TY - JOUR T1 - The limits of shared decision making JF - BMJ Evidence-Based Medicine JO - BMJ EBM DO - 10.1136/bmjebm-2022-112089 SP - bmjebm-2022-112089 AU - Glyn Elwyn AU - Amy Price AU - Juan Victor Ariel Franco AU - Pål Gulbrandsen Y1 - 2022/12/15 UR - http://ebm.bmj.com/content/early/2022/12/15/bmjebm-2022-112089.abstract N2 - The foundation of shared decision making (SDM) is the view that people should be aware of relevant choices, and that their personal views, priorities and preferences are relevant factors when determining action. The degree to which people wish to engage in decisions will vary, as will the level to which they will be made aware that decisions exist, or become informed about the relevant information.1 There is increasing interest in SDM, an ethical imperative,2 and supporting evidence that well-designed tools help people compare options and make more informed choices.3 We as authors, are strong advocates of SDM, and think the approach can be applied widely, perhaps more widely than many health professionals think possible.4 5Nevertheless we have identified situations where we consider there to be clear limits to SDM, where wider interests can override the priority given to individual preferences. While we think individual priorities and preferences should be respected where possible, there are situations where other factors determine decisions.6We feel it is essential to make these situations clear. SDM can be too easily dismissed as an impossible ideal if we do not acknowledge that the approach has limitations. In addition, delineating exceptions will serve to illustrate the demarcation between what can be thought of as the pinnacle of patient-centred care and situations where the approach is rightly constrained by ethical, professional or societal factors.5First, let’s agree that decisions come in different forms: some are conscious and episodic, as in ‘Shall I have this procedure?’. Some are the result of commitment decisions, such as when agreeing to take medication for a long-term illness.7 Others go unnoticed in conversations, such as when a clinician suggests a solution and results in assumed acceptance. Such subtle decisions may well occur because of deference … ER -