SHARED DECISION MAKIN are inherently limited because of un- ates and accentuates the trend toward ventive Despite its dominance, many have conscious influences, Katz views dia- specialization and impersonalization fervent: found the informative model "arid. o logue as a mechanism for greater self- within the medical profession The Presidents Commission and others understanding Most importantly, the health-r contend that the ideal relationship does objectives. According to Katz, this view model s conception of patient autonomy not vest moral authority and medical places a duty on physicians and patients seems philosophically untenable. Thein- terol lew dietary patient but must be a process of shared patients can gain a greater self- decision making constructed around understanding and self-determination. but this is inaccurate. People are often therapy "mutual participation and respect. "20, Katz' insight is also available on uncertain about what they actually want. changes The President's Commission argues that grounds other than Freudian psycho- Further, unlike animals, people have their h∈ the physicians role is"to help the pa- logic eory and is consistent with the what philosophers call "second order de- tient understand the medical situation interpretive model res, that is, the capacity to reflect on their wishes and to revise their own and available courses of action, and the OBJECTIONS TO THE atient conveys his or her concerns and PATERNAUSTIc MODEL wishes, m0 Brock and Wartman2stress this fact-value"division of labor"--hav It is widely recognized that the pater- having"second order desires"and be- ing the physician provide information nalistic model is justified during emer- ing able to change our preferences and not mac pa while the makes value deci. gencies when the time taken to obtain in- modify our identity. Self-reflection and ng"shared decision formed consent might irreversibly harm the capacity to change what we want on an al making as umstances, however, it is no longer ten- liberation in which we assess the value make able to assume that the physician and pa- of what we want. And this is a process cians bring their medical training, knowl. tient espouse similar values and views of that occurs with other people who know siCi &se, and exv the diaailable treatment even physicians rarely advocate the pa- we ought to be that we can assent to. 1 to the diagnosis and manage- ternalistic model as an ideal for routine Even though changes in health or im- OBJEC DELIBE dition. Patients bril lementation of alternative interven ons can have profound effects on what The ft values, through which risks and benefits of OBJECTIONS TO THE we desire and how we realize our de- libera ous treatment options ean be evaluated. INFORMATIVE MODEL nent for a particular patient requires the seriptively and prescriptively inaccu- physician-patienoie in the informative ion. The infor- t ms to have no mative models possess Similarly, in discussing ideal place for essential qualities of the ideal atible n ot a ority of decision making, Eddy> argues for physician-patient relationship. The in- that incorporate fact-value division of labor betwe plural physician and patient as the tient in the sense of competently imple- OBJECTONSTOTHE mouse It is important to separate the decision pro- menting the patient s selected interven- INTERPRETIVE MODEL The first step tions. However, the informative physi- The interpretive model rectifies this of whicl w IThe second step is a understanding what the patient values have second-order desires and dynamic f personal values or or should value and how his or her ill- value structures and placing the eluci- ness impinges on these values. Patients dation of values in the context of the liberat ytic but personal and subjective.. [I]t. seem to expect their physician to have. patient's medical condition at the center t, tI caring approach; they deem a techni- of th ally proficient but detached physician Nevertheless, there are objections t Ithe physician not in the picture. What as deficient, and properly condemned. the interpretive model matters is what Mrs. Smith thinks Further, the informative physician is Technical specialization militates This view of shared decision making proscribed from giving a recommenda- against physicians cultivating the skills seems to vest the medical decision- tion for fear of imposing his or her will necessary to the interpretive model n the l aking authority with the patient while on the patient and thereby competing With limited interpretive talents and relegating physicians to technicians for the decision-making control that has limited time, physicians may unwittingly SiCL "transmitting medieal information and been given to the patient. Yet, if one their own values under the guis using their technieal skills as the patient of the essential qualities of the ideal phy-. of articulating the patient's values. And directs.Thus, while the advocates of sician is the ability to assimilate medical patients, overwhelmed by their medieal "shared decision making may aspire to- facts, prior experience of similar situa- condition and uncertain of their own ward a mutual dialogue between physi- tions, and intimate knowledge of the views, may too easily accept this impo- cian and patient, the substantive viewin atient's view into a recommendation sition. Such eircumstances may push the forming their ideal reembodies the infor- designed for the patients specific med- interpretive model toward the pater- patients mative model under a different lab ical and personal condition, 34.2 then the nalistic model in actual practice Other commentators have informative physician cannot be ideal Further, autonomy viewed as self-un- 1 lated more mutual models of Second, in the informative model the derstanding excludes evaluative judg ledical ment of the patient's values or attempts nent among these efforts is Katz" The cialist who provides detailed factual infor- to persuade the patient to adopt other Thire Silent World of the Doctor and Patient. mation and competently implements the values. This constrains the guidance and berati