Interdisciplinary Support For The Shared Decision-Making Model
Tarun Yandamuri
Introduction
Clinical medicine was historically paternalistic. However, for about thirty years the academic community has increasingly challenged paternalism in favor of patient autonomy.[1] This dramatic paradigm shift has created a void in the bioethical literature on how to effectively balance autonomy and medical care that enhances patient wellness. Moreover, the literature’s overwhelming support of patient autonomy calls to question the physicians’ decision-making process in clinical medicine. From a historical and societal perspective, this paper will first assess reasons for the shift from impractical paternalism to patient autonomy, before arguing for the greater clinical integration of shared decision-making through an interdisciplinary lens that borrows from sociology, psychology, and philosophical ideology.
The Goal of Medicine:
Many authors have written on the goal(s) of medicine. Some may assert that good treatment and a healthy outcome is the only goal, claiming that the patient’s preferences are not as important. However, this paper eschews this consequentialist outlook and rests on the fundamental assumption that the goal of medicine is to care for the patient as a human being.[2] Caring for the patient involves more than treating physical maladies or psychological diseases; the physician should also appreciate the patient’s wishes, values, and goals. Understanding the goal of medicine as caring for the whole patient is fundamental when evaluating the shared decision-making model of care presented in this paper.
A Brief History of Paternalistic Medicine and Autonomy:
Examining the historical roots of paternalistic medicine will reveal the need for a more humanistic and modern model of patient care. Philosopher Gerald Dworkin broadly defined paternalism as “interference with a person’s liberty of action justified by reasons referring exclusively to the welfare, good, happiness, needs, interests, or values of the person being coerced.”[3] In the medical context, paternalism refers to physicians implementing whatever treatment they believe best for the patient. This decision may either align or dissent with the patient’s independent values and wishes.
Support for the paternalistic model of the physician-patient relationship dates back to some of the earliest sources of Western medicine. The English translations of Hippocrates’ writings are strewn with paternalistic implications of the physician’s role in decision-making, including the following declaration taken from the original Hippocratic Oath: “I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients [emphasis added].”[4] Medicine was therefore traditionally predisposed to paternalism; the physician acts as the patient’s protector by unilaterally articulating the best treatment on behalf of the patient.[5] For thousands of years, paternalism remained mostly unchallenged as the guiding principle to medical decision-making.
Contrasting traditional paternalism, the founding fathers of the United States established the country under a fundamentally autonomous code of liberty and unalienable rights for all citizens.[6] Most definitions of autonomy are inspired by Kant’s categorical imperative, which asserts “the idea of the will of every rational being as a will giving universal law.”[7] Dworkin condenses this explanation of an autonomous individual as one who acts according to his or her own thoughts and values, under legal boundaries -- this is the definition of ‘autonomy’ that I will use as well.[8] American civic life has always emphasized individual expression and personal autonomy primary in lawful decision-making. Meanwhile, medical decision-making has been fixed on paternalism, failing to develop a novel approach to align with societal views.[9]
The social contract between medicine and society is greatly responsible for the disparity between societal autonomy and medical paternalism. This unwritten contract can be described as a ‘bargain,’ in which society grants medicine the privileges of prestige, autonomy, and self-regulation with the expectation that physicians will act altruistically, honestly, and in the patient’s best interest.[10] Medicine’s social contract was only developed in the early 1900s, yet has since firmly established physicians as sovereign professionals.[11] For decades society has been relatively complacent with this system, conceding decision-making capacity to benefit the greater good.
More recently major social forces have shifted the public’s interest from passively deferring medical decision-making to actively engaging in the process. Pellegrino and Thomasma outline these forces as the “expansion of political democracy” and “increasingly divergent moral pluralism” throughout civic life.[12] In essence, the public has the right and is encouraged to participate in decisions that have a personal effect.. For example, the government encourages its citizens to be proactive about their health through preventative care. The media is largely fueling this change by publicizing astounding medical advancements and the corresponding ethical and legal dilemmas.[13] Deep-seated concerns, such as abortion and physician-assisted suicide, have called the public’s attention to the intimacy of healthcare decisions. As the public gains insight into health care and its deficiencies, the physicians’ commanding grasp weakens. This inevitable confrontation of paternalism and patient autonomy is only a microcosm of the larger clash between societal views and conventional medicine.[14]
A Critique of Paternalistic Medicine:
Contemporary societal norms are incompatible with a dogmatic paternalism. Superficially, paternalistic medicine fulfills the goals of medicine to the extent that well-being is measured by a patient’s physical responses to treatment. However, the goal of medicine includes caring for the patient’s psyche by considering the patient’s values and goals. Paternalism threatens psychological harm by ignoring the patient’s preferences.
Beauchamp and Childress explain that the principle of beneficence is the foundation of paternalism, defined as the physician’s “obligation to act for the benefit of others.”[15] Paternalistic medicine is a natural manifestation of beneficence according to the physician’s best judgment. However, this beneficence is disseminated from a largely one-sided perspective. Emanuel and Emanuel point out that the physician and patient likely hold different views and values, meaning the physician cannot consistently make a reasonable decision that constitutes benefit for the patient devoid of information.[16] The physician conceives patient autonomy as ‘patient assent,’ and assumes that the patient will agree with the decision at some point.[17] This does not match our previous definition of patient autonomy, because the patient cannot express preferences. True paternalism frequently infringes upon patient autonomy to some degree. While some publications have suggested models that incorporate both paternalism and patient autonomy, a clinically practical model remains elusive.[18]
Another concern with medical paternalism is the potential for physicians abusing their power. For example, there have been cases of corrupt physicians intentionally misdiagnosing patients to increase billing. In July 2015, a Michigan oncologist was sentenced with 45 years in prison for falsely misdiagnosing hundreds patients with cancer and accepting millions of dollars in fraudulent Medicare payments.[19] In these situations, irreversible harm is done before the patient discovers the truth. On an individual basis, implicit bias might corrupt the physician’s decision-making without any conscious dishonesty from the physician. Yet in other cases, such as this one, the physician is knowingly deceitful.
In the larger picture, medicine’s esteemed social status is partly to blame for some unethical behavior. People tend to venerate any source that allows them to live well and long; the public places its trust in physicians as a source of support in maintaining health.[20] In general, physicians are highly regarded figures in daily life. John Stuart Mill once commented on the dangers of class imbalances by saying, “Wherever there is an ascendant class, a large portion of the morality of the country emanates from its class interests and its feelings of class superiority.”[21] As members of an ascendant class, physicians’ interests become paramount to those of the general public. Paternalistic medicine provides the platform for physicians to endorse their own interests, even when those interests oppose those of their patients.
Most physicians object to medical paternalism under normal circumstances. A 2001 cross-sectional survey of 1,050 U.S. physicians found that only 14% of physicians preferred paternalism.[22] On the other hand, 75% of the respondents preferred to share decision-making with their patients.[23] The reasons for why physicians generally dislike paternalism are far and varied. For example, physicians may not want to impose their will on the patients. They recognize that the patient’s dignity is injured when the physician dominates the decision. Physicians recognize that paternalism generally disregards how the patient feels, and thereby opposes the goal of medicine.
While paternalism is not suitable to normal clinical encounters, it is a necessary approach under certain circumstances. For example, if a patient is in critical condition and cannot provide informed consent to a procedure, a quick paternalistic intervention by the physician is almost always justified.[24] The value for patient autonomy is so high that even such extenuating cases are often handled through surrogate decision-makers, such as the patient’s family members or an external health care proxy, or a prewritten advanced directive. When all other reasonable options are unavailable, physicians can fairly (and legally) implement paternalistic care for patients who lack the decision-making capacity to relay their values. Another such exception is therapeutic privilege, which allows physicians to paternalistically withhold certain information from the patient to indirectly prevent serious harm.[25] Paternalistic interventions can be justified when the patient may harm self or others. Although children are often treated paternalistically and do not entirely possess decision-making capacity, the physician still considers the child’s wishes.[26] Lastly, certain patients may even prefer to forgo any decision-making authority in favor of the physician’s paternalistic judgment. Although shared decision-making is the gold standard for clinical interactions, certain situations require the physician to default to paternalistic measures.
A Need for Shared Decision-Making in Medicine:
The decline in medical paternalism and the emphasis on patient autonomy made seeking informed consent from the patient before making a health decision crucial. The moral significance of informed consent became so important that informed consent has transformed from a recommendation into a legal necessity. The 1972 court case Canterbury v. Spence mandated that for a competent patient, “all risks potentially affecting the decision must be unmasked” to obtain informed consent.[27] One proposed model of the physician-patient relationship, the informative model, overstates informed consent and patient autonomy by requiring the physician to strictly transfer discrete information to the patient.[28] The patient then uses this information to make a wholly independent decision according to his or her values. However, the informative model assumes that the patient has known, fixed values and severely restricts the physician from making any recommendations whatsoever.[29] In reality, the patient often has dynamic values that may be unknown altogether.[30] While the paternalistic model limits patient autonomy, the informative model grants an impractical definition of patient autonomy. Several intermediate models, such as the physician-as-agent model, have described the physician attempting to make treatment decisions by choosing as the patient would choose.[31] The physician thereby unearths the patient’s values and chooses accordingly as the sole decision-maker. These models have been omitted from discussion for simplicity. However, all of these models fail to respect both the physician and patient as important, cooperative agents in decision-making.
As a response to this inequality of decision-making between the physician and patient, bioethical literature has increasingly supported the implementation of shared decision-making in clinical medicine. For cases in which multiple treatment options exist, the patient’s preferences become especially salient, and shared decision-making provides the patient a practical avenue to explore those choices. At its core, shared decision-making stresses the physician-patient relationship as a two-way street.[32] In other words, both parties are expected to contribute to the overall decision-making process. This is distinct from the paternalistic and informative models, which support unilateral decision-making. If either party is unable or unwilling to participate in the decision-making process, then shared decision-making cannot reasonably occur.[33] In this case, the paternalistic model can be reasonably justified.[34]
The literature notes that several criteria exist for shared decision-making to successfully occur. As mentioned, both parties should be motivated to proactively contribute. Research has shown that even though patients overwhelmingly desire medical information, they are much less willing to ask for that information from the physician and subsequently assume responsibility for medical decision-making.[35] Oftentimes patients may default to a passive role because they feel burdened by the process, embarrassed to ask questions, or simply scared to complain to the physician.[36] For these reasons, shared decision-making suggests that the physician provide a favorable, friendly environment to maximize the patient’s comfort. This can range from regularly asking the patient open questions to a warm smile. The physician should not ask yes or no questions, such as “Do you have any questions for me?” because the patient is more likely to answer “no” as a default.[37] Instead, asking open-ended questions such as “What questions do you have for me?” allows the physician to elicit the patient’s preferences so that treatment options can be personalized according to the patient’s needs and goals.[38] Physicians often misinterpret the patient’s preferences through conjecture.[39] In accordance with the ‘two-way information flow’ axiom, while the patient communicates these personal preferences, the doctor should provide the technical information pertaining to all relevant treatment options as clearly as possible.[40]
In addition to standard communication, the physician may employ various decision aids to better inform the patient. Shared decision-making suggests that the physician convey the risks and benefits of each treatment while consciously trying to prevent imposing personal preferences onto the patient. At best, the physician can merely recommend one particular treatment option over another without coercing the patient to choose the same. Research has shown that patients feel mental and emotional comfort when they receive full information.[41] Like most physician-patient relationships, shared decision-making has little function without mutual trust between the patient and physician. Many of these criteria can only be met if the physician can initially solidify a meaningful professional relationship centered on trust.
The potential benefits of shared decision-making are significant. Shared decision-making may create a more knowledgeable patient. The patient feels lower levels of anxiety over the unknown, and a greater sense of control over the decision-making process.[42] Decision aids, such as written fact sheets and informational videos, offer other effective methods of information delivery. A recent review of the effectiveness of decision aids for patients undergoing stressful screening and treatment decisions found that patients consistently felt better informed and more realistic about their expectations of risks and benefits.[43] Furthermore, the physician often feels less stress since the patient is better prepared for consultation.[44]
Some research shows that shared decision-making may help reduce healthcare costs, with up to 20% of patients involved in shared decision-making selecting less expensive surgical options.[45] A 2012 observational study of knee or hip osteoarthritis patients found that providing decision aids resulted in 26% fewer hip replacement and 38% fewer knee replacement surgeries, thereby significantly reducing costs overall.[46] Although additional data is needed to solidify these claims, the preliminary research looks promising. Perhaps the most important benefit to shared decision-making is its wholesome approach to contemporary healthcare. Shared decision-making strengthens the physician-patient relationship and grants practical patient autonomy in a society that values patient empowerment.
On paper, the shared-decision making model is the current standard of care; however, the literature still calls for greater integration of shared-decision making in clinical practice.[47] What the academic medical community suggests and how physicians actually behave is not always in sync. The medical shared-decision model has great potential, particularly by borrowing from other well-established disciplines. Integration of this information provided by fields that study human behavior is important for improvements to shared decision-making between physicians and patients.
A Sociological Perspective on Decision-Making:
Any relationship intrinsically involves making decisions towards conflict resolution. Sociological factors can dictate how decisions are perceived between parties, remedying or worsening the conflict at play. The physician-patient relationship is no exception. Sociology has long studied decision-making and its many contextual elements. The physician-patient relationship is complex, comprising many sociological factors. The patient’s personal characteristics, the physician’s personal characteristics, and the physician’s interaction with the healthcare system all can impact medical decision-making.[48]
A patient’s socioeconomic status can affect how a physician perceives and diagnoses the patient, even if not intentionally.[49] One systematic review found that patients from lower socioeconomic classes are less often encouraged to participate and less likely to understand medical information when discussing treatment options.[50] The review also showed that physicians are less informative when consulting with patients from lower classes.[51] Several plausible reasons exist as to why patients from a lower socioeconomic class are treated with less attention in medical decision-making. Families with a lack of financial resources have frequently been correlated with a poor access to education.[52] Consequently, patients with a lower educational background are much less likely to participate in the decision-making process when compared to their well-educated counterparts.[53]
Some studies have reported that patients of a lower socioeconomic status feel less control over medical situations, and may believe that health and disease are beyond their authority.[54] Physicians may identify these passive patients as unwilling or unable to comprehend information and meaningfully contribute to medical decisions.[55] A reciprocating negative cycle emerges when the patient remains inactive and the physician incorrectly assumes the patient’s unwillingness to contribute, leading to further patient inactivity.[56] In contrast, higher educated patients with a privileged socioeconomic background are often vocal in their healthcare decisions, eliciting an informative and positive attitude from the physician as well.[57] These patients belong to a socioeconomic class that is closer to the physician’s, and often feel comfortable in asking questions and participating.[58] In order for shared decision-making to work, physicians should realize that socioeconomic variables can impact patients’ participation in decision-making and thereby the quality of care administered.
The patient’s race might subtly affect the decision-making process as well. One study showed differences in the quality of how well physicians communicate with patients of different races; physicians were found to be more verbally dominant and less emotionally perceptive with African American patients than white patients.[59] Another study used an implicit-association test to find that cardiologists were less likely to recommended African American patients for thrombolysis than white patients.[60] An implicit bias may exist in healthcare, impeding shared decision-making with African Americans as compared to white patients.[61] While additional research is needed to reach any firm conclusions, the idea of a potential racial bias among physicians, either conscious or unintentional, should not be dismissed.
Female patients are predisposed to a gender bias in healthcare, since women are underrepresented in clinical research studies compared to men.[62] The abundance of male research data may be incorrectly extrapolated to women, even if certain biological gender differences require different treatments for women.[63] For example, women’s blood vessels are naturally narrower than men’s, allowing for easier plaque buildup and a higher chance of rupture.[64] Pharmaceutical companies and physicians should compensate for such biological differences when developing or prescribing drugs. Biological gender differences may manifest into entirely different symptoms for men and women.[65] If these differences are neglected, physicians run the risk of failing to identify symptoms and diagnose key issues pertaining in female patients. In fact, women with coronary artery disease are given a disproportionately lower amount of lipid-lowering treatment than men with coronary artery disease.[66] Gender biases are therefore prevalent in research and clinical medicine as well. The patient’s age and physical appearance may also factor into how the physician allocates decision-making with the patient.
The sociological characteristics of the physician are equally relevant to medical decision-making. Not all physicians treat clinical encounters in the same manner. Some physicians are disease-oriented and will prefer to take prompt action with the patient.[67] Other physicians are oriented towards health maintenance and will observe the patient’s situation for some time before discussing treatment options.[68] The physician’s gender may play a role in decision-making as well. Several studies suggest that female physicians take more time with their patients and give greater consideration to psychosocial issues than their male counterparts.[69], [70] This may suggest that female physicians are generally more patient-oriented.
Medicine’s constantly evolving nature over time sets the physician’s age as an influencing factor, caused by differences in belief and training between younger and older physicians. One study published by the American Sociological Association found that older physicians tend to more frequently diagnose depression in female patients than younger physicians.[71] One plausible explanation for this disparity is that depression was once mistakenly believed to be a female-specific condition caused by postmenopausal changes.[72] Through a cohort effect, older physicians may still consider these claims when treating female patients.[73] While the effects of the physician’s race on decision-making are inconclusive, patients in race-concordant relationships with their physicians tend to report higher levels of satisfaction than patients who are not race-concordant.[74] Physicians may claim a uniform standard of care to all patients and deny the relevance of any of these patient or physician characteristics. However, subconscious perceptions, biases, and stereotypes cannot be avoided until first acknowledged by the physician.
The physician’s interaction with the medical profession can easily affect the physician’s decision-making behavior. A commonly held belief among physicians is that overdiagnosing patients, even in the absence of patient benefit, is better than missing a diagnosis completely.[75] Some physicians may overdiagnose to satisfy the patient’s desire to identify that something is truly wrong, while others may overdiagnose either due to the peer pressure of examining all differential diagnoses or avoiding the threat of a malpractice suit.[76] In either case, adding diagnoses most likely adds additional pharmacological treatment and unnecessarily burdens a patient. Furthermore, physicians who are actively engaged in the medical community and better informed on pharmacological advances are more likely to prescribe new drugs to patients.[77] The influence that pharmaceutical drug companies have on physicians is so great that medical students even undergo workshops that teach how to interact with pharmaceutical representatives.[78] These representatives persuade physicians to prescribe up-and-coming drugs. Physicians may feel compelled to recommend these novel drugs to patients based on qualitative claims in the community and a higher tolerance for risk. Other physicians may prefer to avoid risks and prescribe traditional drugs with confirmed data.
Sociology highlights the subtle social factors that affect decision-making, showing that physician treatment can never be perfectly uniform for all patients. Physicians and patients possess certain social and socioeconomic characteristics that naturally lead to biases in either party. If the goal of medicine truly is to care for the whole patient, then prejudices disrupt the goal entirely. Rather than ignoring such biases, physicians should instead expand their awareness of potential biases that may exist. The shared decision-making model can incorporate this awareness and encourage physicians to reflect on socioeconomic inequalities between themselves and their patients, allowing for the physician to subjectively compensate and provide less-biased patient care.
A Psychological Perspective on Decision-Making:
Another discipline that studies human behavior is psychology, and therefore can help reveal intra-personal undertones to decision-making. While sociological decision-making is largely impacted by relationships between people, the psychological perspective of decision-making is concerned with the human mind and emotions. Psychology offers excellent insight into underlying character traits that affect how people make decisions, specifically physicians and patients.
In 1889 William Osler, widely considered to be the father of modern medicine, emphasized the importance of physician equanimity in his valedictory speech to the University of Pennsylvania graduating medical class: “a certain measure of insensibility is not only an advantage, but a positive necessity in the exercise of a calm judgment.”[79] Osler believed that a physician should strive to control his or her mental state and conceal any external emotions when treating a patient.[80] By maintaining an aura of coolness, Osler argued that physicians can cover up mental weaknesses and easily “see into” the patient’s deeper self.[81] Osler’s influence helped standardize physicians as objective beings who should view patients with an air of detached concern, out of respect to both the patient and the physician.[82] These attitudes have echoed throughout popular culture, personifying the doctor as an aloof and emotionally distant caretaker.[83] Numerous medical dramas contain apathetic physicians, such as famed characters Ben Casey and Gregory House, who treat their patients from an emotional distance.[84] The truth is that physicians possess innate personality traits and emotions that comprise their character, just like any rational human being with the ability to think freely. The ideal of objectivity is unrealistic in clinical practice, as even emotionally detached physicians are subject to raw emotions.[85] Detached concern only masks already present emotions. These psychological traits and emotions can greatly influence how physicians and patients engage in decision-making activities together and should not be underplayed in the clinical setting.
The profusion of personality traits can mostly be narrowed down to five major psychological dimensions: openness, conscientiousness, extraversion, agreeableness, and neuroticism.[86] These dimensions refer to a person’s ability to be tolerant of others, dependable and responsible, talkative and assertive, cooperative with others, and anxious or depressed, respectively.[87] However, one study found that these “Big Five” personality characteristics do not influence ethical decision-making nearly as much as a person’s narcissism of self-worth and cynicism of other people.[88] Feelings of narcissistic entitlement and cynical assumptions about others’ motives were consistently correlated with less ethical decision-making.[89] A narcissistic individual may exploit others to advance their own goals, while a cynical individual may trust others less.[90] For example, narcissistic physicians might prescribe patients expensive treatments for profit. A cynical patient can undermine trust through skepticism, even though trust is integral to the physician-patient relationship and therefore decision-making.[91] Narcissistic or cynical behavior can negatively impact communication and even create feelings of resentment.
While personality traits are integral to a person’s character, emotions represent a short-lived response to external forces.[92] Discrete emotions, such as fear, anger, happiness, and sadness, can all alter how decisions are made.[93] Anger is one of the most intense emotions, and has been found to induce riskier decision-making behavior.[94] Anger can cause physicians to recommend riskier options than the patient, and other physicians, would typically be okay with. On the other hand, fearful individuals tend to overestimate risky events and instead select the safer option.[95] A fearful patient is likelier to avoid risky treatment options. Happiness and sadness can be polarized as well; while happy patients tend to select safer options, sad individuals feel a loss of control and may select risker options.[96] When adverse emotions begin dominating a relationship, oftentimes the best answer is for both parties to separate for some time and cool down. The physician-patient relationship, however, is not so fortunate. Even through emotional turmoil, the physician cannot abandon the patient.
Rather than resist natural emotional tendencies like Osler suggested, physicians should strive to be empathetic towards their patients. Physicians who practice empathetic communication have been shown to substantially increase patient satisfaction and compliance in decision-making, simply by relating to patients on a sentimental level.[97] Empathetic physicians can strengthen trust in the physician-patient relationship and allow for a mutually beneficial decision-making process. When both the physician and patient are angry or frustrated, physicians can still cultivate the mental fortitude needed to form an empathetic connection with their patients through basic conflict management.[98] By first actively acknowledging their own negative emotions and then self-reflecting on why they exist, physicians can attune to what clues their own emotions reveal about their patients’ feelings.[99]
Increased awareness when listening to patient’s story can often expose hidden emotional concerns that may be missed if the physician is listening only for objective facts.[100] Such receptivity is especially crucial to nonverbal communication, since patients do not always express concerns explicitly.[101] For example, a patient with a quivering vocal tone or poor eye contact may have a hidden undiscussed issue.[102] Physicians have the opportunity to connect with patients in these moments by adjusting their own nonverbal behavior, such as spending less time reading the patient’s chart and making more eye contact or more gestures.[103] If the situation is appropriate, the physician may verbally engage the patient to elicit this issue. During conflicts, physicians also become controlling and less open to criticism.[104] Instead physicians can overcome future conflicts by accepting negative feedback from their patients, consequently improving patient satisfaction as well.[105] Physicians who are genuinely connected to their patients on an emotional level can effectively share decision-making. Physicians who practice detached concern often miss these key psychological factors of the physician-patient relationship.
Psychology reveals that objectivity is an impossible ideal for physicians. Detached concern is an archaic outlook that hinders the goal of treating the whole and is incompatible with patient empathy. Ingrained personality traits and discrete emotions will always influence how physicians and patients make decisions. More importantly, these elements can be hidden entirely. The shared decision-making model should encourage physicians to remain empathetic with their patients, even through conflicts, in order to generate true curiosity in the patient’s interests and possibly discover hidden concerns as well.
A Philosophical Appeal to Action:
Medical ethicist Dan Sulmasy argues that an act is not made good simply because it has been chosen, and that contemporary bioethics sometimes mistakenly grants a skewed perception of autonomy.[106] It is not enough for one to believe that he or she is doing good if the decision made is not fundamentally ‘good.’ Sulmasy bases his thesis in the largely deontological theory of Catholic natural law, which states that actions are inherently right or wrong as an objective truth[107]. For example, Sulmasy explains that the people who attacked the World Trade Center believed they made the correct decision, but instead committed a reprehensible act.[108] Rather, Sulmasy contends that the moral goal of natural law should be to help people understand what is truly good so that they may freely make that decision. In the medical context, when a patient’s rationality fails and he or she makes decisions that are inherently wrong, the physician can override these decisions with the justification of natural law.[109] Many additional philosophical theories exist pertaining to human judgment and decision-making, but these theories have been omitted for simplicity.
Physicians are obligated to recognize variables impeding shared decision-making in the clinical encounter. A patient will not necessarily make a ‘good’ choice every time; the physician should try to identify when a ‘bad’ action threatens to cause damage. Still, this should be balanced with a patient’s autonomous right to choose during the shared decision-making encounter. Does a patient’s right to autonomy condone bad decision-making? To what extent can a physician’s judgment trump a patient’s bad decision-making?
The literature has shown that the best model for appreciating the goal of whole patient care is currently shared decision-making. Evidence-based medicine, such as shared decision-making, only works when physicians accept research and adopt methods into clinical practice. Most physicians believe that their patient interaction is already good, yet what happens if physicians continue to dismiss evidence? Interdisciplinary methods show support for shared decision-making; why aren’t physicians taking action? Now more than ever, physicians should support philosophical research that may help uncover some of these answers in the clinical encounter.
Addressing Criticism to the Interdisciplinary Shared-Decision Making Model:
Several possible criticisms can be made in response to the interdisciplinary shared-decision making model. Perhaps the biggest criticism is the physicians’ time limitation to implement shared-decision making in every clinical encounter. In order to integrate aspects of sociology, psychology, and philosophical undertones into shared decision-making, the physician needs sufficient time for self-reflection and deliberating choices with the patient. As physicians consistently utilize this model and habituate, the shared decision-making process will hopefully become ingrained and automatic. The overall interaction between physician and patient will eventually be more efficient, since patients are better informed. As familiarity with shared decision-making increases, physicians will be able to streamline their clinical encounters to be more time-efficient. Another plausible criticism is that the interdisciplinary shared decision-making model is impractical under certain clinical settings. For example, emergency physicians will rarely use shared decision-making since the majority of their patients require immediate attention.
Furthermore, this paper only presents limited research on the benefits of shared decision-making. Although shared decision-making is the current standard of care, not all physicians use the model. In the 2010 National Health Interview Survey, roughly two-thirds of men who underwent prostate cancer screening reported no evidence of shared decision-making with their physicians.[110] This interdisciplinary approach strengthens the arguments for shared decision-making beyond that which medicine can do on its own. Further research is necessary to fully understand the benefits and shortcomings of such a comprehensive model. Shared decision-making is not an ideal model, as it does not work in every clinical scenario. Although more criticisms may exist, inadequate time, improper setting, and limited research are among the greatest concerns.
Conclusion:
Clinical medicine has evolved from historically paternalistic care to the contemporary standard of shared decision-making. Although the literature overwhelmingly supports shared decision-making for its respect of patient autonomy, the current shared decision-making model cannot uphold under modern society’s increasing medical self-awareness. It is no longer acceptable for physicians to dismiss underlying biases or conceal emotions in the presence of their patients. Physicians should not dismiss variables affecting the clinical encounter, such as underlying biases or concealed emotions. The interdisciplinary approach seeks to support and shape shared decision-making into a more robust model of care that recognizes and responds to medical disparities from a multi-faceted perspective. By expanding the depth of shared decision-making through the sociological, psychological, and philosophical disciplines, physicians stand to translate the academic community’s acclamation for respecting the patient’s preferences into real clinical practice.
Notes:
[1] Timothy E. Quill, “Physician Recommendations And Patient Autonomy: Finding A Balance Between Physician Power And Patient Choice,” Annals of Internal Medicine 125, no. 9 (1996): 763.
[2] Eric J Cassell, The Nature Of Suffering (New York: Oxford University Press, 1994), 140.
[3] Gerald Dworkin, “Paternalism,” Monist 56, no. 1 (1972): 65.
[4] Hippocrates. et al., Hippocratic Writings (Chicago: Encyclopædia Britannica, 1955): xiii.
[5] Ezekiel J. Emanuel and Linda L. Emanuel, “Four Models Of The Physician-Patient Relationship,” JAMA 267, no. 16 (1992): 2221.
[6] Herbert Friedenwald, The Declaration Of Independence: An Interpretation And An Analysis (New York: The Macmillan Company, 1904): 263.
[7] Immanuel Kant, Allen W. Wood and J. B. Schneewind, Groundwork For The Metaphysics Of Morals (New Haven: Yale University Press, 2002): xviii.
[8] Gerald Dworkin, The Theory And Practice Of Autonomy (Cambridge: Cambridge University Press, 1988): 7-12.
[9] Edmund D. Pellegrino and David C. Thomasma, “The Conflict Between Autonomy And Beneficence In Medical Ethics,” Journal of Contemporary Health Law & Policy 3, no. 1 (1987): 23.
[10] Rudolf Klein, The New Politics Of The NHS (Oxford: Radcliffe, 2006).
[11] Paul Starr, The Social Transformation Of American Medicine (New York: Basic Books, 1982): 3-6.
[12] Pellegrino and Thomasma, “The Conflict Between Autonomy And Beneficence,” 24-25.
[13] Ibid.
[14] Matthew K. Wynia, “The Short History And Tenuous Future Of Medical Professionalism: The Erosion Of Medicine’s Social Contract,” Perspectives in Biology and Medicine 51, no. 4 (2008): 576.
[15] Tom L Beauchamp and James F Childress, Principles Of Biomedical Ethics (New York, N.Y.: Oxford University Press, 2001): 165-166.
[16] Emanuel and Emanuel, 2221.
[17] Ibid.
[18] Pellegrino and Thomasma, “The Conflict Between Autonomy And Beneficence,” 23-46.
[19] Ed White, “Michigan Doctor Gets 45 Years In Prison For Hurting Patients,” Associated Press, 2015, accessed July 20, 2015, http://bigstory.ap.org/article/dea1e9256cfa46d782e513d160557ee3/judge-sentence-detroit-area-cancer-doctor-fraud-scheme.
[20] Joseph Katz, “The Functions of a Profession: Social Status of Medicine and Education,” Phi Delta Kappan 32, no. 9 (1951): 398-400.
[21] John Stuart Mill, On Liberty, 4th ed. (London: Longman, Roberts & Green, 1869): 6.
[22] Elizabeth Murray et al., “Clinical Decision-Making: Physicians' Preferences And Experiences,” BMC Fam Pract 8, no. 1 (2007): 10.
[23] Ibid
[24] Robert M. Veatch, A Theory Of Medical Ethics (New York: Basic Books Inc Publishers, 1981).
[25] Claude Richard, Yvette Lajeunesse and Marie-Thérèse Lussier, “Therapeutic Privilege: Between The Ethics Of Lying And The Practice Of Truth,” Journal of Medical Ethics 36, no. 6 (2010): 353-357.
[26] Katherine Brown, “Can Medical Paternalism Be Justified?” Canadian Medical Association Journal 133, no. 7 (1985): 678-680.
[27] Canterbury V. Spence. 464 F.2d 772 (United States Court of Appeals for the District of Columbia Circuit 1972).
[28] Emanuel and Emanuel, 2221.
[29] Ibid.
[30] Ibid.
[31] Robert G Evans, Strained Mercy (Toronto: Butterworths, 1984): 75.
[32] Cathy Charles, Amiram Gafni and Tim Whelan, “Shared Decision-Making In The Medical Encounter: What Does It Mean? (Or It Takes At Least Two To Tango),” Social Science & Medicine 44, no. 5 (1997): 685.
[33] Ibid.
[34] Emanuel and Emanuel, 2221.
[35] Analee E. Beisecker and Thomas D. Beisecker, “Patient Information-Seeking Behaviors When Communicating With Doctors,” Medical Care 28, no. 1 (1990): 19-28.
[36] Ibid.
[37] Suzanne Graham and John Brookey, “Do Patients Understand?” The Permanente Journal 12, no. 3 (2008): 67-69.
[38] Charles, Gafni, and Whelan, 687-688. Shared decision-making does not support the physician inferring the patient’s preferences, but rather suggests the physician encourage the patient to explicitly express his or her personal preferences.
[39] William M. Strull, “Do Patients Want To Participate In Medical Decision Making?” Journal of the American Medical Association 252, no. 21 (1984): 2990-2994.
[40] Charles, Gafni, and Whelan, 683-684.
[41] Gavin Mooney and Mandy Ryan, “Agency In Health Care: Getting Beyond First Principles,” Journal of Health Economics 12, no. 2 (1993): 125-135.
[42] Charles, Gafni, and Whelan, 686-688.
[43] Dawn Stacey et al., “Decision Coaching To Prepare Patients For Making Health Decisions: A Systematic Review Of Decision Coaching In Trials Of Patient Decision Aids,” Medical Decision Making 32, no. 3 (2012): E22-E33.
[44] Ibid.
[45] Dawn Stacey et al. “Decision aids for people facing health treatment or screening decisions,” Cochrane Database Systematic Review, no. 10 (2011): CD001431.
[46] D. Arterburn et al., “Introducing Decision Aids At Group Health Was Linked To Sharply Lower Hip And Knee Surgery Rates And Costs,” Health Affairs 31, no. 9 (2012): 2094-2104.
[47] A. M. Stiggelbout et al., “Shared Decision Making: Really Putting Patients At The Centre Of Healthcare,” The BMJ 344, no. 271 (2012): e256.
[48] John M. Eisenberg, “Sociologic Influences On Decision-Making By Clinicians,” Annals of Internal Medicine 90, no. 6 (1979): 957.
[49] S. Willems et al., “Socio-Economic Status Of The Patient And Doctor–Patient Communication: Does It Make A Difference?” Patient Education and Counseling 56, no. 2 (2005): 139-146.
[50] Ibid.
[51] Ibid.
[52] Bruce J Biddle, Social Class, Poverty, And Education (New York: RoutledgeFalmer, 2001): 14.
[53] Richard L. Street et al., “Patient Participation In Medical Consultations,” Medical Care 43, no. 10 (2005): 960-969.
[54] Michael W. Kraus, Paul K. Piff and Dacher Keltner, “Social Class, Sense Of Control, And Social Explanation,” Journal of Personality and Social Psychology 97, no. 6 (2009): 992-1004.
[55] S. Willems et al., 139-146.
[56] Ibid.
[57] Richard L. Street et al., 960-969.
[58] Ibid.
[59] Rachel L. Johnson et al., “Patient Race/Ethnicity And Quality Of Patient–Physician Communication During Medical Visits,” American Journal of Public Health 94, no. 12 (2004): 2084-2090.
[60] Alexander R. Green et al., “Implicit Bias Among Physicians And Its Prediction Of Thrombolysis Decisions For Black And White Patients,” Journal of General Internal Medicine 22, no. 9 (2007): 1231-1238.
[61] I. V. Blair et al., “Clinicians' Implicit Ethnic/Racial Bias And Perceptions Of Care Among Black And Latino Patients,” Annals of Family Medicine 11, no. 1 (2013): 43-52.
[62] Regina M. Vidaver et al., “Women Subjects In NIH-Funded Clinical Research Literature: Lack Of Progress In Both Representation And Analysis By Sex,” Journal of Women's Health & Gender-Based Medicine 9, no. 5 (2000): 495-504.
[63] J. K. Bush, “The Industry Perspective On The Inclusion Of Women In Clinical Trials,” Academic Medicine 69, no. 9 (1994): 708-715.
[64] Kevin R. Campbell, Women And Cardiovascular Disease (London: Imperial College Press, 2015), 18-19.
[65] Ibid.
[66] Akram Abuful, Yori Gidron and Yaakov Henkin, 'Physicians' Attitudes Toward Preventive Therapy For Coronary Artery Disease: Is There A Gender Bias?', Clin Cardiol 28, no. 8 (2005): 389-393.
[67] John M. Eisenberg, 960.
[68] Ibid.
[69] Debra L. Roter, Judith A. Hall and Yutaka Aoki, “Physician Gender Effects In Medical Communication,” Journal of the American Medical Association 288, no. 6 (2002): 756.
[70] Laura Jefferson et al., “Effect Of Physicians' Gender On Communication And Consultation Length: A Systematic Review And Meta-Analysis,” Journal of Health Services Research & Policy 18, no. 4 (2013): 242-248.
[71] John B. McKinlay et al., “The Unexpected Influence Of Physician Attributes On Clinical Decisions: Results Of An Experiment,” Journal of Health and Social Behavior 43, no. 1 (2002): 92.
[72] Ibid.
[73] Ibid.
[74] Thomas A. LaVeist and Amani Nuru-Jeter, “Is Doctor-Patient Race Concordance Associated With Greater Satisfaction With Care?” Journal of Health and Social Behavior 43, no. 3 (2002): 296.
[75] Ibid.
[76] Ibid.
[77] Helen Prosser, “New Drug Uptake: Qualitative Comparison Of High And Low Prescribing Gps' Attitudes And Approach,” Family Practice 20, no. 5 (2003): 583-591.
[78] James L. Wofford and Christopher A. Ohl, “Teaching Appropriate Interactions With Pharmaceutical Company Representatives,” BMC Medical Education 5, no. 1 (2005): 5.
[79] Danielle Ofri, What Doctors Feel (Boston: Beacon Press, 2013): 4.
[80] Jodi Halpern, From Detached Concern To Empathy (Oxford: Oxford University Press, 2001): 22-24.
[81] Ibid.
[82] Ibid.
[83] Ofri, 4.
[84] Ibid.
[85] Ibid.
[86] Robert R. McCrae and Paul T. Costa, Personality In Adulthood (New York: Guilford Press, 2003).
[87] Alison L. Antes et al., “Personality And Ethical Decision-Making In Research: The Role Of Perceptions Of Self And Others,” Journal of Empirical Research on Human Research Ethics: An International Journal 2, no. 4 (2007): 16.
[88] Ibid, 16-17.
[89] Ibid.
[90] Ibid.
[91] David H. Thom, “Patient Trust In The Physician: Relationship To Patient Requests,” Family Practice 19, no. 5 (2002): 476-483.
[92] Amanda D. Angie et al., “The Influence Of Discrete Emotions On Judgement And Decision-Making: A Meta-Analytic Review,” Cognition & Emotion 25, no. 8 (2011): 1394.
[93] Ibid, 1395.
[94] Ibid.
[95] Ibid.
[96] Ibid.
[97] Sung Soo Kim, “The Effects Of Physician Empathy On Patient Satisfaction And Compliance,” Evaluation & the Health Professions 27, no. 3 (2004): 246-247.
[98] Jodi Halpern, “Empathy And Patient–Physician Conflicts,” Journal of General Internal Medicine 22, no. 5 (2007): 696-700. This article describes conflict management by a physician as a conscious process of attempting to develop curiosity for a patient’s distinct perspective. The process often involves the physician conceding his or her ego. This is important during conflict because negative emotions, such as fear and anger, can cloud the physician’s cognition and damage the physician-patient relationship.
[99] Ibid.
[100] Ibid.
[101] Wendy Levinson, “A Study Of Patient Clues And Physician Responses In Primary Care And Surgical Settings,” Journal of the American Medical Association 284, no. 8 (2000): 1021.
[102] Ibid.
[103] Judith A. Hall, Jinni A. Harrigan and Robert Rosenthal, “Nonverbal Behavior In Clinician—Patient Interaction,” Applied and Preventive Psychology 4, no. 1 (1995): 26-27.
[104] Jodi Halpern, “Empathy And Patient–Physician Conflicts,” 696-700.
[105] Ibid.
[106] Dan P. Sulmasy, “Informed Consent Without Autonomy,” Fordham Urban Law Journal 30, no. 1 (2002): 212.
[107] Ibid.
[108] Ibid.
[109] Ibid.
[110] Paul K. J. Han et al., “National Evidence On The Use Of Shared Decision Making In Prostate-Specific Antigen Screening,” Annals of Family Medicine 11, no. 4 (2013): 309.
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Clinical medicine was historically paternalistic. However, for about thirty years the academic community has increasingly challenged paternalism in favor of patient autonomy.[1] This dramatic paradigm shift has created a void in the bioethical literature on how to effectively balance autonomy and medical care that enhances patient wellness. Moreover, the literature’s overwhelming support of patient autonomy calls to question the physicians’ decision-making process in clinical medicine. From a historical and societal perspective, this paper will first assess reasons for the shift from impractical paternalism to patient autonomy, before arguing for the greater clinical integration of shared decision-making through an interdisciplinary lens that borrows from sociology, psychology, and philosophical ideology.
The Goal of Medicine:
Many authors have written on the goal(s) of medicine. Some may assert that good treatment and a healthy outcome is the only goal, claiming that the patient’s preferences are not as important. However, this paper eschews this consequentialist outlook and rests on the fundamental assumption that the goal of medicine is to care for the patient as a human being.[2] Caring for the patient involves more than treating physical maladies or psychological diseases; the physician should also appreciate the patient’s wishes, values, and goals. Understanding the goal of medicine as caring for the whole patient is fundamental when evaluating the shared decision-making model of care presented in this paper.
A Brief History of Paternalistic Medicine and Autonomy:
Examining the historical roots of paternalistic medicine will reveal the need for a more humanistic and modern model of patient care. Philosopher Gerald Dworkin broadly defined paternalism as “interference with a person’s liberty of action justified by reasons referring exclusively to the welfare, good, happiness, needs, interests, or values of the person being coerced.”[3] In the medical context, paternalism refers to physicians implementing whatever treatment they believe best for the patient. This decision may either align or dissent with the patient’s independent values and wishes.
Support for the paternalistic model of the physician-patient relationship dates back to some of the earliest sources of Western medicine. The English translations of Hippocrates’ writings are strewn with paternalistic implications of the physician’s role in decision-making, including the following declaration taken from the original Hippocratic Oath: “I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients [emphasis added].”[4] Medicine was therefore traditionally predisposed to paternalism; the physician acts as the patient’s protector by unilaterally articulating the best treatment on behalf of the patient.[5] For thousands of years, paternalism remained mostly unchallenged as the guiding principle to medical decision-making.
Contrasting traditional paternalism, the founding fathers of the United States established the country under a fundamentally autonomous code of liberty and unalienable rights for all citizens.[6] Most definitions of autonomy are inspired by Kant’s categorical imperative, which asserts “the idea of the will of every rational being as a will giving universal law.”[7] Dworkin condenses this explanation of an autonomous individual as one who acts according to his or her own thoughts and values, under legal boundaries -- this is the definition of ‘autonomy’ that I will use as well.[8] American civic life has always emphasized individual expression and personal autonomy primary in lawful decision-making. Meanwhile, medical decision-making has been fixed on paternalism, failing to develop a novel approach to align with societal views.[9]
The social contract between medicine and society is greatly responsible for the disparity between societal autonomy and medical paternalism. This unwritten contract can be described as a ‘bargain,’ in which society grants medicine the privileges of prestige, autonomy, and self-regulation with the expectation that physicians will act altruistically, honestly, and in the patient’s best interest.[10] Medicine’s social contract was only developed in the early 1900s, yet has since firmly established physicians as sovereign professionals.[11] For decades society has been relatively complacent with this system, conceding decision-making capacity to benefit the greater good.
More recently major social forces have shifted the public’s interest from passively deferring medical decision-making to actively engaging in the process. Pellegrino and Thomasma outline these forces as the “expansion of political democracy” and “increasingly divergent moral pluralism” throughout civic life.[12] In essence, the public has the right and is encouraged to participate in decisions that have a personal effect.. For example, the government encourages its citizens to be proactive about their health through preventative care. The media is largely fueling this change by publicizing astounding medical advancements and the corresponding ethical and legal dilemmas.[13] Deep-seated concerns, such as abortion and physician-assisted suicide, have called the public’s attention to the intimacy of healthcare decisions. As the public gains insight into health care and its deficiencies, the physicians’ commanding grasp weakens. This inevitable confrontation of paternalism and patient autonomy is only a microcosm of the larger clash between societal views and conventional medicine.[14]
A Critique of Paternalistic Medicine:
Contemporary societal norms are incompatible with a dogmatic paternalism. Superficially, paternalistic medicine fulfills the goals of medicine to the extent that well-being is measured by a patient’s physical responses to treatment. However, the goal of medicine includes caring for the patient’s psyche by considering the patient’s values and goals. Paternalism threatens psychological harm by ignoring the patient’s preferences.
Beauchamp and Childress explain that the principle of beneficence is the foundation of paternalism, defined as the physician’s “obligation to act for the benefit of others.”[15] Paternalistic medicine is a natural manifestation of beneficence according to the physician’s best judgment. However, this beneficence is disseminated from a largely one-sided perspective. Emanuel and Emanuel point out that the physician and patient likely hold different views and values, meaning the physician cannot consistently make a reasonable decision that constitutes benefit for the patient devoid of information.[16] The physician conceives patient autonomy as ‘patient assent,’ and assumes that the patient will agree with the decision at some point.[17] This does not match our previous definition of patient autonomy, because the patient cannot express preferences. True paternalism frequently infringes upon patient autonomy to some degree. While some publications have suggested models that incorporate both paternalism and patient autonomy, a clinically practical model remains elusive.[18]
Another concern with medical paternalism is the potential for physicians abusing their power. For example, there have been cases of corrupt physicians intentionally misdiagnosing patients to increase billing. In July 2015, a Michigan oncologist was sentenced with 45 years in prison for falsely misdiagnosing hundreds patients with cancer and accepting millions of dollars in fraudulent Medicare payments.[19] In these situations, irreversible harm is done before the patient discovers the truth. On an individual basis, implicit bias might corrupt the physician’s decision-making without any conscious dishonesty from the physician. Yet in other cases, such as this one, the physician is knowingly deceitful.
In the larger picture, medicine’s esteemed social status is partly to blame for some unethical behavior. People tend to venerate any source that allows them to live well and long; the public places its trust in physicians as a source of support in maintaining health.[20] In general, physicians are highly regarded figures in daily life. John Stuart Mill once commented on the dangers of class imbalances by saying, “Wherever there is an ascendant class, a large portion of the morality of the country emanates from its class interests and its feelings of class superiority.”[21] As members of an ascendant class, physicians’ interests become paramount to those of the general public. Paternalistic medicine provides the platform for physicians to endorse their own interests, even when those interests oppose those of their patients.
Most physicians object to medical paternalism under normal circumstances. A 2001 cross-sectional survey of 1,050 U.S. physicians found that only 14% of physicians preferred paternalism.[22] On the other hand, 75% of the respondents preferred to share decision-making with their patients.[23] The reasons for why physicians generally dislike paternalism are far and varied. For example, physicians may not want to impose their will on the patients. They recognize that the patient’s dignity is injured when the physician dominates the decision. Physicians recognize that paternalism generally disregards how the patient feels, and thereby opposes the goal of medicine.
While paternalism is not suitable to normal clinical encounters, it is a necessary approach under certain circumstances. For example, if a patient is in critical condition and cannot provide informed consent to a procedure, a quick paternalistic intervention by the physician is almost always justified.[24] The value for patient autonomy is so high that even such extenuating cases are often handled through surrogate decision-makers, such as the patient’s family members or an external health care proxy, or a prewritten advanced directive. When all other reasonable options are unavailable, physicians can fairly (and legally) implement paternalistic care for patients who lack the decision-making capacity to relay their values. Another such exception is therapeutic privilege, which allows physicians to paternalistically withhold certain information from the patient to indirectly prevent serious harm.[25] Paternalistic interventions can be justified when the patient may harm self or others. Although children are often treated paternalistically and do not entirely possess decision-making capacity, the physician still considers the child’s wishes.[26] Lastly, certain patients may even prefer to forgo any decision-making authority in favor of the physician’s paternalistic judgment. Although shared decision-making is the gold standard for clinical interactions, certain situations require the physician to default to paternalistic measures.
A Need for Shared Decision-Making in Medicine:
The decline in medical paternalism and the emphasis on patient autonomy made seeking informed consent from the patient before making a health decision crucial. The moral significance of informed consent became so important that informed consent has transformed from a recommendation into a legal necessity. The 1972 court case Canterbury v. Spence mandated that for a competent patient, “all risks potentially affecting the decision must be unmasked” to obtain informed consent.[27] One proposed model of the physician-patient relationship, the informative model, overstates informed consent and patient autonomy by requiring the physician to strictly transfer discrete information to the patient.[28] The patient then uses this information to make a wholly independent decision according to his or her values. However, the informative model assumes that the patient has known, fixed values and severely restricts the physician from making any recommendations whatsoever.[29] In reality, the patient often has dynamic values that may be unknown altogether.[30] While the paternalistic model limits patient autonomy, the informative model grants an impractical definition of patient autonomy. Several intermediate models, such as the physician-as-agent model, have described the physician attempting to make treatment decisions by choosing as the patient would choose.[31] The physician thereby unearths the patient’s values and chooses accordingly as the sole decision-maker. These models have been omitted from discussion for simplicity. However, all of these models fail to respect both the physician and patient as important, cooperative agents in decision-making.
As a response to this inequality of decision-making between the physician and patient, bioethical literature has increasingly supported the implementation of shared decision-making in clinical medicine. For cases in which multiple treatment options exist, the patient’s preferences become especially salient, and shared decision-making provides the patient a practical avenue to explore those choices. At its core, shared decision-making stresses the physician-patient relationship as a two-way street.[32] In other words, both parties are expected to contribute to the overall decision-making process. This is distinct from the paternalistic and informative models, which support unilateral decision-making. If either party is unable or unwilling to participate in the decision-making process, then shared decision-making cannot reasonably occur.[33] In this case, the paternalistic model can be reasonably justified.[34]
The literature notes that several criteria exist for shared decision-making to successfully occur. As mentioned, both parties should be motivated to proactively contribute. Research has shown that even though patients overwhelmingly desire medical information, they are much less willing to ask for that information from the physician and subsequently assume responsibility for medical decision-making.[35] Oftentimes patients may default to a passive role because they feel burdened by the process, embarrassed to ask questions, or simply scared to complain to the physician.[36] For these reasons, shared decision-making suggests that the physician provide a favorable, friendly environment to maximize the patient’s comfort. This can range from regularly asking the patient open questions to a warm smile. The physician should not ask yes or no questions, such as “Do you have any questions for me?” because the patient is more likely to answer “no” as a default.[37] Instead, asking open-ended questions such as “What questions do you have for me?” allows the physician to elicit the patient’s preferences so that treatment options can be personalized according to the patient’s needs and goals.[38] Physicians often misinterpret the patient’s preferences through conjecture.[39] In accordance with the ‘two-way information flow’ axiom, while the patient communicates these personal preferences, the doctor should provide the technical information pertaining to all relevant treatment options as clearly as possible.[40]
In addition to standard communication, the physician may employ various decision aids to better inform the patient. Shared decision-making suggests that the physician convey the risks and benefits of each treatment while consciously trying to prevent imposing personal preferences onto the patient. At best, the physician can merely recommend one particular treatment option over another without coercing the patient to choose the same. Research has shown that patients feel mental and emotional comfort when they receive full information.[41] Like most physician-patient relationships, shared decision-making has little function without mutual trust between the patient and physician. Many of these criteria can only be met if the physician can initially solidify a meaningful professional relationship centered on trust.
The potential benefits of shared decision-making are significant. Shared decision-making may create a more knowledgeable patient. The patient feels lower levels of anxiety over the unknown, and a greater sense of control over the decision-making process.[42] Decision aids, such as written fact sheets and informational videos, offer other effective methods of information delivery. A recent review of the effectiveness of decision aids for patients undergoing stressful screening and treatment decisions found that patients consistently felt better informed and more realistic about their expectations of risks and benefits.[43] Furthermore, the physician often feels less stress since the patient is better prepared for consultation.[44]
Some research shows that shared decision-making may help reduce healthcare costs, with up to 20% of patients involved in shared decision-making selecting less expensive surgical options.[45] A 2012 observational study of knee or hip osteoarthritis patients found that providing decision aids resulted in 26% fewer hip replacement and 38% fewer knee replacement surgeries, thereby significantly reducing costs overall.[46] Although additional data is needed to solidify these claims, the preliminary research looks promising. Perhaps the most important benefit to shared decision-making is its wholesome approach to contemporary healthcare. Shared decision-making strengthens the physician-patient relationship and grants practical patient autonomy in a society that values patient empowerment.
On paper, the shared-decision making model is the current standard of care; however, the literature still calls for greater integration of shared-decision making in clinical practice.[47] What the academic medical community suggests and how physicians actually behave is not always in sync. The medical shared-decision model has great potential, particularly by borrowing from other well-established disciplines. Integration of this information provided by fields that study human behavior is important for improvements to shared decision-making between physicians and patients.
A Sociological Perspective on Decision-Making:
Any relationship intrinsically involves making decisions towards conflict resolution. Sociological factors can dictate how decisions are perceived between parties, remedying or worsening the conflict at play. The physician-patient relationship is no exception. Sociology has long studied decision-making and its many contextual elements. The physician-patient relationship is complex, comprising many sociological factors. The patient’s personal characteristics, the physician’s personal characteristics, and the physician’s interaction with the healthcare system all can impact medical decision-making.[48]
A patient’s socioeconomic status can affect how a physician perceives and diagnoses the patient, even if not intentionally.[49] One systematic review found that patients from lower socioeconomic classes are less often encouraged to participate and less likely to understand medical information when discussing treatment options.[50] The review also showed that physicians are less informative when consulting with patients from lower classes.[51] Several plausible reasons exist as to why patients from a lower socioeconomic class are treated with less attention in medical decision-making. Families with a lack of financial resources have frequently been correlated with a poor access to education.[52] Consequently, patients with a lower educational background are much less likely to participate in the decision-making process when compared to their well-educated counterparts.[53]
Some studies have reported that patients of a lower socioeconomic status feel less control over medical situations, and may believe that health and disease are beyond their authority.[54] Physicians may identify these passive patients as unwilling or unable to comprehend information and meaningfully contribute to medical decisions.[55] A reciprocating negative cycle emerges when the patient remains inactive and the physician incorrectly assumes the patient’s unwillingness to contribute, leading to further patient inactivity.[56] In contrast, higher educated patients with a privileged socioeconomic background are often vocal in their healthcare decisions, eliciting an informative and positive attitude from the physician as well.[57] These patients belong to a socioeconomic class that is closer to the physician’s, and often feel comfortable in asking questions and participating.[58] In order for shared decision-making to work, physicians should realize that socioeconomic variables can impact patients’ participation in decision-making and thereby the quality of care administered.
The patient’s race might subtly affect the decision-making process as well. One study showed differences in the quality of how well physicians communicate with patients of different races; physicians were found to be more verbally dominant and less emotionally perceptive with African American patients than white patients.[59] Another study used an implicit-association test to find that cardiologists were less likely to recommended African American patients for thrombolysis than white patients.[60] An implicit bias may exist in healthcare, impeding shared decision-making with African Americans as compared to white patients.[61] While additional research is needed to reach any firm conclusions, the idea of a potential racial bias among physicians, either conscious or unintentional, should not be dismissed.
Female patients are predisposed to a gender bias in healthcare, since women are underrepresented in clinical research studies compared to men.[62] The abundance of male research data may be incorrectly extrapolated to women, even if certain biological gender differences require different treatments for women.[63] For example, women’s blood vessels are naturally narrower than men’s, allowing for easier plaque buildup and a higher chance of rupture.[64] Pharmaceutical companies and physicians should compensate for such biological differences when developing or prescribing drugs. Biological gender differences may manifest into entirely different symptoms for men and women.[65] If these differences are neglected, physicians run the risk of failing to identify symptoms and diagnose key issues pertaining in female patients. In fact, women with coronary artery disease are given a disproportionately lower amount of lipid-lowering treatment than men with coronary artery disease.[66] Gender biases are therefore prevalent in research and clinical medicine as well. The patient’s age and physical appearance may also factor into how the physician allocates decision-making with the patient.
The sociological characteristics of the physician are equally relevant to medical decision-making. Not all physicians treat clinical encounters in the same manner. Some physicians are disease-oriented and will prefer to take prompt action with the patient.[67] Other physicians are oriented towards health maintenance and will observe the patient’s situation for some time before discussing treatment options.[68] The physician’s gender may play a role in decision-making as well. Several studies suggest that female physicians take more time with their patients and give greater consideration to psychosocial issues than their male counterparts.[69], [70] This may suggest that female physicians are generally more patient-oriented.
Medicine’s constantly evolving nature over time sets the physician’s age as an influencing factor, caused by differences in belief and training between younger and older physicians. One study published by the American Sociological Association found that older physicians tend to more frequently diagnose depression in female patients than younger physicians.[71] One plausible explanation for this disparity is that depression was once mistakenly believed to be a female-specific condition caused by postmenopausal changes.[72] Through a cohort effect, older physicians may still consider these claims when treating female patients.[73] While the effects of the physician’s race on decision-making are inconclusive, patients in race-concordant relationships with their physicians tend to report higher levels of satisfaction than patients who are not race-concordant.[74] Physicians may claim a uniform standard of care to all patients and deny the relevance of any of these patient or physician characteristics. However, subconscious perceptions, biases, and stereotypes cannot be avoided until first acknowledged by the physician.
The physician’s interaction with the medical profession can easily affect the physician’s decision-making behavior. A commonly held belief among physicians is that overdiagnosing patients, even in the absence of patient benefit, is better than missing a diagnosis completely.[75] Some physicians may overdiagnose to satisfy the patient’s desire to identify that something is truly wrong, while others may overdiagnose either due to the peer pressure of examining all differential diagnoses or avoiding the threat of a malpractice suit.[76] In either case, adding diagnoses most likely adds additional pharmacological treatment and unnecessarily burdens a patient. Furthermore, physicians who are actively engaged in the medical community and better informed on pharmacological advances are more likely to prescribe new drugs to patients.[77] The influence that pharmaceutical drug companies have on physicians is so great that medical students even undergo workshops that teach how to interact with pharmaceutical representatives.[78] These representatives persuade physicians to prescribe up-and-coming drugs. Physicians may feel compelled to recommend these novel drugs to patients based on qualitative claims in the community and a higher tolerance for risk. Other physicians may prefer to avoid risks and prescribe traditional drugs with confirmed data.
Sociology highlights the subtle social factors that affect decision-making, showing that physician treatment can never be perfectly uniform for all patients. Physicians and patients possess certain social and socioeconomic characteristics that naturally lead to biases in either party. If the goal of medicine truly is to care for the whole patient, then prejudices disrupt the goal entirely. Rather than ignoring such biases, physicians should instead expand their awareness of potential biases that may exist. The shared decision-making model can incorporate this awareness and encourage physicians to reflect on socioeconomic inequalities between themselves and their patients, allowing for the physician to subjectively compensate and provide less-biased patient care.
A Psychological Perspective on Decision-Making:
Another discipline that studies human behavior is psychology, and therefore can help reveal intra-personal undertones to decision-making. While sociological decision-making is largely impacted by relationships between people, the psychological perspective of decision-making is concerned with the human mind and emotions. Psychology offers excellent insight into underlying character traits that affect how people make decisions, specifically physicians and patients.
In 1889 William Osler, widely considered to be the father of modern medicine, emphasized the importance of physician equanimity in his valedictory speech to the University of Pennsylvania graduating medical class: “a certain measure of insensibility is not only an advantage, but a positive necessity in the exercise of a calm judgment.”[79] Osler believed that a physician should strive to control his or her mental state and conceal any external emotions when treating a patient.[80] By maintaining an aura of coolness, Osler argued that physicians can cover up mental weaknesses and easily “see into” the patient’s deeper self.[81] Osler’s influence helped standardize physicians as objective beings who should view patients with an air of detached concern, out of respect to both the patient and the physician.[82] These attitudes have echoed throughout popular culture, personifying the doctor as an aloof and emotionally distant caretaker.[83] Numerous medical dramas contain apathetic physicians, such as famed characters Ben Casey and Gregory House, who treat their patients from an emotional distance.[84] The truth is that physicians possess innate personality traits and emotions that comprise their character, just like any rational human being with the ability to think freely. The ideal of objectivity is unrealistic in clinical practice, as even emotionally detached physicians are subject to raw emotions.[85] Detached concern only masks already present emotions. These psychological traits and emotions can greatly influence how physicians and patients engage in decision-making activities together and should not be underplayed in the clinical setting.
The profusion of personality traits can mostly be narrowed down to five major psychological dimensions: openness, conscientiousness, extraversion, agreeableness, and neuroticism.[86] These dimensions refer to a person’s ability to be tolerant of others, dependable and responsible, talkative and assertive, cooperative with others, and anxious or depressed, respectively.[87] However, one study found that these “Big Five” personality characteristics do not influence ethical decision-making nearly as much as a person’s narcissism of self-worth and cynicism of other people.[88] Feelings of narcissistic entitlement and cynical assumptions about others’ motives were consistently correlated with less ethical decision-making.[89] A narcissistic individual may exploit others to advance their own goals, while a cynical individual may trust others less.[90] For example, narcissistic physicians might prescribe patients expensive treatments for profit. A cynical patient can undermine trust through skepticism, even though trust is integral to the physician-patient relationship and therefore decision-making.[91] Narcissistic or cynical behavior can negatively impact communication and even create feelings of resentment.
While personality traits are integral to a person’s character, emotions represent a short-lived response to external forces.[92] Discrete emotions, such as fear, anger, happiness, and sadness, can all alter how decisions are made.[93] Anger is one of the most intense emotions, and has been found to induce riskier decision-making behavior.[94] Anger can cause physicians to recommend riskier options than the patient, and other physicians, would typically be okay with. On the other hand, fearful individuals tend to overestimate risky events and instead select the safer option.[95] A fearful patient is likelier to avoid risky treatment options. Happiness and sadness can be polarized as well; while happy patients tend to select safer options, sad individuals feel a loss of control and may select risker options.[96] When adverse emotions begin dominating a relationship, oftentimes the best answer is for both parties to separate for some time and cool down. The physician-patient relationship, however, is not so fortunate. Even through emotional turmoil, the physician cannot abandon the patient.
Rather than resist natural emotional tendencies like Osler suggested, physicians should strive to be empathetic towards their patients. Physicians who practice empathetic communication have been shown to substantially increase patient satisfaction and compliance in decision-making, simply by relating to patients on a sentimental level.[97] Empathetic physicians can strengthen trust in the physician-patient relationship and allow for a mutually beneficial decision-making process. When both the physician and patient are angry or frustrated, physicians can still cultivate the mental fortitude needed to form an empathetic connection with their patients through basic conflict management.[98] By first actively acknowledging their own negative emotions and then self-reflecting on why they exist, physicians can attune to what clues their own emotions reveal about their patients’ feelings.[99]
Increased awareness when listening to patient’s story can often expose hidden emotional concerns that may be missed if the physician is listening only for objective facts.[100] Such receptivity is especially crucial to nonverbal communication, since patients do not always express concerns explicitly.[101] For example, a patient with a quivering vocal tone or poor eye contact may have a hidden undiscussed issue.[102] Physicians have the opportunity to connect with patients in these moments by adjusting their own nonverbal behavior, such as spending less time reading the patient’s chart and making more eye contact or more gestures.[103] If the situation is appropriate, the physician may verbally engage the patient to elicit this issue. During conflicts, physicians also become controlling and less open to criticism.[104] Instead physicians can overcome future conflicts by accepting negative feedback from their patients, consequently improving patient satisfaction as well.[105] Physicians who are genuinely connected to their patients on an emotional level can effectively share decision-making. Physicians who practice detached concern often miss these key psychological factors of the physician-patient relationship.
Psychology reveals that objectivity is an impossible ideal for physicians. Detached concern is an archaic outlook that hinders the goal of treating the whole and is incompatible with patient empathy. Ingrained personality traits and discrete emotions will always influence how physicians and patients make decisions. More importantly, these elements can be hidden entirely. The shared decision-making model should encourage physicians to remain empathetic with their patients, even through conflicts, in order to generate true curiosity in the patient’s interests and possibly discover hidden concerns as well.
A Philosophical Appeal to Action:
Medical ethicist Dan Sulmasy argues that an act is not made good simply because it has been chosen, and that contemporary bioethics sometimes mistakenly grants a skewed perception of autonomy.[106] It is not enough for one to believe that he or she is doing good if the decision made is not fundamentally ‘good.’ Sulmasy bases his thesis in the largely deontological theory of Catholic natural law, which states that actions are inherently right or wrong as an objective truth[107]. For example, Sulmasy explains that the people who attacked the World Trade Center believed they made the correct decision, but instead committed a reprehensible act.[108] Rather, Sulmasy contends that the moral goal of natural law should be to help people understand what is truly good so that they may freely make that decision. In the medical context, when a patient’s rationality fails and he or she makes decisions that are inherently wrong, the physician can override these decisions with the justification of natural law.[109] Many additional philosophical theories exist pertaining to human judgment and decision-making, but these theories have been omitted for simplicity.
Physicians are obligated to recognize variables impeding shared decision-making in the clinical encounter. A patient will not necessarily make a ‘good’ choice every time; the physician should try to identify when a ‘bad’ action threatens to cause damage. Still, this should be balanced with a patient’s autonomous right to choose during the shared decision-making encounter. Does a patient’s right to autonomy condone bad decision-making? To what extent can a physician’s judgment trump a patient’s bad decision-making?
The literature has shown that the best model for appreciating the goal of whole patient care is currently shared decision-making. Evidence-based medicine, such as shared decision-making, only works when physicians accept research and adopt methods into clinical practice. Most physicians believe that their patient interaction is already good, yet what happens if physicians continue to dismiss evidence? Interdisciplinary methods show support for shared decision-making; why aren’t physicians taking action? Now more than ever, physicians should support philosophical research that may help uncover some of these answers in the clinical encounter.
Addressing Criticism to the Interdisciplinary Shared-Decision Making Model:
Several possible criticisms can be made in response to the interdisciplinary shared-decision making model. Perhaps the biggest criticism is the physicians’ time limitation to implement shared-decision making in every clinical encounter. In order to integrate aspects of sociology, psychology, and philosophical undertones into shared decision-making, the physician needs sufficient time for self-reflection and deliberating choices with the patient. As physicians consistently utilize this model and habituate, the shared decision-making process will hopefully become ingrained and automatic. The overall interaction between physician and patient will eventually be more efficient, since patients are better informed. As familiarity with shared decision-making increases, physicians will be able to streamline their clinical encounters to be more time-efficient. Another plausible criticism is that the interdisciplinary shared decision-making model is impractical under certain clinical settings. For example, emergency physicians will rarely use shared decision-making since the majority of their patients require immediate attention.
Furthermore, this paper only presents limited research on the benefits of shared decision-making. Although shared decision-making is the current standard of care, not all physicians use the model. In the 2010 National Health Interview Survey, roughly two-thirds of men who underwent prostate cancer screening reported no evidence of shared decision-making with their physicians.[110] This interdisciplinary approach strengthens the arguments for shared decision-making beyond that which medicine can do on its own. Further research is necessary to fully understand the benefits and shortcomings of such a comprehensive model. Shared decision-making is not an ideal model, as it does not work in every clinical scenario. Although more criticisms may exist, inadequate time, improper setting, and limited research are among the greatest concerns.
Conclusion:
Clinical medicine has evolved from historically paternalistic care to the contemporary standard of shared decision-making. Although the literature overwhelmingly supports shared decision-making for its respect of patient autonomy, the current shared decision-making model cannot uphold under modern society’s increasing medical self-awareness. It is no longer acceptable for physicians to dismiss underlying biases or conceal emotions in the presence of their patients. Physicians should not dismiss variables affecting the clinical encounter, such as underlying biases or concealed emotions. The interdisciplinary approach seeks to support and shape shared decision-making into a more robust model of care that recognizes and responds to medical disparities from a multi-faceted perspective. By expanding the depth of shared decision-making through the sociological, psychological, and philosophical disciplines, physicians stand to translate the academic community’s acclamation for respecting the patient’s preferences into real clinical practice.
Notes:
[1] Timothy E. Quill, “Physician Recommendations And Patient Autonomy: Finding A Balance Between Physician Power And Patient Choice,” Annals of Internal Medicine 125, no. 9 (1996): 763.
[2] Eric J Cassell, The Nature Of Suffering (New York: Oxford University Press, 1994), 140.
[3] Gerald Dworkin, “Paternalism,” Monist 56, no. 1 (1972): 65.
[4] Hippocrates. et al., Hippocratic Writings (Chicago: Encyclopædia Britannica, 1955): xiii.
[5] Ezekiel J. Emanuel and Linda L. Emanuel, “Four Models Of The Physician-Patient Relationship,” JAMA 267, no. 16 (1992): 2221.
[6] Herbert Friedenwald, The Declaration Of Independence: An Interpretation And An Analysis (New York: The Macmillan Company, 1904): 263.
[7] Immanuel Kant, Allen W. Wood and J. B. Schneewind, Groundwork For The Metaphysics Of Morals (New Haven: Yale University Press, 2002): xviii.
[8] Gerald Dworkin, The Theory And Practice Of Autonomy (Cambridge: Cambridge University Press, 1988): 7-12.
[9] Edmund D. Pellegrino and David C. Thomasma, “The Conflict Between Autonomy And Beneficence In Medical Ethics,” Journal of Contemporary Health Law & Policy 3, no. 1 (1987): 23.
[10] Rudolf Klein, The New Politics Of The NHS (Oxford: Radcliffe, 2006).
[11] Paul Starr, The Social Transformation Of American Medicine (New York: Basic Books, 1982): 3-6.
[12] Pellegrino and Thomasma, “The Conflict Between Autonomy And Beneficence,” 24-25.
[13] Ibid.
[14] Matthew K. Wynia, “The Short History And Tenuous Future Of Medical Professionalism: The Erosion Of Medicine’s Social Contract,” Perspectives in Biology and Medicine 51, no. 4 (2008): 576.
[15] Tom L Beauchamp and James F Childress, Principles Of Biomedical Ethics (New York, N.Y.: Oxford University Press, 2001): 165-166.
[16] Emanuel and Emanuel, 2221.
[17] Ibid.
[18] Pellegrino and Thomasma, “The Conflict Between Autonomy And Beneficence,” 23-46.
[19] Ed White, “Michigan Doctor Gets 45 Years In Prison For Hurting Patients,” Associated Press, 2015, accessed July 20, 2015, http://bigstory.ap.org/article/dea1e9256cfa46d782e513d160557ee3/judge-sentence-detroit-area-cancer-doctor-fraud-scheme.
[20] Joseph Katz, “The Functions of a Profession: Social Status of Medicine and Education,” Phi Delta Kappan 32, no. 9 (1951): 398-400.
[21] John Stuart Mill, On Liberty, 4th ed. (London: Longman, Roberts & Green, 1869): 6.
[22] Elizabeth Murray et al., “Clinical Decision-Making: Physicians' Preferences And Experiences,” BMC Fam Pract 8, no. 1 (2007): 10.
[23] Ibid
[24] Robert M. Veatch, A Theory Of Medical Ethics (New York: Basic Books Inc Publishers, 1981).
[25] Claude Richard, Yvette Lajeunesse and Marie-Thérèse Lussier, “Therapeutic Privilege: Between The Ethics Of Lying And The Practice Of Truth,” Journal of Medical Ethics 36, no. 6 (2010): 353-357.
[26] Katherine Brown, “Can Medical Paternalism Be Justified?” Canadian Medical Association Journal 133, no. 7 (1985): 678-680.
[27] Canterbury V. Spence. 464 F.2d 772 (United States Court of Appeals for the District of Columbia Circuit 1972).
[28] Emanuel and Emanuel, 2221.
[29] Ibid.
[30] Ibid.
[31] Robert G Evans, Strained Mercy (Toronto: Butterworths, 1984): 75.
[32] Cathy Charles, Amiram Gafni and Tim Whelan, “Shared Decision-Making In The Medical Encounter: What Does It Mean? (Or It Takes At Least Two To Tango),” Social Science & Medicine 44, no. 5 (1997): 685.
[33] Ibid.
[34] Emanuel and Emanuel, 2221.
[35] Analee E. Beisecker and Thomas D. Beisecker, “Patient Information-Seeking Behaviors When Communicating With Doctors,” Medical Care 28, no. 1 (1990): 19-28.
[36] Ibid.
[37] Suzanne Graham and John Brookey, “Do Patients Understand?” The Permanente Journal 12, no. 3 (2008): 67-69.
[38] Charles, Gafni, and Whelan, 687-688. Shared decision-making does not support the physician inferring the patient’s preferences, but rather suggests the physician encourage the patient to explicitly express his or her personal preferences.
[39] William M. Strull, “Do Patients Want To Participate In Medical Decision Making?” Journal of the American Medical Association 252, no. 21 (1984): 2990-2994.
[40] Charles, Gafni, and Whelan, 683-684.
[41] Gavin Mooney and Mandy Ryan, “Agency In Health Care: Getting Beyond First Principles,” Journal of Health Economics 12, no. 2 (1993): 125-135.
[42] Charles, Gafni, and Whelan, 686-688.
[43] Dawn Stacey et al., “Decision Coaching To Prepare Patients For Making Health Decisions: A Systematic Review Of Decision Coaching In Trials Of Patient Decision Aids,” Medical Decision Making 32, no. 3 (2012): E22-E33.
[44] Ibid.
[45] Dawn Stacey et al. “Decision aids for people facing health treatment or screening decisions,” Cochrane Database Systematic Review, no. 10 (2011): CD001431.
[46] D. Arterburn et al., “Introducing Decision Aids At Group Health Was Linked To Sharply Lower Hip And Knee Surgery Rates And Costs,” Health Affairs 31, no. 9 (2012): 2094-2104.
[47] A. M. Stiggelbout et al., “Shared Decision Making: Really Putting Patients At The Centre Of Healthcare,” The BMJ 344, no. 271 (2012): e256.
[48] John M. Eisenberg, “Sociologic Influences On Decision-Making By Clinicians,” Annals of Internal Medicine 90, no. 6 (1979): 957.
[49] S. Willems et al., “Socio-Economic Status Of The Patient And Doctor–Patient Communication: Does It Make A Difference?” Patient Education and Counseling 56, no. 2 (2005): 139-146.
[50] Ibid.
[51] Ibid.
[52] Bruce J Biddle, Social Class, Poverty, And Education (New York: RoutledgeFalmer, 2001): 14.
[53] Richard L. Street et al., “Patient Participation In Medical Consultations,” Medical Care 43, no. 10 (2005): 960-969.
[54] Michael W. Kraus, Paul K. Piff and Dacher Keltner, “Social Class, Sense Of Control, And Social Explanation,” Journal of Personality and Social Psychology 97, no. 6 (2009): 992-1004.
[55] S. Willems et al., 139-146.
[56] Ibid.
[57] Richard L. Street et al., 960-969.
[58] Ibid.
[59] Rachel L. Johnson et al., “Patient Race/Ethnicity And Quality Of Patient–Physician Communication During Medical Visits,” American Journal of Public Health 94, no. 12 (2004): 2084-2090.
[60] Alexander R. Green et al., “Implicit Bias Among Physicians And Its Prediction Of Thrombolysis Decisions For Black And White Patients,” Journal of General Internal Medicine 22, no. 9 (2007): 1231-1238.
[61] I. V. Blair et al., “Clinicians' Implicit Ethnic/Racial Bias And Perceptions Of Care Among Black And Latino Patients,” Annals of Family Medicine 11, no. 1 (2013): 43-52.
[62] Regina M. Vidaver et al., “Women Subjects In NIH-Funded Clinical Research Literature: Lack Of Progress In Both Representation And Analysis By Sex,” Journal of Women's Health & Gender-Based Medicine 9, no. 5 (2000): 495-504.
[63] J. K. Bush, “The Industry Perspective On The Inclusion Of Women In Clinical Trials,” Academic Medicine 69, no. 9 (1994): 708-715.
[64] Kevin R. Campbell, Women And Cardiovascular Disease (London: Imperial College Press, 2015), 18-19.
[65] Ibid.
[66] Akram Abuful, Yori Gidron and Yaakov Henkin, 'Physicians' Attitudes Toward Preventive Therapy For Coronary Artery Disease: Is There A Gender Bias?', Clin Cardiol 28, no. 8 (2005): 389-393.
[67] John M. Eisenberg, 960.
[68] Ibid.
[69] Debra L. Roter, Judith A. Hall and Yutaka Aoki, “Physician Gender Effects In Medical Communication,” Journal of the American Medical Association 288, no. 6 (2002): 756.
[70] Laura Jefferson et al., “Effect Of Physicians' Gender On Communication And Consultation Length: A Systematic Review And Meta-Analysis,” Journal of Health Services Research & Policy 18, no. 4 (2013): 242-248.
[71] John B. McKinlay et al., “The Unexpected Influence Of Physician Attributes On Clinical Decisions: Results Of An Experiment,” Journal of Health and Social Behavior 43, no. 1 (2002): 92.
[72] Ibid.
[73] Ibid.
[74] Thomas A. LaVeist and Amani Nuru-Jeter, “Is Doctor-Patient Race Concordance Associated With Greater Satisfaction With Care?” Journal of Health and Social Behavior 43, no. 3 (2002): 296.
[75] Ibid.
[76] Ibid.
[77] Helen Prosser, “New Drug Uptake: Qualitative Comparison Of High And Low Prescribing Gps' Attitudes And Approach,” Family Practice 20, no. 5 (2003): 583-591.
[78] James L. Wofford and Christopher A. Ohl, “Teaching Appropriate Interactions With Pharmaceutical Company Representatives,” BMC Medical Education 5, no. 1 (2005): 5.
[79] Danielle Ofri, What Doctors Feel (Boston: Beacon Press, 2013): 4.
[80] Jodi Halpern, From Detached Concern To Empathy (Oxford: Oxford University Press, 2001): 22-24.
[81] Ibid.
[82] Ibid.
[83] Ofri, 4.
[84] Ibid.
[85] Ibid.
[86] Robert R. McCrae and Paul T. Costa, Personality In Adulthood (New York: Guilford Press, 2003).
[87] Alison L. Antes et al., “Personality And Ethical Decision-Making In Research: The Role Of Perceptions Of Self And Others,” Journal of Empirical Research on Human Research Ethics: An International Journal 2, no. 4 (2007): 16.
[88] Ibid, 16-17.
[89] Ibid.
[90] Ibid.
[91] David H. Thom, “Patient Trust In The Physician: Relationship To Patient Requests,” Family Practice 19, no. 5 (2002): 476-483.
[92] Amanda D. Angie et al., “The Influence Of Discrete Emotions On Judgement And Decision-Making: A Meta-Analytic Review,” Cognition & Emotion 25, no. 8 (2011): 1394.
[93] Ibid, 1395.
[94] Ibid.
[95] Ibid.
[96] Ibid.
[97] Sung Soo Kim, “The Effects Of Physician Empathy On Patient Satisfaction And Compliance,” Evaluation & the Health Professions 27, no. 3 (2004): 246-247.
[98] Jodi Halpern, “Empathy And Patient–Physician Conflicts,” Journal of General Internal Medicine 22, no. 5 (2007): 696-700. This article describes conflict management by a physician as a conscious process of attempting to develop curiosity for a patient’s distinct perspective. The process often involves the physician conceding his or her ego. This is important during conflict because negative emotions, such as fear and anger, can cloud the physician’s cognition and damage the physician-patient relationship.
[99] Ibid.
[100] Ibid.
[101] Wendy Levinson, “A Study Of Patient Clues And Physician Responses In Primary Care And Surgical Settings,” Journal of the American Medical Association 284, no. 8 (2000): 1021.
[102] Ibid.
[103] Judith A. Hall, Jinni A. Harrigan and Robert Rosenthal, “Nonverbal Behavior In Clinician—Patient Interaction,” Applied and Preventive Psychology 4, no. 1 (1995): 26-27.
[104] Jodi Halpern, “Empathy And Patient–Physician Conflicts,” 696-700.
[105] Ibid.
[106] Dan P. Sulmasy, “Informed Consent Without Autonomy,” Fordham Urban Law Journal 30, no. 1 (2002): 212.
[107] Ibid.
[108] Ibid.
[109] Ibid.
[110] Paul K. J. Han et al., “National Evidence On The Use Of Shared Decision Making In Prostate-Specific Antigen Screening,” Annals of Family Medicine 11, no. 4 (2013): 309.
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