The Paternalism Preference—Choosing Unshared Decision Making

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Abstract

Informed consent has been a subject of controversy since as early as 1959, when a patient developed paralysis-associated complications from surgery and then sued his neurosurgeon, claiming that he had not received adequate information regarding paralysis risk. Subsequently, the “more information is always better” dogma has become standard practice for informed consent. In this article, the author challenges this dogma by discussing how overwhelming patients with information, for which they possess no framework, can have a negative effect on rational decision making and information processing. Citing support from previous studies, the author establishes that patients make better choices when presented with only few salient points, rather than with multiple parameters. Her second argument is that patients, especially in emotionally charged situations, will often choose to favor present comfort (avoidance of pain) over long-term benefits. For example, patients with coronary heart disease will usually always choose to avoid coronary artery bypass grafting, despite its proven superiority to other treatments in regard to positive long-term outcomes. Another way to say this is that patients are often fearful and thus highly susceptible to information framing. They are more willing to undergo a surgery carrying 95% chance of survival than those carrying 5% chance of death. A final, particularly interesting point that the author introduces is how sense of responsibility affects emotions and decision making during care. One study, in which a group of patients was recommended a medication by a doctor whereas another had to make an informed decision by themselves, found that the group with less direction was less willing to take the medication because of significantly increased concern of risks. As this study implies, patient fear prevented appropriate decision making, especially when the patient carried the burden of responsibility for her own care. So who should carry the burden of responsibility? In a personal anecdote, the author describes a case in which she felt relief when her patient had been informed enough to make a decision, but conflicted because he avoided the appropriate treatment because of fear of future pain. She writes, “Since the decision was his, it was no longer mine. I had informed him. But had I been his doctor?” She concludes with the following points. More information may not be the answer. It may just exacerbate a patient’s sense of vulnerability. Previous clinicians who have found themselves in the role of patient have said, “What patients seek is not scientific knowledge that doctors hide, but existential authenticity each must find on her own.” As the author posits, perhaps the role of a clinician is both to know how to best share information without overloading the patient and to assume responsibility for the patient’s care in a paternalistic manner. It may not only be comforting, but also improve decision making if the patient hears, “I don’t know how things are going to turn out, but I promise I’ll be there with you the whole way.”

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