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Shared Decision Making, Paternalism and Patient Choice

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In patient centred care, shared decision making is a central feature and widely referred to as a norm for patient centred medical consultation. However, it is far from clear how to distinguish SDM from standard models and ideals for medical decision making, such as paternalism and patient choice, and e.g., whether paternalism and patient choice can involve a greater degree of the sort of sharing involved in SDM and still retain their essential features. In the article, different versions of SDM are explored, versions compatible with paternalism and patient choice as well as versions that go beyond these traditional decision making models. Whenever SDM is discussed or introduced it is of importance to be clear over which of these different versions are being pursued, since they connect to basic values and ideals of health care in different ways. It is further argued that we have reason to pursue versions of SDM involving, what is called, a high level dynamics in medical decision-making. This leaves four alternative models to choose between depending on how we balance between the values of patient best interest, patient autonomy, and an effective decision in terms of patient compliance or adherence: Shared Rational Deliberative Patient Choice, Shared Rational Deliberative Paternalism, Shared Rational Deliberative Joint Decision, and Professionally Driven Best Interest Compromise. In relation to these models it is argued that we ideally should use the Shared Rational Deliberative Joint Decision model. However, when the patient and professional fail to reach consensus we will have reason to pursue the Professionally Driven Best Interest Compromise model since this will best harmonise between the different values at stake: patient best interest, patient autonomy, patient adherence and a continued care relationship.

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  1. Since Emanuel and Emanuel [8] criticises the patient choice model (which they call the informative model) for its lack of caring ingredients, it appears that they believe the venting, affirmation and caring models of sharing to be better suited to paternalism. Possibly, this may be due to a confusion of the (true) fact that all of these models of sharing connect to beneficence (which may conflict with autonomy) with the (false) assumption that beneficence can never be combined with a concern for autonomy. There is, as they note, a possibility of the professional to some extent influencing the decision of the patient by showing an interest and/or attending to his emotional needs. However, this in itself does not make for any paternalism—as long as the professional does not exploit these needs of the patient in order to covertly assume control over the decision making process.

  2. Emanuel and Emanuel [8] see this as strength of the interpretative model over patient choice. As will transpire, however, this aspect may perfectly well be incorporated in the patient choice model.

  3. Sandman L. The Concept of Negotiation in Shared Decision Making, Health Care Analysis, accepted.


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The article is written within PICAP, a project to implement patient centred care for patients with chronic heart failure. The project is financed by Gothenburg University.

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Correspondence to Lars Sandman.

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Sandman, L., Munthe, C. Shared Decision Making, Paternalism and Patient Choice. Health Care Anal 18, 60–84 (2010).

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