Shared decision making has become an ideal in contemporary clinical practice, and guidelines recommend exploring patients' preferences and providing them with options so they can make informed decisions. This paper examines how the ideal of sharedness is maintained and negotiated through epistemic and deontic resources in secondary care consultations where patients are given a choice between invasive and non-invasive treatment options. The analysis suggests that the physician's presentation of treatment options is often tilted in favor of one proposal over the other, yet giving the patient the right to make the final decision. The patients on the other hand regularly resist this responsibility by claiming lack of epistemic authority (e.g. I know nothing about it) or by making the decision contingent on the physician taking a stronger deontic stance (e.g. if you think so). This may be characterized as an inverted use of deontic authority from both parties: Physicians give patients deontic rights in their pursuit of independent commitment to their preferred option, while patients orient to physicians' epistemic and deontic rights as a way to resist committing to the physicians' propositions. These conflicting orientations to epistemic and deontic authority counteract the ideal of shared decision making.

This conversation analytic study investigates how couples manage conflicting knowledge claims when one of the persons has dementia (PWD). The data are video-recordings of 16 couples talking with a third party. The analysis focuses on the negotiation of epistemic rights, more precisely how partners initiate repair and correct claims made by the PWD on matters belonging to the latter’s epistemic domain. We identified three main practices for correcting the PWD: (1) correcting the statement, thereby claiming epistemic authority for oneself and denying it to the PWD, (2) inviting the PWD to self-correct, thereby attributing some epistemic authority to the PWD, and (3) disagreeing and providing reasons for one’s alternative claim, establishing a more symmetric epistemic gradient. The PWDs responses to the corrections displayed different degrees of acceptance, ranging from self-denigration to resistance and insistence.

Eliciting patients' values and treatment preferences is an essential element in models of shared decision making, yet few studies have investigated the interactional realizations of how physicians do this in authentic encounters. Drawing on video-recorded encounters from Norwegian secondary care, the present study uses the fine-grained empirical methodology of conversation analysis (CA) to identify one conversational practice physicians use, namely, formulations of patients' stance, in which physicians summarize or paraphrase their understanding of the patient's stance towards treatment. The purpose of this study is twofold: (1) to explore what objectives formulations of patients' stance achieve while negotiating treatment and (2) to discuss these objectives in relation to core requirements in shared decision making. Our analysis demonstrates that formulating the patient's stance is a practice physicians use in order to elicit, check, and establish patients' attitudes towards treatment. This practice is in line with general recommendations for making shared decisions, such as exploring and checking patients' preferences and values. However, the formulations may function as a device for doing more than merely checking and establishing common ground and bringing up patients' preferences and views: Accompanied by subtle deprecating expressions, they work to delegitimize the patients' stances and indirectly convey the physicians' opposing stance. Once established, these positions can be used as a basis for challenging and potentially altering the patient's attitude towards the decision, thereby making it more congruent with the physician's view. Therefore, in addition to bringing up patients' views towards treatment, we argue that physicians may use formulations of patients' stance as a resource for directing the patient towards decisions that are congruent with the physician's stance in situations with potential disagreement, whilst (ostensibly) avoiding a more authoritarian or paternalistic approach.

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