A Typology of Shared Decision Making, Informed Consent, and Simple Consent

Abstract

Enhancing patient choice is a central theme of medical ethics and law. Informed consent is the legal process used to promote patient autonomy; shared decision making is a widely promoted ethical approach. These processes may most usefully be seen as distinct in clinically and ethically important respects. The approach outlined in this article uses a model that arrays all medical decisions along 2 axes: risk and certainty. At the extremes of these continua, 4 decision types are produced, each of which constrains the principal actors in predictable ways. Shared decision making is most appropriate in situations of uncertainty, in which 2 or more clinically reasonable alternatives exist. When there is only 1 realistic choice, patient and physician may gather and exchange information; however, the patient cannot be empowered to make choices that do not exist. In contrast, informed consent does not require the presence of clinical choice; it is appropriate for all decisions of significant risk, even if there is only one option. When a clinical decision contains both risk and uncertainty, shared decision making and informed consent are both appropriate. For decisions of lower risk, consent should still be present, but it can be simple rather than informed. Clinicians may use this analysis as a guide to their own interactions with patients. In the continuing effort to provide patients with appropriate decisional authority over their own medical choices, shared decision making, informed consent, and simple consent each has a distinct role to play.

A typology of preferences for participation in healthcare decision making

“…Some have taken the view that physicians should never make decisions for patients (McNutt, 2004). Others have suggested that patients should not be forced to make medical decisions if they prefer not to be involved (Whitney, McGuire, & McCullough, 2004). We support the view that patient-centered care should strive to respond to individual patient's needs and preferences when possible.…”

“…The main advantage of this item is that is refers to a situation where a true choice exists ("more than one method"), which is the situation generally touted as ideal for shared decision making (Whitney, McGuire, & McCullough, 2004). This item was also chosen because of its generality, i.e., preference for information not specific to laboratory tests, illness, side effects of medication, etc.…”

“…A mandatory role for patients as autonomous decision makers has recently been recommended, since patients alone weather the consequences of their medical care (McNutt, 2004). However, others advocate that patients be allowed to participate to the extent they desire, completely delegating decisions to their physicians if they so choose (Whitney, McGuire, & McCullough, 2004). The model of patient participation where both physician and patient communicate information and values and make decisions together-called shared decision making-has been embraced in literature (Charles, Gafni, & Whelan, 1999;Emanuel & Emanuel, 1992;Quill & Brody, 1996), and the Institute of Medicine has recommended including it in medical school curricula as a mechanism to improve care (Institute of Medicine, 2004).…”

Varieties of Uncertainty in Health Care: A Conceptual Taxonomy

“…The relational nature of this act places differing responsibilities on clinicians and patients to exchange information and to achieve a shared consciousness of uncertainty. This is a goal articulated in the ideal of shared decision making 52, 59 and in what Epstein has described as the achievement of “shared mind.” 60 …”

Communicating information concerning potential medication harms and benefits: What gist do numbers convey?

“…However, all medications also have the potential to cause harm (e.g., unpleasant side effects, allergic reactions) and most carry some risk of serious adverse effects. Principles of informed consent, informed and shared decision-making, and professional ethics all emphasize the importance of patients' understanding the potential harms and benefits of recommended therapies [2][3][4][5]. To help achieve this goal, many countries require that patients be given written medication information (WMI), usually in leaflet form, when they obtain a licensed medication [6][7][8].…”