In patient-centred care, shared decision-making is advocated as the preferred form of medical decision-making. Shared decision-making is supported with reference to patient autonomy without abandoning the patient or giving up the possibility of influencing how the patient is benefited. It is, however, not transparent how shared decision-making is related to autonomy and, in effect, what support autonomy can give shared decision-making. In the article, different forms of shared decision-making are analysed in relation to five different aspects of autonomy: (1) self-realisation; (...) (2) preference satisfaction; (3) self-direction; (4) binary autonomy of the person; (5) gradual autonomy of the person. It is argued that both individually and jointly these aspects will support the models called shared rational deliberative patient choice and joint decision as the preferred versions from an autonomy perspective. Acknowledging that both of these models may fail, the professionally driven best interest compromise model is held out as a satisfactory second-best choice. (shrink)

In patient centred care, shared decision making is a central feature and widely referred to as a norm for patient centred medical consultation. However, it is far from clear how to distinguish SDM from standard models and ideals for medical decision making, such as paternalism and patient choice, and e.g., whether paternalism and patient choice can involve a greater degree of the sort of sharing involved in SDM and still retain their essential features. In the article, different versions of SDM (...) are explored, versions compatible with paternalism and patient choice as well as versions that go beyond these traditional decision making models. Whenever SDM is discussed or introduced it is of importance to be clear over which of these different versions are being pursued, since they connect to basic values and ideals of health care in different ways. It is further argued that we have reason to pursue versions of SDM involving, what is called, a high level dynamics in medical decision-making. This leaves four alternative models to choose between depending on how we balance between the values of patient best interest, patient autonomy, and an effective decision in terms of patient compliance or adherence: Shared Rational Deliberative Patient Choice, Shared Rational Deliberative Paternalism, Shared Rational Deliberative Joint Decision, and Professionally Driven Best Interest Compromise. In relation to these models it is argued that we ideally should use the Shared Rational Deliberative Joint Decision model. However, when the patient and professional fail to reach consensus we will have reason to pursue the Professionally Driven Best Interest Compromise model since this will best harmonise between the different values at stake: patient best interest, patient autonomy, patient adherence and a continued care relationship. (shrink)

While promoting population health has been the classic goal of public health practice and policy, in recent decades, new objectives in terms of autonomy and equality have been introduced. These different goals are analysed, and it is demonstrated how they may conflict severly in several ways, leaving serious unclarities both regarding the normative issue of what goal should be pursued by public health, what that implies in practical terms, and the descriptive issue of what goal that actually is pursued in (...) different contexts. A basic conflict of perspective is handled by integrating the ideas of public health striving for health-related autonomy and equality, resulting in a prioritarian oriented population approach to health-related autonomy. This integrated goal is demonstrated to constrain itself in several ways attractive from the point of view of the classic goal, but several serious problems remain. For this reason, a model where all of the three goals are integrated into one coherent structure where they can be assigned varying degrees of importance relative to the level of population health is described. It is argued that this model avoids the problems set out earlier, and is actually normatively preferable to the classic goal alone. It is furthermore argued that the model may be employed as a useful tool for descriptive ethics, as well as a vehicle for international harmonisation of public health policies. A number of practical implications regarding, e.g., the importance of respecting autonomy and the allocation of public health resources are noted, as are a battery of questions for further research. (shrink)

Compliance is a key concept in health care and affects all areas of health care including diabetes. Non-compliance has previously been a label attached to many patients without much thought having been given to the causes of poor compliance. Over the last few decades there has been a large volume of research focusing on compliance that has exposed the multitude of factors affecting compliance. Even the definition is not clear cut and so comparability between studies is not without difficulties. A (...) better understanding of the factors affecting compliance, including the doctor/patient relationship, has allowed the evolution of “concordance”. Concordance views the patient as being the equal of the healthcare provider and as having a right to make informed decisions. In a condition such as diabetes, which has many potential long term complications, it is vital that concordance is embraced in the healthcare system in order to improve care. (shrink)

Non-compliance is a label often used about patients who do not follow therapeutic advice. This paper analyses the notion of compliance, and tries to show that this notion is inextricably bound to a paternalistic conception of the doctor-patient relationship. It is proposed that we should perhaps not talk so much about the non-compliant patient, but instead shift the focus towards the non-compliant doctor.

ABSTRACT Accurate self‐administration of antiretroviral medication therapy for HIV/aids is a significant clinical and ethical concern because of its implications for individual morbidity and mortality, the health of the public, and escalating healthcare costs. However, the traditional construction of patient medication adherence is oversimplified, myopic, and ethically problematic. Adherence relies on existing social power structures and western normative assumptions about the proper roles of patients and providers, and principally focuses on patient variables, obscuring the powerful socioeconomic and institutional influences on (...) behaviour. Some professionals advocate for alternate approaches to adherence, but many of the available alternatives remain conceptually underdeveloped. Using HIV/aids as an exemplar, this paper presents medication practice as a theoretical reconstruction and explicates its conceptual and ethical evolution. We first propose that one of these alternatives, medication practice, broadens the understanding of individuals’ medication‐taking behaviour, speaks to the inherent power inequities in the patient‐provider interaction, and addresses the ethical shortcomings in the traditional construal. We then integrate medication practice with feminist thought, further validating individuals’ situated knowledge, choices, and multiple roles; more fully recognizing the individual as a multidimensional, autonomous human being; and reducing notions of obedience and deference to authority. Blame is thus extricated from the healthcare relationship, reshaping the traditionally adversarial components of the interaction, and eliminating the view of adherence as a patient problem in need of patient‐centred interventions. (shrink)

ABSTRACT Accurate self‐administration of antiretroviral medication therapy for HIV/aids is a significant clinical and ethical concern because of its implications for individual morbidity and mortality, the health of the public, and escalating healthcare costs. However, the traditional construction of patient medication adherence is oversimplified, myopic, and ethically problematic. Adherence relies on existing social power structures and western normative assumptions about the proper roles of patients and providers, and principally focuses on patient variables, obscuring the powerful socioeconomic and institutional influences on (...) behaviour. Some professionals advocate for alternate approaches to adherence, but many of the available alternatives remain conceptually underdeveloped. Using HIV/aids as an exemplar, this paper presents medication practice as a theoretical reconstruction and explicates its conceptual and ethical evolution. We first propose that one of these alternatives, medication practice, broadens the understanding of individuals’ medication‐taking behaviour, speaks to the inherent power inequities in the patient‐provider interaction, and addresses the ethical shortcomings in the traditional construal. We then integrate medication practice with feminist thought, further validating individuals’ situated knowledge, choices, and multiple roles; more fully recognizing the individual as a multidimensional, autonomous human being; and reducing notions of obedience and deference to authority. Blame is thus extricated from the healthcare relationship, reshaping the traditionally adversarial components of the interaction, and eliminating the view of adherence as a patient problem in need of patient‐centred interventions. (shrink)