Whose decision? Negotiating epistemic and deontic rights in medical treatment decisions

Abstract

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.

Communicating cancer risk in the primary care consultation when using a cancer risk assessment tool: Qualitative study with service users and practitioners

“…Practitioners can sometimes underestimate the degree to which patients wish to be informed about or involved in decisions about their health; that is, decisions are sometimes made assuming what patients prefer, rather than involving them in the decision‐making process. If patients were not informed when a cancer risk assessment tool was being used, this could detract from gathering their views or preferences in the decision‐making process, as some patients may want to be informed about available options but may not want to be involved in the entire decision . It could also depart from the more widespread acknowledgement that people should be enabled to be involved in decisions about their care .…”

“…If patients were not informed when a cancer risk assessment tool was being used, this could detract from gathering their views or preferences in the decision-making process, as some patients may want to be informed about available options but may not want to be involved in the entire decision. 43 It could also depart from the more widespread acknowledgement that people should be enabled to be involved in decisions about their care. 13 Participants in this study, both service users and practitioners, agreed that practitioners should involve patients during consultations when using a cancer risk assessment tool.…”

Social deontics: A nano‐level approach to human power play

“…Treating the normative organization of the adjacency‐pair sequence as the central locus of negotiation over deontic rights, I will now consider how this negotiation happens in practice. Drawing on previous studies by myself (Stevanovic, 2011; Stevanovic, ; Stevanovic, ; Stevanovic, ; Stevanovic, ; Stevanovic, ; Stevanovic, ; Stevanovic & Peräkylä, ; Stevanovic & Monzoni, ) and others (Couper‐Kuhlen & Etelämäki, ; Ekberg & LeCouteur, ; Heritage, ; Ishino & Okada, ; Keevallik, ; Kent, ; Landmark, Gulbrandsen, & Svennevig, ; Lindström & Weatherall, ; Stivers et al, ; Svennevig & Djordjilovic, ; Toerien, ), I will discuss three different patterns of managing deontic concerns in and through sequential relations. Arguably, deontic concerns are a potential part of all adjacency pairs, but they are particularly relevant in those sequences where future actions are at issue.…”

Intersubjectivity and the domains of social interaction: proposal of a cross-sectional approach

“…Despite their distinctive characteristics, we may assume that these three domains are not independent of each other but that they support each other in specific ways. The precise ways in which these, and potentially other, orientations exist in interaction and regulate one another, is a question that continues to be pursued (see e.g., Ekberg & LeCouteur, 2015;Landmark, et al, 2015;Lindström & Weatherall, 2015;Stevanovic, 2013). What is new here, however, is our proposal that there are crucial processes taking place on a third axis, i.e., a flow of influence running through the levels and domains diagonally.…”