Patient–doctor decision-making about treatment within the consultation—A critical analysis of models

Abstract

This paper highlights some of the limitations of models of patient involvement in decision-making and explores the reasons for, and implications of, these limitations. Taking the three models of interpretative, shared and informed decision-making as examples, we focus on two limitations of the models: (1) neglect of which decisions the patient should be involved in (the framing problem) and (2) how the patient should be involved in decision-making (the nature of reasoning problem). Although there will inevitably be a gap between models and practice—this much is in the nature of the models—we suggest that these two issues are substantially neglected by the models and yet are fundamental to understanding patient–doctor decision-making. We also suggest that the fundamental problem that lies behind these limitations is insufficient attention to, and explicitness about, the dilemmas of professional ethics, which are played out in the professional–patient relationships that the models are supposed to represent, particularly with respect to the issue of expert and lay accountability.

Introduction

In this paper we want to explore some of the limitations of models of patient involvement in treatment decision-making. Specifically, we will consider the models of interpretative decision-making, shared decision-making and informed decision-making. To some extent these limitations are simply limitations of models (i.e. models are inherently and necessarily limited—that is, so-to-speak, how they work), and we will begin by acknowledging this fact. But we also want to highlight two aspects of the process of decision-making, which, we would argue, are crucial to an understanding of doctor–patient decision-making and yet are substantially neglected by the models. These two aspects relate to the questions ‘which decisions should patients be involved in?’ and ‘how should patients be involved in decision-making?’ More specifically they concern (1) the framing problem—the construction of the option-set which both frames decision-making and is, in part, a product of decision-making; (2) the nature of reasoning problem—the nature of the reasoning–communication represented in any process of joint decision-making. Lying behind these limitations, we want to suggest, is a more fundamental problem. We would argue that whilst these models represent some very important aspirations, they pay insufficient attention to, and are insufficiently explicit about, the dilemmas of professional ethics which are played out in professional–patient relationships. This, it seems to us, is where their real limitation lies.

In the main body of the paper we will not spend much time interrogating the nature and variety of models. We will proceed as if the models discussed have relatively clear-cut and broadly similar purposes. However, it is essential to signal at the outset that the role and value of these kinds of model are both contested and varied. However, one thing that might be said by way of generalisation is that it is in the nature of models to ‘abstract from’ and simplify the multi-dimensional realities that they represent. (As is often said a ‘map’ which contained all the information found in the reality it depicted would be valueless as a map.) It is, therefore, not a credible criticism of models to point out that they do not include all the things that they might include. Nor can we expect there to be any straightforward ‘match’ between models and the world of practice. There is inevitably an ‘interpretative space’ between the models and practice. Thus, it is not simply that there may sometimes be a kind of mismatch between a model and practice, it is also that we are often unsure what would count as an application of a specific model in real-world circumstances.

Having acknowledged some of these complexities we will take it that models of patient involvement are designed to describe and/or prescribe some conception of ‘good practice’, i.e. patient involvement is being made salient through the models because of its instrumental or intrinsic value. Instrumental (or practical) value refers to such things as patient involvement leading to patients who “make wiser decisions, come to a common understanding with their physicians, and adhere more fully to treatment” (Epstein, Alper, & Quill, 2004); hopefully this leads to a happier, healthier patient. Intrinsic value refers to philosophical or ethical ideals, such as ‘respect for persons’, which underlie or inform patient involvement policies; ideals that can be seen as crucially important in themselves, irrespective of the practical effects of involvement. Given that this account describes the basic thrust underpinning models such as the ones considered here, there are three broad sets of evaluative issues that arise about the ‘space’ between models and practice. We could, for example, ask (1) Is there a rough fit between (any of) these models and some real world practices? (2) What are the factors that might enable or constrain the possible realisation and enactment of the model in practice? (3) Do (or would) enactments of the models serve the instrumental or intrinsic ends that their advocates would wish? The remarks we make in the review of the models that make up the main body of the paper will touch upon all of these questions, but these questions do not form the central thread of our account. Rather, as we have already indicated, we will concentrate on exploring what we see as some of the limitations of the models—limitations which, we would argue, make it difficult to answer any of these questions satisfactorily. These models of doctor–patient decision-making, we are suggesting, are not sufficiently well-defined to answer these crucial evaluative questions. It seems to us that before they can be subjected to these kinds of evaluations the underlying assumptions that these models make about the relative roles of professionals and patients need to be questioned and further elaborated.