Shared decision-making: enhancing the clinical relevance

Shared decision-making is increasingly advocated to enable patients to participate in decisions that affect them, to protect patients from insufficiently individualized supply-driven care, and to reduce health care costs and waste by avoiding the provision of unwanted interventions.1–3
The concept of shared decision-making can be understood in several ways. A number of definitions and descriptive models have been offered, emphasizing different aspects of clinician-patient interaction and decision-making.4 Most definitions and models can be variously interpreted when considered in relation to the complex realities of healthcare provision. Clinicians' understandings of shared decision-making can have important implications for clinical practice.5 They can diverge, for example, over questions of whether, when and how it is appropriate to recommend a particular treatment or challenge a patient's expressed preferences.
This paper considers the practical and ethical implications of, ‘narrow’ and ‘broader’ ways of thinking about shared decision-making. It illustrates how narrow understandings of shared decision-making, which focus on informing patients so they can choose between options, can make it hard for many patients to share meaningfully in decision-making that affects them. It then outlines how broader understandings, which allow for more clinician influence and extend the relevance of shared decision-making to diverse situations, can be justified in principle and appraised for appropriateness.
Table 1 compares the key features of narrow and broader understandings of shared decision-making.