Charles Cathy, Gafni Amiram
Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, 1280 Main St West, 2nd Floor, CRL Building, Hamilton, ON, L8S4K1, Canada.
J Comp Eff Res. 2014 Mar;3(2):197-209. doi: 10.2217/cer.13.91.
Two international movements, evidence-based medicine (EBM) and shared decision-making (SDM) have grappled for some time with issues related to defining the meaning, role and measurement of values/preferences in their respective models of treatment decision-making. In this article, we identify and describe unresolved problems in the way that each movement addresses these issues. The starting point for this discussion is that at least two essential ingredients are needed for treatment decision-making: research information about treatment options and their potential benefits and risks; and the values/preferences of participants in the decision-making process. Both the EBM and SDM movements have encountered difficulties in defining the meaning, role and measurement of values/preferences in treatment decision-making. In the EBM model of practice, there is no clear and consistent definition of patient values/preferences and no guidance is provided on how to integrate these into an EBM model of practice. Methods advocated to measure patient values are also problematic. Within the SDM movement, patient values/preferences tend to be defined and measured in a restrictive and reductionist way as patient preferences for treatment options or attributes of options, while broader underlying value structures are ignored. In both models of practice, the meaning and expected role of physician values in decision-making are unclear. Values clarification exercises embedded in patient decision aids are suggested by SDM advocates to identify and communicate patient values/preferences for different treatment outcomes. Such exercises have the potential to impose a particular decision-making theory and/or process onto patients, which can change the way they think about and process information, potentially impeding them from making decisions that are consistent with their true values. The tasks of clarifying the meaning, role and measurement of values/preferences in treatment decision-making models such as EBM and SDM, and determining whose values ought to count are complex and difficult tasks that will not be resolved quickly. Additional conceptual thinking and research are needed to explore and clarify these issues. To date, the values component of these models remains elusive and underdeveloped.
循证医学（EBM）和共同决策（SDM）这两大国际运动，在一段时间里一直在努力解决各自治疗决策模型中与价值观/偏好的定义、作用及衡量相关的问题。在本文中，我们识别并描述了这两大运动在处理这些问题的方式上尚未解决的问题。本次讨论的出发点是，治疗决策至少需要两个基本要素：关于治疗方案及其潜在益处和风险的研究信息；以及决策过程参与者的价值观/偏好。循证医学运动和共同决策运动在定义治疗决策中价值观/偏好的含义、作用及衡量方面都遇到了困难。在循证医学的实践模式中，对于患者价值观/偏好没有清晰一致的定义，也未就如何将其纳入循证医学实践模式提供指导。所倡导的衡量患者价值观的方法也存在问题。在共同决策运动中，患者价值观/偏好往往以一种受限且简化的方式被定义和衡量，即患者对治疗方案或方案属性的偏好，而更广泛的潜在价值结构则被忽视。在这两种实践模式中，医生价值观在决策中的含义和预期作用都不明确。共同决策的倡导者建议在患者决策辅助工具中进行价值观澄清练习，以识别并传达患者对不同治疗结果的价值观/偏好。此类练习有可能将特定的决策理论和/或过程强加给患者，这可能会改变他们思考和处理信息的方式，有可能阻碍他们做出符合其真实价值观的决策。在循证医学和共同决策等治疗决策模型中，阐明价值观/偏好的含义、作用及衡量，以及确定哪些人的价值观应该被考虑，是复杂且困难的任务，不会很快得到解决。需要更多的概念性思考和研究来探索和澄清这些问题。迄今为止，这些模型中的价值观部分仍然难以捉摸且发展不足。
