Layla McCay: Down with paternalism; long live shared decision making

Paternalism is so last century. In this new era of patient centered care, the modern health professional knows the importance of involving patients in decisions about their care, particularly when there is more than one appropriate option, and the decision hinges on personal preferences and values.

The economic argument for shared decision making is well recognised and attractive to resource limited health services: research shows that when patients are given an informed choice, including being helped to understand the risks, they tend to choose conservative treatment over invasive options (1). For example, one study of people deemed clinically eligible for hip or knee surgery found that only 15 out of 100 people would have wanted that surgery if it was offered (2). But is the economic case just the tip of an iceberg of patient safety and ethical arguments for implementing shared decision making?

The recent Salzburg Global Seminar on Informing and Involving Patients in Decisions About their Care (12-17th December 2010) concluded with a resounding “yes.” Facilitating patient access to high quality information is a key part of a health professional’s role. Imbuing that information with said health professional’s own particular values, priorities, and preferences leads to safety and ethical concerns.

There are well known and important risks from orthopaedic surgery, including death. Of the 85 in 100 patients who would have preferred conservative treatment, how many might have been persuaded into surgery and its associated risks by a well meaning health professional who did not fully explore the patient’s personal options, values, and preferences before signing them up?

Unless you live in a beehive, biasing a patient towards a health professional’s personal preferences rather than helping them to understand their own seems unethical. While it may be true that “if it was me, Mr Patient, I’d have the surgery,” for preference sensitive choices this statement is meaningless at best and harmful at worst. The point is that it is not you; your personal preferences should not feature in someone else’s decisions about what happens to their body or mind. Expertise and factual information, yes; preference, clearly not. And many health choices really are a matter of preference. Jack Wennberg, shared decision making guru (listen to Jack Wennberg discussing his word with BMJ editor in chief, Fiona Godlee), demonstrates that point with an apt example: facing a choice about prostate surgery, how can any health professional advise a man whether he should opt for good peeing or good sex?

There will always be a role for paternalism. If I’m in a car crash, I want the emergency team to make the urgent decisions needed to save my life. But for choices where the key variable is preference, it’s a matter of treating people as human beings. Having a conversation. Helping them with accessing the information and tools they need to make a decision that feels right for them.

It’s a nice side effect that by giving people the care they want, delivered in a safe and ethical way, we might even save the health service some money.

Layla McCay is the assistant medical director, Bupa

Competing interest: Health Dialog, which implements shared decision making tools, is part of the Bupa Group; Bupa sponsored the Salzburg Global Seminar.

1. O’Connor AM., Bennett CL, Stacey D, Barry M, Col NF, Eden KB, Entwistle VA, Fiset V, Holmes-Rovner M, Khangura S, Llewellyn-Thomas H, Rovner D. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD001431. DOI: 10.1002/14651858.CD001431.pub2

2. G.A. Hawker et al., “Determining the Need for Hip and Knee Arthroplasty: The Role of Clinical Severity and Patients’ Preferences,” Medical Care 39, no. 3 (2001): 206–216