Are Patient Autonomy and Shared Decision Making Overrated?

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In the olden days, physicians practiced in a paternalistic fashion, simply informing patients of the next steps to be taken.  This anachronistic practice falls well beyond today’s professional boundaries, although several decades ago, this was the norm.  And the public did not object.  They came to their doctors for advice and, in general, they accepted the recommendations that were offered.  Both sides of the relationship believed that the system was functioning well.  There was no preoccupation with autonomy or with shared decision making, the process whereby physicians and patients today collaborate as they tease through various options.

While I conform to today’s professional norms and expectations, on occasion a patient seems to unknowingly seek to be transported back to the Era of Paternalism, with statements such as, “Doc, just tell me what to do.”

Similarly, when a patient poses the hypothetical inquiry, “Doctor, what you would advise me to do if I were you mother?”, the patient is stating an aversion to shared decision making.  Every doctor has heard questions like this from patients throughout his or her career.  Personally, I do not offer a response as I explain to patients that not only is my mother an entirely different human being - and is her own person - but also that physicians should not be proffering medical advice to close family members as their judgment might be tainted.  But obviously, I understand that these patients simply want to be told what I think is the best course for them to follow.

Here is my mom!

I maintain that many patients today are quite content to accept advice from physicians they trust without engaging in a collaborative process.  They feel, with justification, that a well-equipped professional with a long trail of experience may likely know the best pathway to follow.  And, if the doctor and the patient are well acquainted, then the physician can tailor the advice to the patient whom he or she knows well.  For example, if a doctor knows that a patient is facing challenging personal circumstances, then the doctor might not feel that this is the best time to pursue a knee replacement.

Although all types professionals typically present various options to clients, often the professional clearly knows the right answer.   Of course, particularly in the business world, the financial costs of different options and clients’ risk tolerance are relevant factors for clients to weigh.  But these professionals can generally create a hierarchy of options ranging from best to satisfactory to inadequate.  Shared decision making with lawyers and accountants is usually on account of costs more than it is on quality.

If, for example, I truly feel that surgery for a patient is the best choice, and the other options are clearly inferior, then shouldn’t I say this plainly?  (Of course, every patient has the right to refuse any and all physician recommendations.)

I’m not advocating a return to the paternalistic days of yore.  And I take the doctrine of informed consent very seriously.  And I respect patients’ autonomy.  But on some level, the notion of ‘leaving it to the professionals’ seems reasonable. 

What do you think?