disease p. Specifically, P22 − P12 is negative for all p and the sign of
D22 − D21 is fixed (positive negative or null), once players’ variables are fixed. On
the contrary, the sign of D11 − D12 and P11 − P21 depend on p.
Solving for pure strategy Firstly, we determine under which conditions a

player has a strictly dominant strategy.
From the point of view of the doctor:
1D. If D11 > D12 and D21 > D22 , R is a dominant strategy (optimal pure
strategy) for the doctor, therefore the patient’s best reply is
(
Trust if P11 > P21
BRII (R) =
No Trust if P11 < P21
If P11 = P21 , the patient is indifferent between choosing Trust or No Trust.
2D. If D11 < D12 and D21 < D22 , No R is a dominant strategy (optimal pure
strategy) for the doctor, therefore patient’s best reply is
BRII (N oR) = Trust
since P22 − P12 < 0 always.
Since the sign of D21 − D22 is fixed, these conditions are mutually exclusive.
Thus, the doctor has a strictly dominant strategy when
D11 − D12
<0
D22 − D21
In analogous way, from the point of view of the patient:
1P. If P11 > P21 and P12 > P22 , Trust is a dominant strategy (optimal pure
strategy) for the patient, therefore the doctor’s best reply is
(
R if D11 > D12
BRI (T rust) =
No R if D11 < D12
If D11 = D12 the doctor is indifferent between choosing or No R.

2P. No Trust cannot be a dominant strategy, since P12 < P22 always.
Thus, the patient has a strictly dominant strategy when
P11 − P21
<0
P22 − P12
Solving for mixed strategies If conditions for pure strategies equilibria are
not met, the best strategy is a mixed strategy, a probability distribution over the
set of pure strategies. It occurs, for both players, when
D11 − D12 P11 − P21

> 0, >0
D22 − D21 P22 − P12
Suppose the doctor recommends the treatment x per cent of time and does not
recommend it 1 − x per cent of time and the patient trusts the doctor y per cent
of time and does not trust him 1 − y per cent of time.
Thus, they both play a mixed strategy, (x, 1 − x) for the doctor and (y, 1 − y) for
the patient.
y 1−y
Trust No Trust
x R (D11 , P11 ) (D21 , P21 )
1−x No R (D12 , P12 ) (D22 , P22 )
Table 4.3: Simultaneous Model A - Mixed strategies
We put ourselves in the position of one of the players and for any choice the
other player can make, we calculate the best response, which is the choice that
maximizes the pay-off.
Patient From the point of view of the patient, his expected pay-off is
EP (x, y) = xyP11 + x(1 − y)P21 + (1 − x)yP12 + (1 − x)(1 − y)P22
= y(x(P11 − P21 + P22 − P12 ) + P12 − P22 ) + x(P12 − P22 ) + P22

| {z }
(∗∗)
When
P11 − P21
>0
P22 − P12
the only possible situation is that P11 − P21 < 0, since P22 − P12 < 0 always. It
results that P11 − P21 + P22 − P12 < 0. Therefore, in order to study patient’s BR,
it is necessary to study the sign of the coefficient (∗∗) of y, since it depends on x.
1
(∗∗) > 0 ⇔ x< P11 −P21
1+ P22 −P12
P11 −P21
Since P22 −P12
> 0, it results that x is a probability, 0 < x < 1.
Thus,  1
y = 1 if x P −P
1+ P11 −P21
22 12
y = 1 means that the patient trusts the doctor, otherwise y = 0 means that he
does not trust.
Doctor When both the players play a mixed strategy, the expected pay-off for
the doctor is
ED (x, y) = xyD11 + x(1 − y)D21 + (1 − x)yD12 + (1 − x)(1 − y)D22
= x(y(D11 − D12 + D22 − D21 ) + D21 − D22 ) + D22

| {z }
(∗)
In order to study doctor’s BR, we need to study the sign of the coefficient (∗) of
x, since it depends on y.
If D11 − D12 > 0 and D22 − D21 > 0,
1
(∗) > 0 ⇔ y> D11 −D12
1+ D22 −D21
D11 −D12
Since D22 −D21
> 0, it results that y is a probability, 0 < y < 1.
Thus,  1
x = 1 if y > D −D
1+ D11 −D12
BRI (y) = 22
1
21
x = 0 if y < D −D
1+ D11 −D12
22 21
x = 1 means that the doctor chooses the strategy R and x = 0 means that he
chooses No R.
Patient, y
1 (x, y)
D −D
1+ D11 −D12
22 21
(0,0) Doctor, x
1
P −P
1
1+ P11 −P21
22 12
Figure 4.4: BR curves, D11 − D12 > 0 and D22 − D21 > 0
The plot in Fig.4.4 shows the best response curves. Specifically, the curve in blue
1
shows that the patient chooses Trust if x < P −P and he chooses No Trust
1+ P11 −P21
22 12
1
otherwise. If x = P −P , the patient is indifferent, hence he chooses any y
1+ P11 −P21
22 12
between 0 and 1.
1
The curve in red shows that the doctor chooses R if y > D −D and he chooses
1+ D11 −D12
22 21
1
No R otherwise. If y = D −D , the doctor is indifferent, hence he chooses any x
1+ D11 −D12
22 21
between 0 and 1. The intersection (x, y) of the two curves is a Nash equilibrium:
each player cannot obtain greater benefits from changing actions, assuming other
players remain constant in their strategies.
If D11 − D12 < 0 and D22 − D21 < 0,
1
(∗) > 0 ⇔ y< D11 −D12
1+ D22 −D21
Thus,  1
x = 1 if y < D −D
1+ D11 −D12
BRI (y) = 22
1
21
x = 0 if y > D −D
1+ D11 −D12
22 21
x = 1 means that the doctor chooses the strategy R and x = 0 means that he
chooses No R.
D11 −D12
Since D22 −D21
> 0, it results that y is a probability, 0 < y < 1.
Patient,y
1 (x, y)
D −D
1+ D11 −D12
22 21
(0,0) Doctor,x
1
P −P
1
1+ P11 −P21
22 12
Figure 4.5: BR curves, D11 − D12 < 0 and D22 − D21 < 0
The plot in Fig.4.5 shows the best response curves. This time, the intersections
indicate that there are three Nash Equilibria: (x, y), (1,0) and (0,1).
For example, the pure strategy equilibrium (1,0) means that R is a best response
of No Trust, and No Trust is the best response of R: under the conditions
P11 − P21 < 0, P22 − P12 < 0, D11 − D12 < 0, D22 − D21 < 0
if the doctor recommends the treatment, the patient does not trust him and if
the patient does not trust the doctor, his best response is to recommend the
treatment. Similarly, (0,1) is another pure strategy equilibrium.
Thus, when
D11 − D12 P11 − P21
>0 , >0
D22 − D21 P22 − P12
(x, y) is always a mixed strategy Nash equilibrium and, under certain condition
(0,1) and (1,0) are two pure strategy Nash equilibria.
Conclusion We now summarise the results obtained in the analysis. A more

specific comment is illustrated in Section 4.3.
1. If D11 − D12 > 0 and D22 − D21 < 0, R (to recommend the treatment)
is a dominant strategy for the doctor. The patient chooses to trust him if
P11 − P21 > 0, otherwise he chooses no to trust.
2. If D11 −D12 < 0 and D22 −D21 > 0, No R (not to recommend the treatment)
is a dominant strategy for the doctor. The patient always chooses to trust,
since P22 < P12 for all p: when the doctor does not recommend the treatment
it is rational for the patient to accept it.
3. If P11 − P21 > 0, Trust is a dominant strategy for the patient. The doctor
should decide depending on the sign of D11 − D12 : he chooses to recommend
the treatment if D11 − D12 > 0 and not to recommend it, otherwise.
P11 −P21
4. If P22 −P12
> 0, D11 − D12 > 0 and D22 − D21 > 0, both players play a mixed
strategy: the rational choice for the patient is to choose Trust y per cent of
time and No Trust 1-y per cent of time, and the rational strategy for the
doctor is to choose R x per cent of time and No R 1-x per cent of time,
where !
1 1
(x, y) = P11 −P21
, D11 −D12
1+ P22 −P12
1+ D22 −D21
P11 −P21
5. If P22 −P12
> 0, D11 − D12 < 0 and D22 − D21 < 0, there are three Nash
equilibria: (1,0), (0,1) and (x, y) where
!
1 1
(x, y) = P11 −P21
, D11 −D12
1+ P22 −P12
1+ D22 −D21
It is interesting to underline that, since D22 − D21 does not depends on the prob-
ability of disease p, when D22 − D21 > 0, No R cannot be a dominant strategy,
for all p and when D22 − D21 < 0, R cannot be a dominant strategy, for all p.
4.1.2 Simultaneous game, model B: the patient demands

treatment and he gets it
Now, we consider model B: the patient asks for the treatment that the doctor
does not recommend and he gets it.
It is a simultaneous game of complete and imperfect information.
s t (D11 , P11 )
Tru
Patient
R No
Tru (D21 , P21 )
s t
Doctor
No s t (D12 , P12 )
R Tru
Patient
No
T
(Ge rust (D22 , P22 )
tR
)
Figure 4.6: Reduced simultaneous model B tree structure
Parameters such as players’ utilities and emotion variables (regret, guilt and frus-
tration) are the same as in model A. The only difference lies in the pay-offs of the
path No R - No Trust, specifically, in different expressions of D22 and P22 .
In details, P22 = P11 and D22 = D11 . This is obvious, since the patient gets
the treatment even when the doctor does not recommend it, so both the utilities
are the same as the ones achieved through the path R - Trust, where the doctor
himself recommends the treatment.
+
I II D (V1 , U1 )
No R No Trust D− (V2 − G · (U4 − V2 ) − Rd · (V4 − V2 ), U2 − Rp · (U4 − U2 ))
(Get R)
D22 = p · V1 + (1 − p) · (V2 − G · (U4 − V2 ) − Rd · (V4 − V2 ))
P22 = p · U1 + (1 − p) · (U2 − Rp · (U4 − U2 ))

Analysis In order to solve the game, we follow the same approach used in the
analysis of model A. Therefore, the game is described into its strategic form.
Trust No Trust
R (D11 , P11 ) (D21 , P21 )
No R (D12 , P12 ) (D22 , P22 )
Table 4.4: Strategic form - Model B
Firstly, it is useful to compare some utilities, in order to study their sign:

p Bd U4 − V2 p U1 − V3
D11 − D12 = −(1 − p)Hd (1 + Rd ) 1 − +G −
1 − p Hd Hd 1 − p Hd

U4 − V2 p Bd
D22 − D21 = −(1 − p)Hd 1 + Rd + G −
Hd 1 − p Hd

p Bp
P11 − P21 = −(1 + Rd )(1 − p)Hd 1 −
1 − p Hp

p Bp
P22 − P12 = −(1 + Rd )(1 − p)Hd 1 −
1 − p Hp
The situation is different from the one found in model A. The signs of all the
differences depend on the probability of disease p. Moreover, it follows that
P11 − P21 = P22 − P12 .
Solving for pure strategy Firstly, we determine under which conditions a

player has a strictly dominant strategy.
From the point of view of the doctor:
1D. If D11 > D12 and D21 > D22 , R is a dominant strategy (optimal pure
strategy) for the doctor, therefore the patient’s best reply is
(
Trust if P11 > P21
BRII (R) =
2D. If D11 < D12 and D21 < D22 , No R is a dominant strategy (optimal pure
strategy) for the doctor, therefore patient’s best reply is
(
Trust if P12 > P22
BRII (N oR) =
Thus, the doctor has a strictly dominant strategy when
D11 − D12
<0
D22 − D21
Since P11 − P12 = P22 − P21 , there are not dominated strategies (optimal pure
P11 −P12
strategies) for the patient and P22 −P21
= 1.
Solving for mixed strategies If conditions for pure strategies equilibria are
not met, the best strategy is a mixed strategy, a probability distribution over the
set of pure strategies. It occurs, for both players, when
D11 − D12
>0
D22 − D21
P11 −P12
since P22 −P21
= 1 > 0 always.
Suppose the doctor recommends the treatment x per cent of time and does not
recommend it 1 − x per cent of time and the patient trusts the doctor y per cent
of time and does not trust him 1 − y per cent of time.
Thus, both players play a mixed strategy, (x, 1 − x) for the doctor and (y, 1 − y)
for the patient.
y 1−y
Trust No Trust
x R (D11 , P11 ) (D21 , P21 )
1−x No R (D12 , P12 ) (D22 , P22 )
Table 4.5: Simultaneous Model B - Mixed strategies
Patient From the point of view of the patient, his expected pay-off is
EP (x, y) = xyP11 + x(1 − y)P21 + (1 − x)yP12 + (1 − x)(1 − y)P22
= y(x(P11 − P21 + P22 − P12 ) + P12 − P22 ) + x(P12 − P22 ) + P22

| {z }
(∗∗)
Therefore, in order to study patient’s BR, it is necessary to study the sign of the
coefficient (∗∗) of y, since it depends on x.
If P11 − P21 = P22 − P12 > 0,
1
(∗∗) > 0 ⇔ x> P11 −P21
1+ P22 −P12
P11 −P21
Since P22 −P12
= 1, it results that
(
1
y = 1 if x > 2
BRII (x) = 1
y = 0 if x < 2
does not trust.
If P11 − P21 = P22 − P12 < 0,
1
(∗∗) > 0 ⇔ x< P11 −P21
1+ P22 −P12
P11 −P21
Since P22 −P12
= 1, it results that
(
1
y = 1 if x < 2
BRII (x) = 1
y = 0 if x > 2
does not trust.
Doctor When both players play a mixed strategy, the expected pay-off for the
doctor is
ED (x, y) = xyD11 + x(1 − y)D21 + (1 − x)yD12 + (1 − x)(1 − y)D22
= x(y(D11 − D12 + D22 − D21 ) + D21 − D22 ) + D22

| {z }
(∗)
In order to study doctor’s BR, it is necessary to study the sign of the coefficient
(∗) of x, since it depends on y. If D11 − D12 > 0 and D22 − D21 > 0
1
(∗) > 0 ⇔ y> D11 −D12
1+ D22 −D21
It results that  1
x = 1 if y > D −D
1+ D11 −D12
BRI (y) = 22
1
21
x = 0 if y < D −D
1+ D11 −D12
22 21
x = 1 means that the doctor chooses the strategy R, x = 0 means that he chooses
No R.
If D11 − D12 < 0 and D22 − D21 < 0
1
(∗) > 0 ⇔ y< D11 −D12
1+ D22 −D21
It results that  1
x = 1 if y < D −D
1+ D11 −D12
BRI (y) = 22
1
21
x = 0 if y > D −D
1+ D11 −D12
22 21
x = 1 means that the doctor chooses the strategy R, x = 0 means that he chooses
No R.
y y
1 1
1 (x, y) 1 (x, y)
D −D D −D
1+ D11 −D12 1+ D11 −D12
22 21 22 21
(0,0) x (0,0) x
1 1 1 1
2 2
(a) (b)
Figure 4.7: BR curves: (a) P11 − P21 = P22 − P12 > 0, D11 − D12 < 0,
D22 − D21 < 0; (b) P11 − P21 = P22 − P12 < 0, D11 − D12 > 0, D22 − D21 > 0
The plots in Fig.4.7 shows the best response curves, when
(a) P11 − P21 = P22 − P12 > 0, D11 − D12 < 0, D22 − D21 < 0;
(b) P11 − P21 = P22 − P12 < 0, D11 − D12 > 0, D22 − D21 > 0.
Under these conditions, there is only one intersection. The Nash equilibrium is
!
1 1
(x, y) = , D11 −D12
2 1 + D22 −D21
y y
1 1
1 (x, y) 1 (x, y)
D −D D −D
1+ D11 −D12 1+ D11 −D12
22 21 22 21
(0,0) x (0,0) x
1 1 1 1
2 2
(c) (d)
Figure 4.8: BR curves: (c) P11 − P21 = P22 − P12 > 0, D11 − D12 > 0,
D22 − D21 > 0; (d) P11 − P21 = P22 − P12 < 0, D11 − D12 < 0, D22 − D21 < 0
Otherwise, when
(c) P11 − P21 = P22 − P12 > 0, D11 − D12 > 0, D22 − D21 > 0;
(d) P11 − P21 = P22 − P12 < 0, D11 − D12 < 0, D22 − D21 < 0.
as shown in Fig.4.8, there are three intersection, hence three Nash equilibria:
(0,0), (1,1), (x, y) and (0,1), (1,0), (x, y) in (c) and (d), respectively, where
!
1 1
(x, y) = , 11 −D12
2 1+ D D22 −D21
Thus, when
D11 − D12
>0
D22 − D21
(x, y) is always a Nash equilibrium. It means that the best behaviour for the
doctor is to choose half the time one strategy and half the time the other one: the
doctor’s decision does not depend on the probability of disease p.

1. If D11 − D12 > 0 and D22 − D21 < 0, R (to recommend the treatment) is
a dominant strategy for the doctor. On the other hand, if D11 − D21 < 0
and D22 − D12 > 0, the dominant strategy is No R (not to recommend
the treatment) Patient’ s choice depends on the sign of P11 − P21 , since
P11 − P21 = P22 − P12 .
If P11 − P21 > 0, no matter what the doctor does, the patient gets the treat-
ment (path R-Trust, No R-No Trust). On the contrary, if P11 − P21 < 0, no
matter what the doctor does, the patient does not get it (path R-No Trust,
No R-Trust).
2. If P11 − P21 = P22 − P12 > 0, D11 − D12 < 0, D22 − D21 < 0 or P11 − P21 =
P22 − P12 < 0, D11 − D12 > 0, D22 − D21 > 0, both players play a mixed
strategy: the rational choice for the patient is to choose Trust y per cent of
time and No Trust 1-y per cent of time, and the rational strategy for the
doctor is to choose R x per cent of time and No R 1-x per cent of time,
where !
1 1
(x, y) = , D11 −D12
2 1 + D22 −D21
3. If P11 − P21 = P22 − P12 > 0, D11 − D12 > 0, D22 − D21 > 0 or P11 − P21 =
P22 − P12 < 0, D11 − D12 < 0, D22 − D21 < 0, there are three Nash equilibria.
It results that in the Nash equilibrium (x, y), x is fixed, while y depends on the
parameters of the model and on the probability of disease p.
4.2 Sequential games for healthcare decisions

In simultaneous games, players move at the same time and therefore they decide
without observing other players’ choice. Specifically, in a clinical encounter be-
tween a doctor and a patient, it means that the patient decides whether or not to
trust the doctor, without knowing what the doctor does. The model presented in
the article Model health care as a game theory problem by Djulbegovic, Hozo and
Ioannidis [4] is founded on this assumption, which is verified in some situations,
when the patient might have to decide a priori or when a patient is not aware of
the doctor’s choice of treatment.
More often, the default medical practice for showing respect to patients is for the
doctor to be direct and truthful in informing the patient of his health, before giv-
ing treatment. Thus, the patient is fully aware of the choice made by the doctor
and he can evaluate it and later decide what to do.
Therefore, it seems reasonable and appropriate to introduce another model to
analyse a simple clinical encounter, specifically a sequential game, describing the
same situation: firstly, the doctor decides whether or not to administer a certain
treatment to a patient who may have a disease or not, secondly the patient decides
whether or not to trust the doctor.
Differently from simultaneous games, the information is complete and perfect:
the structure of the game and the pay-off functions of the players are commonly
known and each player, when making any decision, is perfectly informed of all the
events that have previously occurred. This is the only difference in the model,
since the expressions of the utilities, associated at every possible outcome of the
game, are the same as the ones in the simultaneous games.
Since a strategy specifies player’s move for every possible situation throughout
the game, available strategies for the doctor are:
R: he recommends the treatment to the patient

No R: he does not recommend the treatment to the patient
while, for the patient, they are Trust - Trust, Trust - No Trust, No Trust -
Trust, No Trust - No Trust: they specifies the action in all possible circum-
stances, if the doctor chooses R or No R, respectively. The patient’s strategies
consider even situations (nodes) which are not reached by the actual play of the
game.
In the specific situation when the doctor does not recommend the treatment and
the patient does not trust him (he disagrees with the doctor’s decision not to
recommend the treatment), the patient can ask for the treatment.
It leads to two slightly different models:
Model A : the patient asks for the treatment and he does not get it
Model B : the patient asks for the treatment and he gets it
Since the presence of the disease is a random event, which introduces uncertainty
in the model, the utility function of the players are evaluated in terms of expected
utilities. The expected values are the same as the ones in the simultaneous games.
D
N
o
R
P P
No
No
t
t
s
s
Tru
Tru
Tru
Tru
s
s
t
(D11 , P11 ) (D21 , P21 ) (D12 , P12 ) (D22 , P22 )
Figure 4.9: Simplified extensive form
The method used to understand how rational players will play, in games of perfect
information, is backward induction.
4.2.1 Sequential game, model A: the patient demands treat-

ment but does not get it
Firstly, we consider model A: the patient asks for the treatment that the doctor
does not recommend and he does not get it. Backward induction is applied to
solve the game.
All terminal nodes are associated to the patient (labelled II in Fig.4.10), therefore,
the analysis of the tree starts from patient’s decision nodes, A and B respectively
in Fig.4.10.
t (D11 , P11 )
A Trus
II
R No T
rust (D21 , P21 )
I
No t (D12 , P12 )
R Trus
II
B No
(Dem Trust (D22 , P22 )
and
R)
Figure 4.10: Reduced sequential Model A tree structure, highlighting the pa-
tient’s decision nodes
D11 = p · V1 + (1 − p) · (V2 − G · (U4 − V2 ) − Rd · (V4 − V2 ))
D21 = p · (V3 − Fd · (V1 − V3 )) + (1 − p) · V4
D12 = p · (V3 − G · (U1 − V3 ) − Rd · (V1 − V3 )) + (1 − p) · V4
D22 = p · (V3 − G · (U1 − V3 ) − Rd · (V1 − V3 )) + (1 − p) · V4
P11 = p · U1 + (1 − p) · (U2 − Rp (U4 − U2 ))
P21 = p · (U3 − Rp · (U1 − U3 )) + (1 − p) · U4
P12 = p · (U3 − Rp · (U1 − U3 )) + (1 − p) · U4

Patient: Node A At node A, the patient’s choice depends on the sign of

P11 −P21 . Specifically, if the doctor recommends the treatment, the patient chooses
Trust (he accepts the treatment) if P11 − P21 > 0, since a rational player acts in
order to get the best outcome.
Thus, to determine the patient’s behaviour we study the sign of P11 − P21 . Using
the expressions of the utilities, it follows that

p U1 − U3
P11 − P21 = −(1 + Rp )(1 − p)(U4 − U2 ) 1 −
1 − p U4 − U2
Let Bp = U1 − U3 (Benefit) be the net benefit of the treatment and let Hp =
U4 − U2 (Harm ) be the net risk of the treatment. Given the uncertainty of the
disease, administrating a treatment, known to be effective for the disease under
consideration, will be beneficial if the disease is actually present, but may be
harmful if the disease is absent. So Bp is the benefit, in term of utilities, that
a sick patient (D+ ) achieves in receiving the treatment against not receiving it.
On the other hand Hp represents the risk of harmful consequences for a patient
without disease (D− ), when he receives a treatment instead of not receiving it.
Since 0 ≤ U3 < U2 < U4 < U1 , it follows that Bp and Hp are positive values.
Moreover, according to the assumptions, 1 − p = P (D− ) ≥ 0 and Rp is a non-
negative value.
It results:
p Bp
P11 − P21 ∝− 1−
1 − p Hp
1
P11 − P21 >0 ⇔ p> Bp
1+ H p
The patient’s decision to trust or not to trust the doctor, recommending the
treatment, depends on the assessed probability of disease p and on how the patient
quantifies risk and benefit of the treatment.
Specifically, p∗ = 1
B is a probability threshold: once the doctor recommends
1+ Hp
p
the treatment, if the probability of disease exceeds the threshold, the preferable
course of action is to trust the doctor (recommending the treatment), otherwise
if the probability is below the threshold, the preferable course of action is to

withhold the treatment (No Trust).

1
Trust
 if p > B
1+ Hp
Patient 1
p
No Trust if p <

 B
1+ Hp
p
1
In literature [5], 1+ Benef it is the classic therapeutic threshold, used to help a doc-
Harm
tor making decision in situations of uncertainty about the presence of a disease.

Consider a simple decision tree that describes the possible courses of action avail-
able to a doctor, who has to decide whether or not to recommend a treatment to
a patient.
+
D V1
R D− V2
D No
R +
D V3
D− V4
Figure 4.11: A doctor’s decision tree, facing the decision to treat a patient who
may be or may not be sick
Since uncertainty is present in the model, the doctor should select the option that
maximizes his expected utility.
E[R] = p · V1 + (1 − p) · V2
E[N oR] = p · V3 + (1 − p) · V4
Let Bd = V1 − V3 and Hd = V4 − V2 be the benefit and harm of the treatment,

1
it follows that B represents the threshold probability that makes the doctor
1+ Hd
d
indifferent between treat or not the patient (E[R] = E[N oR]).
Similarly p∗ = 1
B is the threshold probability that makes the patient indifferent
1+ Hp
p
between trusting or not the doctor: it is a relation between the benefit and harm
of a specific treatment, assessed by the patient.
Borderline case The patient is indifferent between choosing Trust or No Trust

when P11 = P21 , that is when p = p∗ = 1
B .
1+ Hp
p
Patient: Node B At node B, the patient’s choice depends on the sign of

P22 − P12 . Specifically, when the doctor chooses not to treat, the patient trust
him if P22 − P12 < 0.
Using the expressions of the utilities, it follows that

p U1 − U3
P22 − P12 = −Fp (1 − p)(U4 − U2 ) 1 + <0
1 − p U4 − U2
Thus, the sign of P22 − P12 is always strictly negative, as according to the assump-
tions, Fp , 1 − p, U4 − U2 are non-negative.
At node B, the patient always chooses to trust the doctor (and consequently
he agrees not to receive the treatment) and this choice does not depend on the
parameter p.
Borderline case P22 − P12 is always strictly negative, therefore the patient is
never indifferent, but he always chooses to trust the doctor.
Doctor Eventually, root node is analysed: the doctor (player I) is called to

move. Since this is a game of perfect information, the doctor knows what the
patient will do at every node. In particular, he knows that, by choosing No R
(node B) the patient’s choice will be always Trust and, therefore, the doctor knows
his pay-off in this specific situation (D12 ). When the doctor chooses the strategy
R, it is necessary to distinguish more cases:
1. p > p∗ the patient chooses Trust
2. p < p∗ the patient chooses No Trust
3. p = p∗ the patient is indifferent

t (D11 , P11 )
A Trus
II p∗ = 1
B
1+ Hp
p
R No T
rust (D21 , P21 )
I
No t (D12 , P12 )
R Trus
II
B No
and
R)
Figure 4.12: Sequential model A - Backward induction
1. If p > p∗ , at node A, the patient chooses to trust the doctor and to accept
the treatment. Therefore, the doctor’s decision depends on the sign of D11 − D12 .
Let Bd = V1 − V3 and Hd = V4 − V2 be the benefit and risk of the treatment,
assessed by the doctor. It follows that
1
D11 − D12 > 0 ⇔ p > p∗∗ := (1+Rd )Bd +G(U1 −V3 )
1+ (1+Rd )Hd +G(U4 −V2 )
p∗∗ is the doctor’s probability threshold: if the probability of disease exceeds the
threshold, the preferable course of action is to recommend the treatment (R),
otherwise if the probability is below the threshold, the preferable course of action
is to withhold the treatment (No R).
(
R if p > p∗∗
Doctor
No R if p < p∗∗
If P (D+ ) = p∗∗ , the doctor is indifferent between choosing R or No R (D11 = D12 ),

i.e. p∗∗ is the probability of disease that makes the doctor indifferent.
• p∗∗ > p∗ : if p > p∗∗ , the doctor recommends the treatment and the pa-
tient trusts him, if p∗ max {p∗ , p∗∗ }.
p∗∗ p∗
p
R
(Trust)
Borderline case when p > p∗ .
D11 = D12 ⇔ p = p∗∗
p = p∗∗ makes sense only if p∗∗ ≥ p∗ : the doctor is indifferent but the patient
decides always to trust the doctor.
2. If p < p∗ , at node A, the patient does not trust the doctor and refuses the
treatment. Therefore, the doctor’s decision depends on the sign of D12 − D21 .
Using the expressions of the utilities, since p is a non-negative probability, it
follows that
D12 − D21 = −p [(Rd − Fd )Bd + G(U1 − V3 )]
∝ Z := −(Rd − Fd )Bd + G(U1 − V3 )

Z does not depend on the parameter p: it is a fixed quantity, once all the param-
eters are fixed. It can be positive, negative or null.
(
R if Z < 0
Doctor
No R if Z > 0
t
A Trus
II
R No T
rust Z<0
I
No t Z>0
R Trus
II
B No
(Dem Trust
and
R)
Figure 4.13: Sequential model A - solution if p < p∗
If Z > 0, the doctor chooses to recommend the treatment to the patient, who
does not trust him and refuses the therapy. On the contrary, if Z > 0 the doctor
does not recommend the treatment and the patient trusts him.
Borderline case when p < p∗ . D12 − D21 = 0 if Z = 0: in this case, the doctor
is indifferent between choosing R or No R.
3. If p = p∗ , at node A, the patient is indifferent between choosing Trust or No

Trust, while, at node B, he always chooses to trust the doctor. In this particular
situation, backward induction does not provide a unique outcome of the game. In
fact, there are two possible outcomes:
• the doctor does not recommend the treatment and the patient trusts him
(path: No R - Trust)
• the doctor recommends the treatment but the patient is indifferent between
choosing to trust or not to trust
t ( D11 , P11 )
A Trus
II
R No T
rust ( D21 , P21 )
I
No t ( D12 , P12 )
R Trus
II
B No
and
R)
Figure 4.14: Sequential model A - solution if p = p∗
For example, suppose that, fixed the values of the utilities, it results that
D21 < D12 < D11
D11 = p · V1 + (1 − p) · (V2 − G · (U4 − V2 ) − Rd · (V4 − V2 ))
D21 = p · (V3 − Fd · (V1 − V3 )) + (1 − p) · V4
D12 = p · (V3 − G · (U1 − V3 ) − Rd · (V1 − V3 )) + (1 − p) · V4
By choosing No R, the doctor guarantees himself the pay-off D12 , otherwise, choos-
ing R he does not know for sure what he will get: he could get the best but also
the worst available pay-off.
To overcome the non-uniqueness of solution, we can assume that, when the pa-
tient is indifferent (p = p∗ ), he would trust the doctor’s decision, assuming past
positive interactions.
Thus, once again, we need to compare D11 and D12 : the doctor’s decision de-
pends on the comparison between the probability of disease p and the threshold
p∗∗ . Specifically, (
R if p > p∗∗
Doctor
No R if p < p∗∗

1. If the doctor chooses No R, the patient always trust him.
2. If p > max {p∗ , p∗∗ }, the doctor recommends the treatment; the patient
trusts the doctor if he chooses either R or No R.
3. If p∗ < p < p∗∗ , the doctor does not recommend the treatment; the patient
trusts the doctor if he chooses either R or No R.
4. If p < p∗ and Z < 0, the doctor recommends the treatment; the patient does
not trust him if he recommends the treatment and trust him otherwise.
5. If p < p∗ and Z > 0, the doctor does not recommend the treatment; the
patient does not trust him if he recommends the treatment and trust trusts
him otherwise.
STRATEGIES
Doctor Patient (A-B)
p > max {p∗ , p∗∗ } R Trust - Trust
p∗ 0 No R No Trust - Trust
1 1
p∗ = Bp
p∗∗ = (1+Rd )Bd +G(U1 −V3 )
Z = −(Rd − Fd )Bd + G(U1 − V3 )
1+ Hp 1+ (1+Rd )Hd +G(U4 −V2 )
4.2.2 Sequential game, model B: the patient demands treat-

ment and gets it
Now, we consider model B: the patient asks for the treatment that the doctor
does not recommend and he gets it.
The parameters in the model are the same as in model A. The only difference lies
in the pay-offs of the path No R - No Trust, specifically, in different expressions
of D22 and P22 .
In details, P22 = P11 and D22 = D11 . This is obvious, since the patient gets the
treatment even when the doctor does not recommend it, so both the utilities are
the same as the ones achieved in the path R - Trust, where the doctor himself
recommends the treatment.
In a similar way to the analysis of model A, backward induction is applied to solve
the game.
All terminal nodes are associated to the patient (labelled II in Fig.4.15), therefore,
the analysis of the tree starts from patient’s decision nodes, A and B respectively
in Fig.4.15. From the point of view of the patient, the tree is symmetric, since
P22 = P11 and P12 = P21 . This remark simplifies the analysis: it is enough to
repeat the analysis of node A, in model A, to determine the patient’s behaviour
at both the decision nodes, in this model.
D11 = p · V1 + (1 − p) · (V2 − G · (U4 − V2 ) − Rd · (V4 − V2 ))
D21 = p · (V3 − Fd · (V1 − V3 )) + (1 − p) · V4
D12 = p · (V3 − G · (U1 − V3 ) − Rd · (V1 − V3 )) + (1 − p) · V4
D22 = p · V1 + (1 − p) · (V2 − G · (U4 − V2 ) − Rd · (V4 − V2 ))
P11 = p · U1 + (1 − p) · (U2 − Rp (U4 − U2 ))
P21 = p · (U3 − Rp · (U1 − U3 )) + (1 − p) · U4
P12 = p · (U3 − Rp · (U1 − U3 )) + (1 − p) · U4
P22 = p · U1 + (1 − p) · (U2 − Rp (U4 − U2 ))

t (D11 , P11 )
A Trus
II
R No T
rust (D21 , P21 )
I
No t (D12 , P12 )
R Trus
II
B No T
r (D22 , P22 )
(Get ust
R)
Figure 4.15: Reduced sequential model B tree structure, highlighting the patient’s
decision nodes
Patient At node A, the patient’s choice depends on the sign of P11 − P21 .
Specifically, the patient chooses Trust (he accepts the treatment recommended) if
P11 − P21 > 0.
Using the expression of the utilities, it follows that

p Bp
P11 − P21 = −(1 + Rp )(1 − p)Hp 1 −
1 − p Hp
Let Bp = U1 −U3 (Benefit) be the net benefit of the treatment and let Hp = U4 −U2
(Harm) be the net risk of the treatment. Since 0 ≤ U3 < U2 < U4 < U1 , it follows
that Bp and Hp are positive values. Moreover, according to the assumptions,
1 − p = P (D− ) ≥ 0 and Rp is a non-negative value.
It results:
1
P11 − P21 > 0 ⇔ p > Bp
1+ Hp
The patient’s decision to trust or not the doctor depends on the probability of
disease p and its comparison with the threshold p∗ = 1
B .
1+ Hp
p

1
Trust
 if p > B
1+ Hp
Patient at node A 1
p
No Trust if p <

 B
1+ Hp
p

1
No Trust if p >
 B
1+ Hp
Patient at node B 1
p
Trust
 if p < B
1+ Hp
p
Borderline case The patient is indifferent between choosing Trust or No Trust

when P11 − P21 = 0, that is when p = p∗ . Since
P11 = P21 ⇔ P12 = P22 ,
if p = p∗ , the patient is indifferent between choosing to trust or not to trust at

both nodes.
Doctor Eventually, root node is analysed: the doctor (player I) is called to

move. Since this is a game of perfect information, the doctor knows what the
patient will do at every node.
To determine doctor’s behaviour, it is necessary to distinguish more cases:
1. p > p∗
2. p < p∗
3. p = p∗
1. If p > p∗ , at node A, the patient chooses to trust the doctor and to accept
the treatment, while, at node B he disagrees with the doctor, he demands for the
treatment and gets it.
Therefore, the doctor’s decision depends on the sign of D11 − D22 . It results that
D11 − D22 = 0, so the doctor is indifferent between choosing to recommend the
treatment, independently of the probability of disease p.
2. If p < p∗ , at node A, the patient does not trust the doctor and refuses the
treatment, while, at node B, he agrees with the doctor’s decision not to recommend
the treatment. Therefore, the doctor’s choice depends on the sign of D12 − D21 .
Using the expressions of the utilities, since p is a non-negative probability, it

follows that
D12 − D21 = −p [(Rd − Fd )Bd + G(U1 − V3 )]
∝ Z := −(Rd − Fd )Bd + G(U1 − V3 )
Obviously, Z is the same quantity calculated in model A, since utilities D21 and
D12 do not change: Z does not depend on the parameter p, but it is a fixed
quantity, once the parameters are fixed. It can be positive, negative or null.
(
R if Z < 0
Doctor
No R if Z > 0
t
A Trus
II
R No T
rust Z>0
I
No t Z<0
R Trus
II
B No T
r
(Get ust
R)
Figure 4.16: Sequential model B - solution if p < p∗
In this case, no matter what the doctor chooses, the patient will not get the
treatment, but doctor’s utility changes. Therefore, his decision depends on the
variable Z. If Z < 0, the doctor chooses to recommend the treatment to the
patient, who does not trust him and refuses the therapy. On the contrary, if
Z > 0 the doctor does not recommend the treatment and the patient trusts him.
Borderline case when p < p∗ . D21 − D12 = 0 if Z = 0: in this case, the doctor
is indifferent between choosing R or No R.
3. If p = p∗ , at both nodes A and B, the patient is indifferent between choosing

Trust or No Trust. Thus, backward induction does not provide a unique outcome
of the game.
t (D11 , P11 )
A Trus
II
R No T
rust (D21 , P21 )
I
No t (D12 , P12 )
R Trus
II
B No T
r (D22 , P22 )
(Get ust
R)
Figure 4.17: Sequential model B - solution if p = p∗

1. If p > p∗ , the doctor is indifferent; if the he chooses R, the patient chooses

Trust, otherwise, if he chooses No R, the patient chooses No Trust.
2. If p < p∗ and Z < 0, the doctor chooses R; if the doctor chooses R, the
patient chooses No Trust, otherwise, the patient chooses Trust.
3. If p < p∗ and Z > 0, the doctor chooses No R; if the doctor chooses R, the
patient chooses No Trust, otherwise, the patient chooses Trust.
STRATEGIES
p > p∗ Indiff Trust - No Trust
1
p∗ = Bp
Z = −(Rd − Fd )Bd + G(U1 − V3 )
1+ Hp
4.3 Comments on the models

In this section, we comment the results obtained in the simultaneous and se-
quential games, more specifically. The results are here rewritten in terms of the
probability of disease p: this way, once all the variables in the models (players’
utilities, emotion variables such as regret, guilt and frustration) are quantified and
fixed, the solutions of the games will be function of p. This probability, in every
specific encounter, is assessed and both players know its value.
The aim is to clearly see models differences and criticalities. Even if the probabil-
ity thresholds for the players are the same in all the models presented, it is difficult
to compare, directly, simultaneous and sequential games, since they describe dif-
ferent situations (in fact, the information of the games is imperfect and perfect,
respectively). Moreover, in a simultaneous game, the solution is a pure or mixed
strategies for both the players, while in a sequential game, the doctor’s optimal
choice is a pure strategy, while for the patient, it is a couple of pure strategies (it
describes the patient’s action in all the possible situations). The solution concept
is what makes the models essentially different.
On a quality level, on one hand, we expect that for high probability of disease p,
the most rational outcome is for the patient to get the treatment, on the other
hand, for low values of p, we expect that the most rational outcome is for the
patient not to get any treatment.
From the different analyses, it seems that the model which better describes a typ-
ical everyday interaction between a patient and a doctor is the sequential model
A. In fact, in this model we assume that the doctor shares his opinion on the
treatment with the patient. Therefore, it is realistic to assume that the patient
observes the doctor’s decision to treat him or not and, in both circumstances, he
knows how to act, in order to maximize his interests.
4.3.1 Simultaneous game - Model A
In simultaneous model A, from the point of view of the patient, since P22 −P12 < 0
for all p, No Trust can never be a dominant strategy. Specifically, it exists a
probability threshold pp such that, if p > pp , Trust is a dominant strategy.
1
P11 − P21 > 0 ⇔ p > pp := Bp
1+ Hp
It is clear that pp < 12 .

Thus, Trust is the most rational strategy for the patient whenever the probability
of disease is larger than pp . This threshold is a relation between benefit and harm
of the treatment, evaluated by the patient.
For example, when the patient assesses that expected net benefit (Bp ) is larger
than expected net harm (Hp ), p is likely to be greater than the threshold.
On the other hand, the doctor has a dominant strategy under the following con-
ditions:
D11 − D12 > 0
)
R is a dominant strategy for the doctor
D22 − D21 < 0
D11 − D12 < 0

)
No R is a dominant strategy for the doctor
D22 − D21 > 0
Since D22 − D21 ∝ − [(Rd − Fd )Bd + G(U1 − V3 )], its sign does not depend on the
probability of disease p, but it is fixed (negative, positive or null), once all the
variables are quantified. Specifically, the sign of D22 − D21 depends on how the
doctor quantifies the emotion variables Rd , Fd and G. For example, the more Rd
is larger than Fd (the doctor prefers to be frustrated than to regret his decision),
the more the sign of D22 − D21 is negative.
Thus, if D22 − D21 > 0, R cannot be a dominant strategy for the doctor, while, if
D22 − D21 < 0, No R cannot be a dominant strategy for the doctor.
Specifically, if D22 − D21 < 0, it exists a probability threshold pd such that, if
p > pd , R is a dominant strategy.
1
D11 − D12 > 0 ⇔ p > pd := (1+Rd )Bd +G(U1 −V3 )
1+ (1+Rd )Hd +G(U4 −V2 )
Otherwise, if D22 − D21 > 0, the same probability threshold pd is such that, if
p < pd , No R is a dominant strategy.
In other words, pd represents either a lower limit for the strategy R to be dom-
inant and an upper limit for the strategy No R to be dominant (under different
conditions).
Moreover, if R is a dominant strategy, the patient chooses Trust, if the expected
benefit are sufficiently greater than the harm. Otherwise, if No R is a dominant
strategy, the patient chooses always Trust. All the possible situations and the
solutions are summarized below.
1. If D22 − D21 < 0 and pp < pd :
p > pd R - Trust;
pp pd :
p > pp R - Trust;
pd 0 and pp < pd :
p > pd R - Trust;
p < pd No R - Trust.
4. If D22 − D21 > 0 and pd < pp :
p > pp R - Trust;
pd max {pp , pd }, the rational strategy is always for
the doctor to recommend the treatment and for the patient to accept it. If No R
is a dominant strategy, for p < pd , the rational strategy is always for the doctor
not to recommend the treatment and for the patient to trust him.
On a quality level, the players play a mixed strategy (x, y), for medium-low values
of the probability of disease p.
1
x= h
p Bp
i
(1+Rp ) 1− 1−p Hp
1+ h
p Bp
i
Fp 1+ 1−p H p
1
y=
p Bd

U −V p U1 −V3

(1+Rd ) 1− 1−p Hd
+G 4H 2 − 1−p Hd
1+ p
h
B
d
U −V
i
1−p
(Rd −Fd ) Hd +G 1H 3
d d
Thus, in order to describe a specific clinical encounter, where the players decides
without knowing others’ moves, as in surgical decisions, the model is quite realistic.
It just seems strange that, under some conditions (D22 − D21 > 0), the strategy R
can never be a dominant one: it means that even for p close to 1 (certainty of the
disease), the doctor does not prefer strategy R over No R, regardless of what the
patient chooses. However, it results that R is the best response to the dominant
strategy Trust (p > pp ). Nevertheless, this situation represents a criticality of this
model. Moreover, assuming that the game can be played only once, it is difficult
to give an interpretations to mixed strategies.
4.3.2 Simultaneous game - Model B
Firstly, in simultaneous model B, the patient has never a dominant strategy, since
P11 − P21 = P22 − P12 . Moreover, let pup and pdown be the probability threshold,
such that D11 − D12 > 0 if and only if p > pup and D22 − D21 > 0 if and only if
p > pdown .
1
D11 − D12 > 0 ⇔ p > pup := (1+Rd )Bd +G(U1 −V3 )
1+ (1+Rd )Hd +G(U4 −V2 )
1
D22 − D21 > 0 ⇔ p > pdown := Bd
.
1+ (1+Rd )Hd +G−Bd
Moreover,
1
P11 − P21 = P22 − P12 > 0 ⇔ p > pp := Bp
.
1+ Hp
Thus, the doctor has a dominant strategy in the following cases:
if pup < pdown

)
p > pup
R is a dominant strategy for the doctor;
p < pdown
if pup > pdown
)
p < pup
No R is a dominant strategy for the doctor
p > pdown
The patient’s best reply depends on the comparison between the probability of
disease p and the patient threshold pp . Specifically, if p > pp , the patient will
replay Trust to R and No Trust to No R, otherwise, if p < pp , he will replay No
Trust to R and Trust to No R.
Moreover,
1. if p > max {pup , pdown , pp }, there are three equilibria: R - Trust, No R - No

Trust and a mixed strategy equilibrium;
2. if p < min {pup , pdown , pp }, there are three equilibria: R - No Trust, No R -

Trust and a mixed strategy equilibrium;
Lastly, if p > pp ∧ p < min {pup , pdown } or if p < pp ∧ p > max {pup , pdown }, both
the players will play a mixed strategy.
Specifically, the mixed strategy is
!
1 1
(x, y) = , D11 −D12
2 1 + D22 −D21
The analysis shows that the doctor’s decision is not relevant. In fact, even if the
doctor has a dominant strategy, the patient is able to choose his favourite out-
come: for example, if No R is a dominant strategy for the doctor and p > pu , the
patient’s best reply is No Trust, which guarantees him to get the treatment, even
if the doctor does not recommend it.
In analogous way, when the players play a mixed strategy, the doctor plays half
the time R and half the time No R, independently from the probability of disease
p.
It follows from the structure of the game: the patient can ask for the treatment
and obtain it, therefore, the game tree is specular, from the point of view of the
patient.
This model is not realistic in describing a typical clinical encounter, since it as-
sumes that a doctor can be consulted but the patient himself assesses if he needs
a treatment or not.
4.3.3 Sequential game - Model A
In sequential model A, the solution of the game, obtained by backward induction,

is always a pure strategy.
Firstly, if the doctor recommends the treatment, the patient always trusts him,
independently of the probability of disease p.
This is obvious, since no matter what the patient chooses to do, he will not receive
the treatment (even if he demands treatment, he does not get it): it is rational
to choose Trust, since this way he does not experience frustration and, therefore,
his pay-off is greater.
P12 = p · (U3 − Rp · (U1 − U3 )) + (1 − p) · U4

Moreover, if the doctor recommends the treatment, let p∗ = 1

B be the proba-
1+ Hp
p
bility threshold such that
(
Trust if p > p∗
Patient
No Trust if p < p∗
Thus, the patient accepts the treatment whenever p is larger than p∗ and, since
p∗ < 21 , the patient refuses the treatment only when the probability of disease p
is low (p < p∗ < 21 ).
If p > p∗ , let p∗∗ another probability threshold such that
(
R if p > p∗∗
Doctor
No R if p < p∗∗
Otherwise, for low values of the probability of disease (p < p∗ ), let

Z = −(Rd − Fd )Bd + G(U1 − V3 ) be a variable such that
(
R if Z < 0
Doctor
No R if Z > 0
Z does not depend on p but it depends on the doctor’s utilities and on how he
quantifies emotion variables such as regret, guilt and frustration.
For example, if the doctor assesses that to regret a choice is worse than to be
frustrated (Rd > Fd , then Z < 0), he will choose to recommend the treatment
(path R - No Trust instead of path No R - Trust).
As expected, if the probability of disease is high (p > max {p∗ , p∗∗ }) the doctor’s
rational choice is for the doctor to recommend the treatment, moreover, the pa-
tient trusts the doctor if he chooses either or not to treat. On the other hand, if
the probability of disease is low (p < p∗ ) the rational outcome is for the patient
not to get the treatment. The possible combinations of strategies are:
• the doctor chooses R, the patient chooses No Trust if R and Trust if No R;
• the doctor chooses No R, the patient chooses No Trust if R and Trust if No

R.
STRATEGIES
p > max {p∗ , p∗∗ } R Trust - Trust
p∗ < p < p∗∗ No R Trust - Trust
1 1
p∗ = Bp
p∗∗ = (1+Rd )Bd +G(U1 −V3 )
Z = −(Rd − Fd )Bd + G(U1 − V3 )
1+ Hp 1+ (1+Rd )Hd +G(U4 −V2 )
Table 4.6: Sequential Model A - Backward induction results (A-B are the pa-
tient’s decision nodes)
This model is realistic to describe a generic clinical encounter: for all the proba-
bility of disease p, backward induction selects the rational path and specifies the
players’ moves in all the possible circumstances.
4.3.4 Sequential game - Model B
Let p∗ = 1
B be a probability threshold such that
1+ Hp
p
(
gets the treatment if p > p∗
The patient
does not get the treatment if p < p∗
Specifically, if p > p∗ , the patient accepts the treatment if the doctor treat him
(path R - Trust) or asks for the treatment and obtain it otherwise (path No R -
No Trust). Under these conditions, the doctor is indifferent, since no matter what
he does, the patient gets the treatment and doctor’s utility does not change.
For low values of probability of disease (p < p∗ ), let
Z = −(Rd − Fd )Bd + G(U1 − V3 )
be a variable such that

(
R if Z < 0
Doctor
No R if Z > 0
Z does not depend on p but it depends on the doctor’s utilities and on how he
quantifies emotion variables such as regret, guilt and frustration.
Under this conditions (p < p∗ < 21 ), the patient does not get the treatment: it
happens if the patient refuses the treatment (path R - No Trust) or if he trusts
the doctor’s choice to withhold the treatment (path No R - Trust).
The analysis shows that the doctor’s decision is not relevant for the outcome
treatment or not treatment: no matter what he chooses, the patient is able to
choose his favourite one. Obviously, the doctor’s utility changes if the path that
leads to the outcome changes.
As simultaneous model B, this model is not realistic in describing a typical clinical
encounter, since it assumes that the patient is the sole agent that decides if he
needs a treatment or not.
STRATEGIES
p > p∗ Indiff Trust - No Trust
1
p∗ = Bp
Z = −(Rd − Fd )Bd + G(U1 − V3 )
1+ Hp
Table 4.7: Sequential Model B - Backward induction results (A-B are the pa-
tient’s decision nodes)
4.4 Data simulations

The solution of the presented games, as all the healthcare games, depends on the
knowledge of the doctor and patient characteristics, such as utilities and emotion
variables (regret, guilt and frustration). Thus, in order to determine the most
optimal strategy for the players, it is important to have reliable data to quantify
all these variables.
Once players’ utilities, emotion variables are assessed, players’ optimal strategy
depends on the probability of disease p.
No empirical data can precisely inform the values of each of the utilities of the
model: usually they are obtained by surveying a sample of experienced clinical
investigators, asking them to provide the values of each of utilities in the model,
first from a patient’s and then from a doctor’s perspective. Regret, guilt and
frustration can be quantified using psychometric measurement approach.
Obviously, the solutions of the game are different if different utilities are assumed
in the models.
Djulbegovic, Hozo and Ioannidis, in their article [4], do not quantify any parameter
or provide any data. The article When it is rational to participate in a clinical
trial? A game theory approach incorporating trust, regret and guilt by Djulbegovic
and Hozo, as seen in Chapter 3, presents a similar model and quantifies the utilities
and the emotion parameters.
Therefore, in this section, similar values are assumed in this model, to present
an example. For all the models, we calculate the solutions, as function of the
probability of disease p.
We consider the following set of values.

Doctor Patient
V1 =90 U1 =95
V2 =50 U2 =40
V3 =25 U3 =35
V4 =75 U4 =80
Rd =0.4 Rp =0.2
Fd =0.1 Fp =0.2
G=0.2 -
Firstly, emotion variables are such that the doctor evaluates regret worse than
frustration (Rd > Fd ): these values determine the sign of D22 − D12 .
Moreover, players’ utilities satisfy the conditions
0 ≤ V3 < V2 < V4 < V1 , V3 ≤ U1
0 ≤ U3 < U2 < U4 < U1 , V2 ≤ U4
and are such that
- if the right action is taken (treatment in presence of the disease and no

treatment in absence of the disease), the patient’s utilities are greater than
the doctor’s;
- otherwise, the doctor’s utilities are greater than the patient’s.
Simultanous game - Model A In simultaneous model A, it follows that
1
D11 − D12 > 0 ⇔ p> (1+Rd )Bd +G(U1 −V3 )
= 0.28
1+ (1+Rd )Hd +G(U4 −V2 )
D22 − D21 < 0 ∀ p

1
P11 − P21 > 0 ⇔ p> Bp
= 0.4
1+ Hp
P22 − P12 < 0 ∀ p
Therefore, pp = 0.4, pd = 0.28 and pp > pd .

If p > pd , R is a dominant strategy for the doctor, if p > pp , Trust is a dominant
strategy for the patient. Moreover, if the patient’s strategy Trust is a dominant
one, the doctor always chooses to recommend the treatment. When the doctor’s
strategy R is a dominant one, the patient’s best strategy is to trust the doctor if
he assesses that the expected benefits outweigh the expected harm (p > pp ).
100
80
60
D11 -D12
40 D22 -D21
20 P11 -P21
P22 -P12
0.2 0.4 0.6 0.8 1.0
-20
-40
Figure 4.18: Simultaneous Model A, first set - Utilities’ differences, as function

of the probability of disease p
Therefore,
• if 0.28 0.4 the rational outcome is R - Trust: the doctor recommends the
treatment and the patient trusts him;
• if p < 0.28 neither strategy is dominant and both players choose a mixed
strategy: the doctor selects R with probability x and No R with probability
1-x and the patient selects Trust with probability y and No Trust with
probability 1-y. (x,y) is a Nash equilibrium.
If the probability of disease is high (p > 0.4) the best strategy is for the doctor to
recommend the treatment and for the patient to accept it. Instead, for low values
of p (p < 0.28), both players play mixed strategy.
1.0 1.0
0.8 0.8
0.6 0.6
0.4 0.4
0.2 0.2
0.0 0.1 0.2 0.3 0.4 0.00 0.05 0.10 0.15 0.20 0.25
Figure 4.19: Simultaneous Model A - The doctor’s mixed strategy x(p) and the
patient’s mixed strategy y(p)
Simultaneous game - Model B In simultaneous model B it follows
D11 − D12 > 0 ⇔ p > 0.28
D22 − D21 > 0 ⇔ p > 0.36
P11 − P21 = P12 − P22 > 0 ⇔ p > 0.4
Therefore, pup = 0.28, pdown = 0.36, pp = 0.4 and pup < pdown . The patient
never has a dominant strategy, while R is a dominant strategy for the doctor, if
pup < p < pdown .
It results that
• if 0.28 < p < 0.36, the rational outcome is R - No Trust: the doctor recom-
mends the treatment but the patient does not accept it;
• if p < 0.28, there are three equilibria: R - No Trust, No R - Trust and a

mixed strategy equilibrium;
• if p > 0.4, there are three equilibria: R - Trust, No R - No Trust and a

mixed strategy equilibrium;
• if 0.36 < p < 0.4, neither strategy is dominant and both players choose
1
a mixed strategy: the doctor selects R with probability 2
and No R with
1
probability 2
and the patient selects Trust with probability y and No Trust
with probability 1-y. ( 21 ,y) is a Nash equilibrium.
The result is what we have already seen in the analysis: the outcome of the game
(treatment or not treatment) depends on the patient’s preference.
Sequential game - Model A In sequential model A, the values of the thresh-

olds are
p∗ = 0.4, p∗∗ = 0.28, Z = −33.5
Therefore, p∗ > p∗∗ and
• if p > 0.4, the doctor recommends the treatment; the patient trusts the
doctor if he chooses either R or No R (R/Trust-Trust);
• if p < 0.4, the doctor recommends the treatment; the patient does not trust
him if he recommends the treatment and trust him otherwise (R/No Trust-
Trust).
For high values of p (p > 0.4) the rational outcome is for the patient to get the
treatment. The doctor’s optimal strategy is always to recommend the treatment:
this choice depends on the sign of Z : he prefers to be frustrated (R - No Trust),
rather than feel guilty (No R - Trust).
Sequential game - Model B In sequential model B, the values of the thresh-

olds are
p∗ = 0.4, Z = −33.5
Thus, it follows that
• if p > 0.4, the doctor is indifferent; if the he chooses R, the patient chooses
Trust, otherwise, if he chooses No R, the patient chooses No Trust.
• If p < 0.4, the doctor chooses R; if the doctor chooses R, the patient chooses
No Trust, otherwise, the patient chooses Trust.
Thus, for high values of p, the patient gets the treatment, no matter what the
doctor does (he is indifferent), otherwise the patient does not get it.
The data simulation shows, once again, how both models B are not realistic in
describing a doctor-patient interaction, since, here, the doctor has only a consul-
tative role.
For high values of probability, the outcome is the same in every models and it is
for the patient to get the treatment. For medium-low values, simultaneous games
provide a mixed strategy, while sequential games suggest always a pure strategy
in every circumstance. Thus, a sequential game can well describe a typical clinical
encounter and it can guide decision-making.
Conclusion
This work presents an application of Game Theory to the doctor-patient inter-

action in a clinical encounter. Specifically, the analysis shows how Game Theory
can be a powerful tool to describe and guide the dynamics between a patient and
a doctor.
Not surprisingly, several of these interactions present a situation like the Pris-
oners’ Dilemma. Thus, the resulting outcome is a very disappointing one. It
happens, for example, in the participation of a patient to a clinical trial, or in the
doctor’s prescription of painkillers to potential abusers. Thus, even if the games
are simplified representation of the real situation, they allow to highlight potential
criticalities in the doctor-patient dynamics or in the healthcare system, which can
therefore be improved.
Here, instead, we analyse and compare two simultaneous and sequential games, de-
scribing the most generic clinical encounter, where a doctor has to decide whether
or not to prescribe a treatment and a patient has to decide whether or not to
accept it, in conditions of diagnostic uncertainty. Therefore, it is provided a deep
analysis of the games, in function of the patient’s probability of disease.
Obviously, this dissertation offers a first presentation of the Game Theory appli-
cations on doctor-patient interactions: the models presented can be generalized as
well as others can be implemented, for example, cooperative games and repeated
games.
92
List of Figures
1.1 Example: an extensive game with two players . . . . . . . . . . . 6

1.2 Example: an extensive game with an information set for the second
player . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.3 Prisoners’ Dilemma Tree . . . . . . . . . . . . . . . . . . . . . . . 12
2.1 S satisfied, D dissatisfied, R professionally rewarding, NR profes-

sionally less rewarding . . . . . . . . . . . . . . . . . . . . . . . . 18
3.1 A sequential game with perfect information to model a RCT clinical

research - Tree structure . . . . . . . . . . . . . . . . . . . . . . . 23
3.2 A sequential game with perfect information to model a RCT clinical
research - Reduced tree structure . . . . . . . . . . . . . . . . . . 27
3.3 Researcher’s best reply . . . . . . . . . . . . . . . . . . . . . . . . 31
3.4 Patient’s best reply if p = 1 . . . . . . . . . . . . . . . . . . . . . 33
3.5 Patient’s best reply if p = 0 (b) . . . . . . . . . . . . . . . . . . . 34
3.6 Patient’s best reply if p = 0 (c) . . . . . . . . . . . . . . . . . . . 35
3.7 Players’ best strategies, function of e and s. The dot shows the
most likely values of e and s . . . . . . . . . . . . . . . . . . . . . 36
4.1 Simultaneous Model A tree structure . . . . . . . . . . . . . . . . 40

4.2 Simultaneous Model A tree structure, highlighting regret, guilt and
frustration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
4.3 Reduced simultaneous model A tree structure . . . . . . . . . . . 45
93
LIST OF FIGURES 94
4.4 BR curves, D11 − D12 > 0 and D22 − D21 > 0 . . . . . . . . . . . 51

4.5 BR curves, D11 − D12 < 0 and D22 − D21 < 0 . . . . . . . . . . . 52
4.6 Reduced simultaneous model B tree structure . . . . . . . . . . . 54
4.7 BR curves: (a) P11 −P21 = P22 −P12 > 0, D11 −D12 < 0, D22 −D21 <
0; (b) P11 − P21 = P22 − P12 < 0, D11 − D12 > 0, D22 − D21 > 0 . 58
4.8 BR curves: (c) P11 −P21 = P22 −P12 > 0, D11 −D12 > 0, D22 −D21 >
0; (d) P11 − P21 = P22 − P12 < 0, D11 − D12 < 0, D22 − D21 < 0 . 59
4.9 Simplified extensive form . . . . . . . . . . . . . . . . . . . . . . . 62
4.10 Reduced sequential Model A tree structure, highlighting the pa-
tient’s decision nodes . . . . . . . . . . . . . . . . . . . . . . . . . 63
4.11 A doctor’s decision tree, facing the decision to treat a patient who
may be or may not be sick . . . . . . . . . . . . . . . . . . . . . . 65
4.12 Sequential model A - Backward induction . . . . . . . . . . . . . 67
4.13 Sequential model A - solution if p < p∗ . . . . . . . . . . . . . . . 69
4.14 Sequential model A - solution if p = p∗ . . . . . . . . . . . . . . . 70
4.15 Reduced sequential model B tree structure, highlighting the pa-
tient’s decision nodes . . . . . . . . . . . . . . . . . . . . . . . . . 73
4.16 Sequential model B - solution if p < p∗ . . . . . . . . . . . . . . . 75
4.17 Sequential model B - solution if p = p∗ . . . . . . . . . . . . . . . 76
4.18 Simultaneous Model A, first set - Utilities’ differences, as function
of the probability of disease p . . . . . . . . . . . . . . . . . . . . 88
4.19 Simultaneous Model A - The doctor’s mixed strategy x(p) and the
patient’s mixed strategy y(p) . . . . . . . . . . . . . . . . . . . . 89
List of Tables
1.1 Prisoners’ Dilemma Bimatrix . . . . . . . . . . . . . . . . . . . . 12
4.1 Strategic form - Model A . . . . . . . . . . . . . . . . . . . . . . . 46

4.2 Strategic form - Model A, highlighting the utilities that are com-
pared in the analysis . . . . . . . . . . . . . . . . . . . . . . . . . 47
4.3 Simultaneous Model A - Mixed strategies . . . . . . . . . . . . . . 49
4.4 Strategic form - Model B . . . . . . . . . . . . . . . . . . . . . . . 55
4.5 Simultaneous Model B - Mixed strategies . . . . . . . . . . . . . . 56
4.6 Sequential Model A - Backward induction results (A-B are the pa-
tient’s decision nodes) . . . . . . . . . . . . . . . . . . . . . . . . 84
4.7 Sequential Model B - Backward induction results (A-B are the pa-
tient’s decision nodes) . . . . . . . . . . . . . . . . . . . . . . . . 85
95
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A Game Theory Application The Interaction Between Physicians and Patients Dissertation

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Politecnico di Milano

Scuola di Ingegneria Industriale e dell’Informazione

A Game Theory application:

Relatore: Prof. Roberto LUCCHETTI

Tesi di Laurea Magistrale di:

Anno Accademico 2014-2015

L’obiettivo di questa tesi è quello di descrivere e analizzare, attraverso la Teoria

1 Introduction to Game Theory 4

3 The participation of a patient to a Randomized Controlled Trial 21

4 Game Theory models for healthcare decisions 38

A clinical encounter, between physicians and patients, is a two-way social inter-

systematic way of selecting, for each incompatible patient-donor pairs, a set of

Introduction to Game Theory

the non cooperative games.

1.1 Non Cooperative Games

presented in extensive form.

(apr , bpr ) (aps , bps ) (aqt , bqt ) (aqu , bqu )

Figure 1.1: Example: an extensive game with two players

1.1.1 Games in strategic form

Strictly dominated strategies The strategic form of a game is useful to anal-

A player does not choose X, if it is available to him Z allowing to

Nash equilibria In many games, however, the rational outcome cannot be

Definition 1.1. Let (X, Y, f : X × Y → R, g : X × Y → R) be a two player non

f (x, y) ≥ f (x, y) for all x ∈ X

g(x, y) ≥ g(x, y) for all y ∈ Y.

BR1 : Y → X : BR1 (y) = max {f (·, y)} .

max {f (·, y)} = {x ∈ X : f (x, y) ≥ f (u, y) ∀u ∈ X}

BR : X × Y → X × Y : BR(x, y) = (BR1 (y), BR2 (x)).

1.1.2 Games in extensive form

Perfect information games and backward induction A game may be of

(apr , bpr ) (aps , bps ) (aqt , bqt ) (aqu , bqu )

1.2 A strategic game: the Prisoners’ Dilemma

sentence: collaboration is appreciated)

The Prisoners’ Dilemma is a non cooperative game. It is useful to present the

Table 1.1: Prisoners’ Dilemma Bimatrix

(5,5) (0,7) (7,0) (1,1)

Figure 1.3: Prisoners’ Dilemma Tree

Modern clinical practice is founded on doctor-patient relationship: through this

2.1 The Prisoners’ Dilemma in a doctor-patient

Prisoners’ Dilemma for prescribing opioids to potentially drug-seeking

I am addicted to [opioids], and it is doctors’ fault

S/R S/NR D D/R

Figure 2.1: S satisfied, D dissatisfied, R professionally rewarding, NR profes-

S/R > S/N R > D/R > D

It results that, for the doctor, Prescribe is a dominant strategy.

2.2 The trust version of the Prisoners’ Dilemma

The participation of a patient to

3.1 A sequential game with perfect information

V1 , U1 are the pay-offs associated with the success of experimental treatment

V2 , U2 are the pay-offs associated with the failure of experimental treatment

V3 , U3 are the pay-offs associated with the success of standard treatment

V4 , U4 are the pay-offs associated with the failure of standard treatment

Since in clinical experiments patients cannot be guaranteed successful outcomes

1. gets the experimental treatment without success → U2

1. gives the patient the experimental treatment without success → V2

our RCT (P1 , R1 )

and let τ be a variable such as

be the researcher’s expected utilities of experimental and standard treatment,

r · (EV [Exp] − EV [Std]) ≥ EV [Exp] − EV [Std] − (1 − e) · G · (V2 − U2 )

be the patient’s expected utilities of experimental and standard treatment, re-

1. if r > r∗ ∧ EV [Exp] > EV [Std] the researcher honours trust (p = 1).

r · EU [Exp] + (1 − r) · EU [Std] > EU [Std] − (1 − s) · R · (U1 − U4 )

2. if r < r∗ ∧ EV [Exp] > EV [Std] the researcher abuses trust (p = 0).