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Correspondence on ‘The limits of shared decision making’ by Elwyn et al: We call for a more nuanced approach
  1. Nadine Ijaz1,2,
  2. L Susan Wieland3,
  3. Daniel F Gallego-Pérez4
  1. 1 Department of Law & Legal Studies, Carleton University, Ottawa, Ontario, Canada
  2. 2 Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
  3. 3 Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
  4. 4 Department of Physical Medicine and Rehabilitation, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  1. Correspondence to Dr Nadine Ijaz, Department of Law & Legal Studies, Carleton University, Ottawa, ON K1S 5B6, Canada; nadine.ijaz{at}carleton.ca

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We read with interest the recent article by Elwyn and colleagues that addressed ‘The limits of shared decision making’ (Elwyn et al, p.1).1 Like the article’s authors, we identify as ‘strong advocates of shared decision-making (SDM)’ while recognizing some limits to its application (Elwyn et al, p.1).1 However, we find the article’s interpretation of SDM principles to be lacking in nuance on multiple fronts.

SDM is an essential component of evidence-based medicine, which requires a ‘recognition that values and preferences are as important as evidence in determining optimal clinical decisions’ (Djulbegovic and Guyatt, p.194).2 SDM is at odds with unwanted paternalistic care, including clinical interactions wherein healthcare professionals may posture empathetically, but ultimately strive to ‘convinc[e] patients to follow their [authoritative] plans’ (Braschi et al, p.177).3 A growing literature furthermore addresses SDM’s centrality in the delivery of culturally responsive, trauma-informed healthcare (eg, Dhawan and LeBlanc4). Such a ‘culturally safe’ approach aims to rectify structural and historical inequities, redress well-founded legacies of medical distrust within marginalised communities and offer care that honours patients’ culturally situated worldviews.5

We firmly believe that when there is no evidence of direct harm and no great urgency, patients must have the autonomy to explore the treatment they prefer—even if this produces disagreement between clinician and patient. We direct our critical comments to two illustrative examples from Elwyn and colleagues’ article (p.3).1 In one case, a patient with ‘multifactorial high cardiovascular risk’ would like ‘to try chia seeds’, a safe approach with ‘no evidence of effectiveness’. On the other, a patient suffering from ‘severe depression, anxiety and panic attacks’ and ‘grounds to be concerned about suicide’ would like to ‘try an herbal preparation’ with neither reports of ‘serious harmful effects’ nor ‘supporting evidence of benefit’. We are surprised to find the authors arguing in both cases that limits might be placed on SDM, owing to an ‘absence or insufficient evidence of benefit’ for the patient’s preferred treatments.

Notably, the authors fail to recognise the extent of limiting or conflicting evidence of effectiveness for many guideline-based treatments, such as those they suggest be urged on patients—to say nothing of the even greater uncertainty that exists regarding treatments applied to a particular individual. In the mental health–focused case, we find the authors’ justification of limits to SDM based on a possible suicide risk especially exaggerated, since antidepressant medications often take weeks to (hopefully) exert an advantageous effect.

Although the authors advise clinicians to ‘explore, listen, inform and take time to build trust’ with the patient in the presented cases (Elwyn et al, p.3),1 we find their risk/benefit calculus to weakly consider patient perspectives except as a ‘problem’ to be solved by the clinician. Such an inadvertently paternalistic approach overlooks potential therapeutic advantages associated with patients feeling truly respected. The article also omits explicit consideration of the possible cultural importance of a patient’s particular treatment preferences (eg, herbal medicine) and the legitimate non-biomedical (eg, traditional/Indigenous) knowledge systems from which such may arise.

By overlooking such considerations, the authors’ proposed limits on SDM may ultimately produce more harm than good.

References

Footnotes

  • Contributors NI: Conceptualisation; writing—original draft. LSW and DFG-P: Conceptualisation; writing—review and editing.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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