Abstract
In patient-centred care, shared decision-making is advocated as the preferred form of medical decision-making. Shared decision-making is supported with reference to patient autonomy without abandoning the patient or giving up the possibility of influencing how the patient is benefited. It is, however, not transparent how shared decision-making is related to autonomy and, in effect, what support autonomy can give shared decision-making. In the article, different forms of shared decision-making are analysed in relation to five different aspects of autonomy: (1) self-realisation; (2) preference satisfaction; (3) self-direction; (4) binary autonomy of the person; (5) gradual autonomy of the person. It is argued that both individually and jointly these aspects will support the models called shared rational deliberative patient choice and joint decision as the preferred versions from an autonomy perspective. Acknowledging that both of these models may fail, the professionally driven best interest compromise model is held out as a satisfactory second-best choice.
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Notes
A review of concepts of SDM found in articles on PubMed showed that onlyabout 40% of the articles presented a conceptual definition of SDM, and these definitions included 31 different concepts of SDM [26]. This indicates a conceptual lack of clarity as to which concept of SDM is used in empirical research, which affects the ability to support conclusions about what kind of SDM is successful or not, and hence affects which values are promoted.
All of these assume that the professional needs to uphold an institutionally-sanctioned minimal standard of care, and that the patient has a basic right to decline whatever offer of care that is made by the professional.
In addition to these nine variants, sharing may also take the form of a therapeutic measure in its own right where the exchange and interaction between the patient and the professional in any of the versions 1–9 may serve the management of immediate psychosocial needs, such as reducing anxiety and uncertainty [4].
The quotation is originally in Swedish and found in [14, p. 97].
The notions of effectiveness employed here are relative to the preceding step. Thus, effective choice is about choosing that which was decided, while effective action is about doing that which was chosen.
Once again, since our argument will support the SDM versions where self-realisation is featured, and since in these versions self-direction is also featured, viewing autonomy as of contributory value will give us reason to adopt the same SDM versions.
It may be that one aspect affecting what balancing is called for is exactly a preference of the person, at least if this preference is of a certain qualified kind. In “A Critique of Utilitarianism,” Bernard Williams has suggested that some preferences may be so deeply entrenched in our personal self-image and/or be such central part of what we take our lives to be about that they have to be accorded a special standing from a moral point of view [27]. Williams’s own examples concern our moral views, but the general idea seems independently applicable to views about value of one’s life. So, for instance, if a person has this type of strong convictions with regard to self-direction, this may justify the compatibility of a good life with preserving such self-direction at the expense of even great amounts of preference satisfaction for this particular person.
This involves two things. First, the options have to be significantly different (relative to the preferences of the person) from each other. Second, as noted above, neither of them should be strongly unattractive or repugnant in that special way which, through the mechanisms of normal human psychology, make them appear as impossible choices.
It should be observed that the rationality of a conviction does not exclude the presence of emotional or affective components. First, evidently, a conviction is partly an emotional mental state (and it is the emotional component that makes it into a conviction rather than, say, a hunch). Second, sometimes consciously employing such phenomena may be an effective way to reach a belief that, in turn, can be supported by arguments.
Thus, we have argued that the professional may find reasons to relax some standard treatment requirements regarding, e.g., the dosage of drugs or exercise regimes in order to secure compliance and, through that, sustainable patient acceptance of a treatment program [4].
We have demonstrated that strategic action of this sort makes SDM reside far from any sort of morally problematic paternalism, and argue that this is one among several reasons to shape SDM in line with this model, rather than some form of bargain [4].
Compulsory mental conditions, which affect cognitive and/or emotional mechanisms, may be cases in point, such as self-destructive compulsions or fixations that severely threaten future preference satisfaction (e.g. through suicide) for no apparent rational reason.
Being hesitant to ‘burden’ the patient with difficult information and decision-making is a classic theme in Hippocratic medical ethics as well as in contemporary caring approaches in nursing ethics.
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Acknowledgements
The paper is written as a part of a patient centred intervention project (PICAP). The research on which the article is based is funded by the University of Gothenburg.
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Sandman, L., Munthe, C. Shared decision-making and patient autonomy. Theor Med Bioeth 30, 289–310 (2009). https://doi.org/10.1007/s11017-009-9114-4
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DOI: https://doi.org/10.1007/s11017-009-9114-4