Shared decision making: a consideration of historical and political contexts

M. Slade1 provides a thought-provoking and helpful review of ways in which shared decision making (SDM) may be understood, its justifications generally and the application of SDM principles in mental health. He suggests adoption of cross-sectoral practices, such as from marketing and hospitality, in promoting SDM. This commentary takes a more medically oriented perspective and further explores some political implications raised by the challenges of SDM.

SDM in mental health care may be formally a relatively recent arrival, but SDM does not exist in historical isolation either within medicine or mental health care. Through the history of medicine, shifts in the power balance have occurred in decision making between physician and patient2, and recent decades may have seen some shifting of this locus of control towards the patient.

Related concepts within modern medicine and medical sociology can be seen as dating back at least half a century. Szasz and Hollander3 and Balint4, in the mid-20th century, advocated for a shift in management of chronic diseases from activity-passivity and guidance-cooperation models towards a model of “mutual participation” in doctor-patient relationships. This approach shares features with what may now be termed SDM.

The chronic disease model elaborated by Wagner and others in the US5 emphasizes an activated and informed patient as a critical component. Sharing of decisions may also be seen as critical to evidence-based medicine best practice, which involves “integrating individual clinical expertise with the best available external clinical evidence… reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences in making clinical decisions about their care”6.

An influential model in medical training and practice, including in psychiatry, is the CanMEDS framework. Here medical training at all levels is seen as leading towards development of connected competencies: that of “medical expert” is described as an integrating role for the work of a doctor as communicator, collaborator, leader, health advocate and scholar7, which can be seen as equipping practitioners potentially to work in alignment with the chronic disease model, evidence-based medicine or SDM.

Work cited by Slade demonstrates that people appreciate being invited to take more autonomy than they may directly ask for. Often the health care consultation starts from a point in which the patient is situationally disadvantaged by power dynamics, cultural expectations, and the potentially disabling nature of interacting with an “expert”8. So, patients or clients appreciate efforts to promote their empowerment even if they don't ask for it. In mental health care, there are also other important convergences: firstly with the challenge of practice in the context of the application or availability of compulsory treatment; then with the politics of the recovery movement and with working towards recovery oriented practice.

While there are multiple convergences across the medical and mental health care literature with the key propositions of SDM, implementation often still faces great challenges. Promoting SDM can challenge clinicians in terms of the depth and breadth of their professional skills and invite commitment through other roles as citizens that may intertwine with those of professional practice.

Slade helpfully makes the point that transitions towards SDM require changes in prevailing service culture. Here we enter a realm that in a broad sense is political, in that it involves processes whereby power is assigned. For instance, by virtue of income, specific legal powers and societal status, not uncommonly psychiatrists can assert influence in many service systems that is not necessarily commensurate with the potency of the interventions they control9. For many psychiatric conditions, medications or other physical treatments that are the special purview of doctors are not particularly more powerful than psychological or social interventions, yet delivery systems and power dynamics can serve to support prioritization of those interventions over others.

A set of issues related to allocative and distributional justice bring into the frame more formal kinds of politics. The breadth of existing services influences the options available to service providers and so conditions what may be considered within the SDM reasoning space. For instance, in Australia at least, there are dramatic differences in what is available in terms of psychological treatments in different parts of the country10, so what is a primary care physician for instance to do where psychological treatments that could substantially improve the lot of someone with a mental health problem are not actually available? Is it within the scope of SDM to advise patients with a current major depressive disorder that, if they lived in a more affluent area or personally were better financially resourced than they are, then they should augment their antidepressants with some well conducted cognitive behaviour therapy but, because of their location and personal circumstance, this isn't an available option? Often this discussion will not occur and the reasoning space of SDM will be constrained by what is practically available, even where that does not conform to evidence-based practice or to principles of justice. Here we encounter a connection between SDM and what in the CanMEDS model7 is described broadly as the health advocacy role and in practice may involve formal political engagement.

Implementation of SDM, as Slade suggests, may benefit from ideas from marketing and hospitality. These can be seen as just two examples among possible strategies that stretch across all the CanMEDS competencies and can present clinicians with political challenges. Even if we succeed in addressing many of the personal politics that allow our practice to move towards more effective use of the range of enablers to SDM that Slade has identified, other critical factors may block progress. Key impediments to SDM may arise because informal politics in institutions constrain exploration of what is possible and because government formal politics constrains the range of possible decisions in ways that may be palpably unjust.

Full engagement with SDM may challenge practitioners with the prospect of participation in processes that may radically shift existing power balances in services systems, and with the challenge of perhaps engaging in formal political activism where there are critical constraints to implementation of SDM that relate to political policies on social justice.