The shared decision making through a behavioural economics view

Pedro Rey

Last year I participated in a session on shared clinical decisions between doctors and patients during the XXXVIII Conference on Health Economics of the AES, which this year was focused on shared decisions making, including a plenary talk by Alistair McGuire. As a behavioural economist, I find that informed decision-making in an area with as much uncertainty as health is precisely one of the fields in which a more interesting and, hopefully, more productive dialogue can be generated among health and behavioural economists. As I have commented in other posts, behavioural economics departs from the traditional economics assumption that which individuals are rational beings that always know what is best for them and make optimal decisions according to established and well-defined preferences. It’s obvious that this theoretical ideal is rarely met, especially in a context such as health where asymmetries of information, uncertainty about our own preferences or the difficulty in interpreting the risks associated with the multiple decisions that must be made makes it very difficult to choose well, and even evaluate ex post if the decision was optimal. Therefore, the premise from which the movement claims for more shared decision making between doctors and patients produces both hope and doubts.

In health, decisions are characterized by three aspects that hinder them. First, we have the information asymmetries between doctor and patient. While the physician has greater clinical knowledge about the disease and possible treatments, the patient knows better how to be in general and has his own preferences about the degree of discomfort he is willing to endure (whether treated or not). It’s in this need that there is a relationship of trust between two unequally informed parties on important issues that underlie the movement of shared decision, raised by doctors like Victor Montori and his recent book “Why We Revolt”.  However, having placed hope in the clinical authority in the healthcare professional may cause the patient to feel oblivious to making decisions about what he believes he does not know, without understanding the importance of his own contribution with information of which he is better informed to make a better decision.

Secondly and closely related to this distrust of the patient who is accustomed to depositing the decision in the clinician, a well-studied aspect of behavioural economics is found: the fact that individuals don’t have unwavering preferences in many aspects about which we must decide. To put it bluntly, we don’t always know what we want. The prospective theory teaches us that we attach more importance to losses than to gains, so that the patient can give more value to the suffering that treatment can cause than to the possible gain in health. This can come in full contradiction with doctor’s view, whose interventionist motivations, either by their own professional incentives, or by their clinical judgment, can often be conflicting. In a similar way, behavioural economics also tells us that our temporary preferences change on many occasions: we want to be well in the future, but we care too much about today's cost (diet, exercise, treatment) to make sacrifices that we allow us to find ourselves better in the future. One of the greatest challenges of the shared decision concept is achieving alignment of the motivations of doctor and patient in terms of immediate suffering to have greater well-being in the future.

The fact that individuals don’t have consistent preferences opens the door to another of the great problems of shared decision: the risk of manipulation by the health professional. If we have a clinically better informed doctor, and therefore with greater authority, and at the same time a patient who trusts and does not know what he wants (or changes his preferences), it’s relatively easy for the doctor to take the patient to choose what seems best to him, even if it occurs in an apparent context of shared decision. Behavioural economists, starting with the recent Nobel Prize in Economics Richard Thaler, don’t have major ethical problems with it. In fact, the so-called "libertarian paternalism" movement uses precisely the malleability of the preferences of individuals to indicate, through "nudges", to choose what, from a paternalistic point of view, someone has decided what is best for you. The Libertarian paternalist argues that the individual always has the possibility to choose between several options but, in turn, uses psychological instruments such as the order in which the options are presented, or what is the decision taken by default, to induce the people to take one or the other decision. This possibility of manipulating the "architecture of the decision", promoted by leading behavioural economists in the field of health, such as Kevin Volpp, can be harmless in contexts in which the patient has a clear goal, say, to reduce their weight, and benefits from psychological tricks such as, for example, the order in which different meals are presented in a cafeteria to choose healthier foods. However, in other contexts in which the patient may not have the clear health goal, or at least does not know well how much he is willing to suffer to achieve it, it does not seem ethical to use these tools to follow him according to what treatment to the clinician for some reasons or other reasons (professional experience biased or not, incentives, etc.), may interest you more.

A third aspect that complicates the shared decision, and in turn gives manipulation capacity to the health professional, are, as Gerd Gingerenzer points out, the difficulties that individuals, both patients and doctors, have to really understand the probabilistic information associated with risk, which is very important in a context as uncertain as the sanitary. This problem has led to the development of patient information tools that simplify the statistical understanding of uncertainty on the subject of the consequences of following one type of clinical practice or another, but even so, there is a risk that, faced with the difficulty of understanding, an interested party communicates information about objective risks in a way that, subjectively, the other party interprets them in line with what the interested party believes is more convenient.

I don’t want to end this entry giving the impression that behavioural economics teaches us that shared decision is, therefore, impossible. On the contrary, I believe that what behavioural economics teaches us is that the shared decision imposes a greater honesty requirement on those who have more information about some of the important aspects for the health decision that can be used to manipulate decisions. If we really want decisions to be shared, and therefore the other party feeling truly comfortable and confident in sharing the part of the information that the clinician does not know and need, it’s essential to rebalance the power relationship between the two parties, so that a trust environment is created in which the exchange of truthful, respectable and necessary information actually takes place.