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The ethical imperative for shared decision-making

Glyn Elwyn, Jon Tilburt, Victor Montori


The promotion of shared decision-making is a central policy initiative in the Patient Protection and Affordable Care Act and a key component of person-centered medicine. Yet, as interest increases, disturbing distortions of shared decision-making have occurred. Fueled by a desire to reduce healthcare costs, reduce litigation and improve cost-effectiveness, the underlying rationale for shared decision-making risks being overshadowed and some portray shared decision-making as a method to bend the cost curve. Opponents of shared decision-making claim it is a ploy to ration care to patients [1]. Both these positions misrepresent the underpinning principles.

The imperative for shared decision-making rests on the principles of good clinical practice, respecting patients’ right to know: that their informed preferences should be the basis for professional actions. Evidence-based medicine has contributed to our understanding that many therapies have marginal benefits. Shared decision-making aims to make the trade-offs between harms and benefits evident to patients rather than ration care. Overutilization arguably arises out of undue corporate influence on the promotion of marginally efficacious therapies with distorted claims of benefit. Other methods should be used to tackle these wider challenges, while the practice of shared decision-making would help medical professionals re-align themselves with patients’ informed preferences and, in so doing, place patients, not making or saving money, at the center of care.

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The Robert Powell Center for Medical Ethics. “Shared Decision making:” How the Obama Health Care Law Tries To Persuade Patients They’re Better Off Without Treatment. (Accessed 17 Aug 2011); available from:

Senate and House of Representatives. (2010). Patient Protection and Affordable Care Act. HR 3590.Washington.

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Stacey, D., Bennett, C., Barry, M., Col, N., Eden, K., Holmes-Rovner, M., Llewellyn-Thomas, H., Lyddiatt, A. et al. (2011). Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews. (10):CD001431.



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