By Stacey Kusterbeck
What do you think is best? “Patients often ask that question directly,” says Robert S. Olick, JD, PhD, associate professor emeritus at SUNY Upstate Medical University’s Center for Bioethics and Humanities. Some patients decide not to follow the healthcare provider’s recommendation. “Respect for patient autonomy means accepting that patients sometimes make decisions contrary to their best interests. But there is nothing wrong with giving patients a nudge in the direction of the preferred treatment by further exploring the pros and cons of the options,” says Olick.
Patients want to know the likelihood of a successful outcome when they consent to a treatment or procedure, for example. “Emphasizing the positive or the negative, while addressing both, can be a nudge toward the patient’s best interests,” says Olick. Physicians can tell patients if they expect that a good outcome is more likely than not. Even so, patients and physicians may have different views on the risks of treatment options. For example, a patient may view a future quality of life with disability or dependence on regular treatment encounters (such as for dialysis or chemotherapy) differently than the physician. Likewise, a physician may view a 30% chance of success with a risk of death as ill-advised, but the patient may think it is well worth the risk. “When conflict between the patient’s choice and what the physician thinks is best persists, ethics consultations can help,” says Olick.
When a patient decides not to follow a medical recommendation, some clinicians hesitate to try to convince the patient to change their mind. “I personally grapple with this as an ethical dilemma. I have worried at times, when I did not push and the patient ended up with a negative outcome, whether I should have tried harder to persuade them,” says Nancy Schoenborn, MD, MHS, an associate professor of medicine at Johns Hopkins University School of Medicine.
This raises the question: If a doctor thinks that an intervention is in the patient’s best interest, is it ethically acceptable to try to persuade the patient? “There has been a lot of theoretical debate on this topic in the scientific literature, but not much data on patient perspectives,” says Schoenborn.
Schoenborn and colleagues interviewed 20 older women in the Baltimore metropolitan area about whether they thought it was ethical for doctors to persuade patients.1 The study participants were given two scenarios: Doctors persuading patients to stop mammograms (after 74 years of age, when guidelines no longer support routine mammograms), and doctors persuading patients to move out of their homes after multiple falls. Participants’ views were mixed. Some supported persuasion because of the potential health benefits for patients. Some were opposed to persuasion regardless of the potential benefits and stated that patients should be the ultimate decision-makers.
Participants were more accepting of hearing about other patients’ experiences as a way for the doctor to try to persuade them. “But they were not accepting of guilt trips or scare tactics as persuasive techniques,” says Schoenfeld. The older women were much more accepting of persuasion if not following the doctor’s recommendations could lead to significant harm, such as fall-related injuries. “The implications for clinicians are that they can consider fact-based and narrative-based persuasion, but not emotional tactics, in high-stake decisions,” says Schoenborn.
The study participants offered these alternative approaches for doctors if patients are refusing recommendations:
- involving other family members or other healthcare providers in the conversation;
- making a point of respecting patients and treating each one as an individual;
- offering alternative options, other than following the recommendation or not following it.
“Having ethicists comment on this dilemma would be very interesting. This is actually the next step of our research project — we will compose a panel of bioethicists to discuss our findings and come up with some recommendations,” reports Schoenborn.
In the pediatric intensive care unit (PICU), clinicians must guide families in making choices about complex medical options that align with their child’s best interests. “Care conferences are pivotal moments where these dynamics play out. Yet there is limited understanding of how clinicians influence family decisions during these discussions,” says Aliza Olive, MD, staff physician in the Division of Pediatric Critical Care at Cleveland Clinic Children’s Institute.
Olive was interested in how much information is provided to patients and families about possible outcomes during the informed consent process and how that information shapes decision-making. This led Olive to explore clinicians’ use of “nudging,” a concept in behavioral economics, and how it affects shared decision-making. Olive and colleagues analyzed 70 transcripts of PICU care conferences from 2015-2019 between physicians and families to assess the frequency and pattern of nudges.2 Nudging occurred in 63 of 70 conferences, suggesting it is pervasive among clinicians. Tracheostomy was the decision type most frequently discussed. “Gain framing” (focusing on the benefits of following the recommendation) was the most frequent nudging strategy used, followed by “loss framing” (highlighting the risks if the recommendation is not followed).
Despite being a seemingly logical tool for guiding decision-making, clinicians rarely used expert opinion as a nudging strategy. “This might reflect the uncertainty inherent in many PICU decisions, where multiple options are viable, or it might reflect clinicians’ emphasis on empowering families rather than appearing overly directive,” suggests Olive.
Nudging could be perceived as coercive if families feel pressured toward a decision that contradicts their preferences or cultural values. “Unintentional or subconscious nudging can lead to a clinician influencing decisions in ways that may not align with family goals. Clinicians must ensure that nudging respects family autonomy and aligns with the child’s best interests,” says Olive.
Hospital ethicists can play a critical role in addressing the ethical dimensions of nudging. “Ethicists can create spaces for clinicians to reflect on their communication strategies, including the intentionality and impact of their nudging practices, during debriefings or ethics rounds,” adds Olive.
References
1. Schoenborn NL, Hannum SM, Gollust SE, et al. Older women’s perspectives on the ethics of persuasion in doctor-patient communication. J Am Geriatr Soc. 2024;72(10):3179-3187.
2. Olive AM, Finnsdottir Wagner A, Mulhall DT, et al. Nudging during pediatric intensive care conferences with family members: Retrospective analysis of transcripts from a single-center, 2015-2019. Pediatr Crit Care Med. 2024;25(5):407-415.
If a doctor thinks that an intervention is in the patient’s best interest, is it ethically acceptable to try to persuade the patient?
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