Shared decision-making is acknowledged as an important part of the informed consent process. “Despite this advancement, we may be omitting a vital component in decision-making: Surgeon subjectivity,” says Paul Kepper, MD, lead author of a recently published paper on this topic.1
Surgeons rely on an immense body of evidence to guide decision-making. Yet much of the perioperative care, even the decision to offer an operation, still requires surgeons to interpret evidence and form an opinion. “We can improve the education of patients by acknowledging and sharing this aspect of decision-making,” says Kepper, resident physician in the department of surgery at Barnes-Jewish Hospital/Washington University in St. Louis.
Sometimes, surgeons lack specific high-level evidence to make perioperative decisions. “The ‘why’ and ‘how’ of surgical planning may depend on training, experience, expertise, and support,” Kepper says, noting that, ideally, surgeons find a way to acknowledge this during the informed consent process.
When clinicians are practicing shared decision-making, tension can arise between the ethical principles of autonomy and beneficence/nonmaleficence. “Physicians should be aware of the level of influence they are trying to have on their patients, and be able to justify that influence ethically,” argues Lauris Kaldjian, MD, PhD, director of the program in bioethics and humanities at the University of Iowa Carver College of Medicine.2
Kaldjian offers this guidance: “Physicians should always inform, usually recommend, sometimes attempt to persuade — but never manipulate or coerce.” At its best, the process of informed consent involves shared understanding that leads to a shared decision. The process encompasses the beliefs and values on which patients base their goals of care, as well as the physician’s beliefs and values regarding good medical practice.
“Patients depend heavily on physicians for help so that the benefits and risks of a treatment can be integrated into the goals and other considerations that matter most to patients,” Kaldjian says.
Ethically justifiable healthcare decisions incorporate a patient’s goals, values, and preferences on the one hand, and their pathophysiology and prognosis on the other, says Virginia L. Bartlett, PhD, assistant director of the Center for Healthcare Ethics at Cedars-Sinai Medical Center in Los Angeles. Both types of information are necessary. For providers, it may help to articulate distinct responsibilities involved in shared decision-making, offers Bartlett:
The patient and surrogate are responsible for articulating what makes the patient’s life meaningful; what kinds of functional status, communication, or interactivity are acceptable; what types of burdens are acceptable; and what likelihood level of success is acceptable. Clinicians are responsible for clarifying the physical conditions and options for treatment (i.e., the pathophysiology and prognosis), recommending a treatment plan that is fitting for a patient, and ensuring the patient (or surrogate) understands and accepts the plan (and engages in further exploration and conversation if they do not).
Clinicians must approach shared decision-making as “a process of discovery that continues throughout the healthcare encounter and beyond, rather than a procedure to be implemented,” Bartlett says.
It is unethical not to offer information to patients when there are options available that are reasonable to consider, according to Glyn Elwyn, BA, MD, MSc, PhD, director of the patient engagement research program at The Dartmouth Institute.
It is ethically problematic if providers abandon people to make decisions alone without any support, or offer information that is overwhelming and confusing. What information should be conveyed, and when should the patient be allowed to decide?
“As always, the answer is: ‘It depends.’ But if shared decision-making is done well and skillfully, it is an ethical imperative,” Elwyn says.
Some clinicians view shared decision-making as providing medical information, and leaving it up to the patient to decide.
“They avoid providing recommendations, fearing that they may be overstepping their boundaries,” says Trevor M. Bibler, PhD, assistant professor of medicine at the Center for Medical Ethics and Health Policy at Baylor College of Medicine in Houston.
Yet clinicians “are not neutral parties,” Bibler adds. “They should feel comfortable in naming what they view good and beneficial medicine to be.”
Clinicians should think about what kinds of decisions are within the realm of their discretion, which decisions should be left completely to the patient, and which decisions require shared decision-making. “Some decisions in medicine should not be shared, while others should,” Bibler says.
For example, patients should not have a say on what kinds of vasopressors to use, their amount, or their timing. On the other hand, decisions must be made on whether to initiate vasopressor support in the first place, when the patient’s blood pressure reaches a dangerously low level. That kind of decision should reflect the values and preferences of the patient.
“Just as the clinical team are the experts on the kinds and amount of vasopressors, the patient is the expert on whether such support is consistent with their own conception of a good life, good medicine, and a good death,” Bibler explains.
Bibler says “the healthy default” is when medical decisions are shared between the healthcare team and the patient. Exceptions should be made if the decision falls squarely and solely within the discretion of clinicians or the patient. For example, if a patient is a candidate for chemotherapy and radiation, it is within the authority of the healthcare team to determine the kind of chemotherapy that is most beneficial, and offer that intervention. There is no need to ask the patient which kind of chemotherapy would be most beneficial, since that falls within the expertise of the oncology department.
“However, decisions on whether the harms of chemo are worth the benefits should be a shared decision,” Bibler says.
The patient is the expert on their conception of a good life and whether chemotherapy is consistent with it. “If we imagine that the patient starts chemo, but then decides that the harms are too great and the benefits are too small, they should have the authority to unilaterally stop,” Bibler offers. The oncology team might object. “However, since that decision is highly dependent on the patient’s values and preferences, there is little reason to think that the healthcare team should have input on that,” Bibler says.
REFERENCES
1. Kepper PJ, Wightman SC, Shakhsheer BA. Shared consent: Acknowledging the subjectivity of surgical decision-making. Ann Surg 2022; Aug 22. doi: 10.1097/SLA.0000000000005682. [Online ahead of print].
2. Kaldjian LC. To inform, recommend, and sometimes persuade: The ethics of physician influence in shared decision making. South Med J 2022;115:244-246.
Physicians should always inform, usually recommend, sometimes attempt to persuade — but never manipulate or coerce.
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