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077 How can shared decision-making turn into paternalism – and how should we think about this ethically?
  1. Anniken Fleisje
  1. Oslo Metropolitan University, Norway


Introduction When a health professional overrides a patient’s preferences for the patient’s own good, we have a case of paternalism. Paternalism is commonly considered ethically problematic and antithetical to shared decision-making (SDM), where all involved parties share their perspectives before a decision is reached. But does SDM necessarily prevent paternalism, and how should we think ethically about a mix between the two?

Methods Qualitative content analysis of 200 video-recorded medical encounters from a Norwegian hospital, combined with philosophical and normative analysis.

Results The analyses revealed that treatment conversations can evolve from non-paternalism to paternalism when a health professional moves from trying to make a patient want treatment (what I call convincing), to making the patient consent to something despite the patient not really wanting it (what I call persuading). This may happen, for example, when patients are overwhelmed by emotions such as fear.

Discussion A treatment conversation may begin as an SDM process in the sense that all parties share their perspectives, with the goal of reaching a joint decision. However, it may unnoticeably end in paternalism if the final decision lies closer to what the health professional thinks is best, than to what the patient wants. That being said, SDM also has its ethical pitfalls, depending on how it is performed.

Conclusion I will argue that health professionals should be aware of the fine line between SDM and paternalism. At the same time, paternalism may be beneficial for the patient – if it borrows central aspects from SDM.

The presentation will be based on my PhD dissertation Doctors Pushing Patients: Communicative Paternalism and Not-So-Shared Decision-Making from December 2023.

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