Department of Psychological Sciences, University of Liverpool, Liverpool, UK.
Health Expect. 2019 Jun;22(3):275-283. doi: 10.1111/hex.12853. Epub 2018 Nov 26.
Shared decision making (SDM) evolved to resolve tension between patients' entitlement to make health-care decisions and practitioners' responsibility to protect patients' interests. Implicitly assuming that patients are willing and able to make "good" decisions, SDM proponents suggest that patients and practitioners negotiate decisions. In practice, patients often do not wish to participate in decisions, or cannot make good decisions. Consequently, practitioners sometimes lead decision making, but doing so risks the paternalism that SDM is intended to avoid. We argue that practitioners should take leadership when patients cannot make good decisions, but practitioners will need to know: (a) when good decisions are not being made; and (b) how to intervene appropriately and proportionately when patients cannot make good decisions. Regarding (a), patients rarely make decisions using formal decision logic, but rely on informal propositions about risks and benefits. As propositions are idiographic and their meanings context-dependent, normative standards of decision quality cannot be imposed. Practitioners must assess decision quality by making subjective and contextualized judgements as to the "reasonableness" of the underlying propositions. Regarding (b), matched to judgements of reasonableness, we describe levels of leadership distinguished according to how directively practitioners act; ranging from prompting patients to question unreasonable propositions or consider new propositions, to directive leadership whereby practitioners recommend options or deny requested procedures. In the context of ideas of relational autonomy, the objective of practitioner leadership is to protect patients' autonomy by supporting good decision making, taking leadership in patients' interests only when patients are unwilling or unable to make good decisions.
共同决策（SDM）的出现是为了解决患者做出医疗决策的权利和医生保护患者利益的责任之间的紧张关系。SDM 的支持者认为，患者有意愿且有能力做出“正确”的决策，因此隐含地假设患者愿意并能够参与决策过程。但实际上，患者往往不愿意参与决策，或者无法做出正确的决策。因此，医生有时会主导决策过程，但这样做可能会导致 SDM 试图避免的家长式作风。我们认为，当患者无法做出正确决策时，医生应该承担领导责任，但医生需要知道：（a）何时患者无法做出正确决策；以及（b）在患者无法做出正确决策时，如何适当地、适度地进行干预。关于（a），患者很少使用正式的决策逻辑来做出决策，而是依赖于关于风险和收益的非正式主张。由于主张是具体的，其含义取决于上下文，因此不能强加决策质量的规范标准。医生必须通过对潜在主张的“合理性”进行主观和上下文化的判断来评估决策质量。关于（b），与合理性判断相匹配，我们描述了根据医生行为的直接程度区分的领导层级；从提示患者质疑不合理的主张或考虑新的主张，到医生建议选择或拒绝请求的程序的直接领导。在关系自主性的概念框架下，医生领导的目标是通过支持良好的决策来保护患者的自主性，只有在患者不愿意或无法做出正确决策时，才会在患者的利益方面承担领导责任。
