Shared Decision-making, Therapeutic Choice, and Decisional Regret in Alopecia Areata—Where Narrative Ethics Meets the Unconscious Bias of Clinicians

Abstract

To the Editor We read with great interest the study by Reyes-Hadsall et al 1 on the use of shared decision-making (SDM) and decisional regret in patients with alopecia areata (AA). Dermatology therapeutics is rapidly evolving, with many associated uncertainties. As a result, our task as clinicians to help navigate patients through treatment options and risk/benefit perception has become more challenging. Internationally, SDM is considered core to good clinical practice. The UK National Institute of Health and Care Excellence has created SDM guidelines covering how to make SDM part of everyday care in health care settings and promotes its inclusion in organizational culture and practices. 2 However, we need to acknowledge barriers to the use of SDM, which depends on clinicians having access to up-todate high-quality evidence. In AA, we often use unlicensed treatments with little or low-level evidence. Until the US Food and Drug Administration approved baricitinib for treating severe AA, there were no licensed systemic treatments. Clinicians are required to support patient autonomy, increase risk perception accuracy, and reduce decisional conflict with very few tools at their disposal. Drug registries (dermatology and pregnancy-related) have enabled us to evaluate the longterm safety and efficacy of treatments in the real world. 3 We envisage that the Global Registry of Alopecia Areata Disease Severity and Treatment Safety pharmacovigilance register will build evidence to further support future treatment recommendations. 4 Shared decision-making depends on clinicians having an in-depth understanding of the treatments to ensure informed counseling and consent as well as minimize decisional regret. However, a study reviewing the use of SDM in women of reproductive age found that dermatologists had "the perception that all biologics are strictly contraindicated during pregnancy," 5 demonstrating the gaps in knowledge.The association between SDM and decisional regret can be interpreted using narrative ethics. In the clinical setting, narrative ethics are applied through understanding the stories and characteristics that comprise the identity and well-