ACA could facilitate shared decision-making
New ethical challenges with informed consent
There is still "a good deal of confusion" about what informed consent and shared decision-making really are, according to Howard Brody, MD, PhD, John P. McGovern Centennial Chair in Family Medicine and director of the Institute for the Medical Humanities at the University of Texas Medical Branch at Galveston.
"Sadly, some of the recent medical literature on shared decision-making has become confused, by resorting to a 'negotiation' model — as if physicians and patients are equally placed contractors trying to hammer out a deal," says Brody.1 Other research has suggested that shared decision-making is appropriate for only some, and not all, medical encounters.2
Brody was co-author of a 1996 paper that addressed the concept of shared decision-making and patient autonomy.3 "The message was that informed consent was not a formula for the physician to turn responsibility for decisions over to the patient and wash her hands of this responsibility," he says.
Shared decision-making means that the patient ultimately has the right to make his or her own decision, but that the average patient wants the physician's help in doing so, says Brody. The physician has an obligation to sensitively and compassionately provide as much of that help as possible without falling back into old-style paternalism of thinking he or she knows what's best for the patient, he adds.
"If you go back to the original statements of shared decision-making — notably, the President's Commission report of 1982, which is based on the writings of Jay Katz — I think you'll find a view that's ethically sound, and that somehow we've managed to obscure in some of our more recent writing," he says.4
Health reform adds both challenges and opportunities for the expansion of shared decision-making, Brody adds. For example, if reform is successful in expanding the model of the patient-centered primary care medical home, the structure and teamwork in such settings should enhance prospects for shared decision-making.
The most important ethical challenge at this time is to keep physicians actively engaged with patients when trying to help them identify what medical options make the most sense for them, "and then work through the patient's personal values to see which option is most suitable, avoiding the twin dangers of paternalism and abandonment," says Brody. "As physicians feel busier and more harassed by bureaucratic details, this type of relationship with patients is increasingly threatened."
Misinformation is concern
Another ethical concern is the vast amount of marketing to both the profession and the public of a variety of pharmaceutical and medical device products, says Harold J. Bursztajn, MD, associate clinical professor of psychiatry at Harvard Medical School and president of the American Unit of the United Nations Educational, Scientific and Cultural Organization Bioethics Chair.
"How can physicians share what uncertainty there is about a medication or medical device when that uncertainty is initially hidden from the physician by the manufacturer?" asks Bursztajn, adding that the Harvard Medical School Program in Psychiatry and the Law laid the groundwork for these questions more than 25 years ago.5
"Although patients want to be more informed, there is a vast amount of misinformation," says Bursztajn. "This is enabled by a range of practices, from industry-tied biased professional practice guidelines to direct-to-consumer advertising that may result in a premature cognitive commitment and uninformed consent." He says that informed consent must be practiced as a process rather than as a one-time event.
"Practice guidelines must be screened for undue industry influence and post-market monitoring of both pharmaceuticals and medical devices," says Bursztajn.
- Charles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: Revisiting the shared treatment decision-making model. Soc Sci Med 1999;49:651-661.
- Whitney SN, McGuire AL, McCullough LB. A typology of shared decision making, informed consent, and simple consent. Ann Intern Med 2004;140:54-59.
- Quill TE, Brody H. Physician recommendations and patient autonomy: Finding a balance between physician power and patient choice. Ann Intern Med 1996;125:763-769.
- President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making health care decisions. Volume One: Report. Washington, DC: U.S. Government Printing Office, 1982.
- Gutheil TG, Bursztajn HJ, Brodsky A. Malpractice prevention through the sharing of uncertainty: Informed consent and the therapeutic alliance. N Engl J Med 1984;311:49-51.
- Howard Brody, MD, PhD, John P. McGovern Centennial Chair in Family Medicine/Director, Institute for the Medical Humanities, University of Texas Medical Branch at Galveston. Phone: (409) 772-9386. E-mail: email@example.com.
- Harold J. Bursztajn, MD, Associate Clinical Professor of Psychiatry, Harvard Medical School, Boston, MA. Phone: (617) 492-8366. E-mail: firstname.lastname@example.org.