In shared decision-making (SDM), patients and clinicians work together to determine the best next steps in health and care. Elwyn et al’s recent paper1 makes an important contribution to the literature about the applicability and limits of SDM.2 Their argument requires adherence to the traditional definition of SDM.

The definition of SDM the authors use—that is, the preference-based selection of an alternative based on its relative merits3—has enabled progress. It has fuelled work on standards for patient decision aids, measurement instruments, efficacy and implementation studies, and policy initiatives. Experts and policy makers believe implementing SDM, considered as something new or as an extrinsic addition to clinical practice, can promote patient engagement and empowerment, reduce the uptake of invasive and expensive care, improve outcomes (particularly adherence to therapy), and correct distortions in healthcare such as unwarranted variations in healthcare.4–6 Cottage industries of decision aid production and decision coaching have emerged as well as a policy initiative, far and few apart in the USA, for example, mandating SDM as a condition for payer reimbursement.7 The evidence to date would support the statement that despite four decades of work by our SDM community, the uptake of SDM is very scant in practice and that, therefore, the improvements …