Bioethics Discussion Blog: "Nudging" Informed Consent Toward One Direction

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Saturday, June 15, 2013

"Nudging" Informed Consent Toward One Direction




 








You  enter a grocery store and as you pass through the front door you find a beautiful display of luscious  looking fresh fruits.  You came to the market to buy some spare ribs and wine for supper but that is way in the back of the store.  Prior to entering the store, you had only the ribs and wine on your shopping list but now you find yourself buying a few pounds of the fruit. Moving back through the market, you find the display of bottles of wine. You find that the more expensive and imported wines are displayed at eye level and the cheaper, local and less noteworthy wines are standing on an elevated shelf, accessable, but you have to reach up for them. Might you be tempted to take one of the wines at eye level? Maybe not, but then you hadn't even previously considered buying an expensive wine for this evening's supper. What I am presenting here as examples of how the grocery market can affect your decision-making by creating
"nudges" to change your shopping list decisions. This example of ways to affect decision-making in the grocery decision-making also can occur in the challenge of making your informed consent medical decisions.

The June 2013 issue of the American Journal of Bioethics has one of its target articles and a number of open-peer commentaries just about "nudging and informed consent". If the healthcare provider presents to the patient the information needed for the patient to make informed consent but yet sets a particular detail "in the front of the store" or "on a lower shelf", representing how the facts are presented to the patient, the provider may be essentially "nudging" the patient toward one decision in place of the other but without denying the patient any loss of autonomy to select either to consent or dissent for any of the options presented. The nudging can vary in intensity from something like a very slight nudge to a nudge which might be considered almost a "push".

To demonstrate directly to my visitors some examples of slight nudges as presented in one peer review article in that journal "Nudging and the Complicated Read Life of "Informed Consent" by Charles Douglas and Emily Proudfoot. I would like to present their two "scripts" which they presented to patients in a study to determine whether a nudge in presenting the facts could affect the patient's decision-making. 

Pretend (and I hope it is only a pretend) that as a woman you are concerned about a breast lump or an abnormality which was found only on a mammogram and that may be a cancer. The doctor is aware that there are two approaches in management which are available: perform a "thru the skin" biopsy of the abnormality which involves at the most only a little local
anesthesia with virtually no risk and present results, if negative for cancer, would still leave only a less than 1% chance that a cancer would be missed but the lump continued to be observed  if no cancer was  or to fully excise the
 abnormality under general anesthesia which would carry the risk of anesthesia and the surgery but provide 100% confidence regarding the diagnosis of the lesion and the lesion would have been removed. The patient can be told the facts, the procedure, risks and conclusions in each of two ways. either may represent a nudge in one direction or the other. My own examples of how the facts could be presented as based on the article would be:

1)  "You may have the lump simply biopsied under local anesthesia with negligible risks from the procedure rather than surgically removed under general anesthesia with its known risks, and the results of the biopsy if negative for cancer would be correct over 99% of the time and missing the cancer less than 1% of the time, I would consider that an acceptable risk. After the biopsy, if negative for cancer, the lump will be continued to be observed"

2)"To have the lump biopsied there would be very little risk from the procedure and a less than 1% chance a cancer would be missed. However, you may have the lump fully removed but with the known risks from the general anesthesia and surgery.  If you want to be 100% certain regarding whether the lump is cancer or not, then we should excise, remove it."

Notice that the facts are presented in both examples for the patient's education and decision but with a difference in the wording and emphasis.  If you were only presented with disclosure #1 how would you respond? Would you agree for a biopsy? If you were only presented with disclosure #2 how would you respond? would you agree for an excision?

Do you see the "nudging" of the patient in one direction or another in each of the patient presentations?  Do you think it is fair, that it is ethical for a doctor to tenderly direct (nudge) the  patient in one direction or another based on the doctor's professional opinion as to what would be in the patient's best interest. Have you, as a patient, felt nudged by your doctor?  ..Maurice.

Graphic: From Google Images.


   

5 Comments:

At Monday, June 17, 2013 3:42:00 PM, Blogger Maurice Bernstein, M.D. said...

Mark Sagoff, writing an Open Peer-Review Article "Trust Versus Paternalism" in response to the American Journal of Bioethics article on "Nudging and Informed Consent", states "Where there is trust, paternalism is unnecessary; where there is no trust, it is unconscionable." In other words, if there is a trusting relationship of the patient to the physician and if the physician has no doubt that the patient will work for his or her own best interest, then the doctor expressing facts to the patient as part of creating informed consent does not need to phrase the communication in a way to encourage the patient to accept the physician's view of what should be done. And, if there is no trust between the patient and the doctor, then for the doctor to do any kind of nudging or pushing the patient to accept the doctor's approach would be beyond unnecessary but also totally unethical and professionally unacceptable. In view of the fact that there is considerable controversy regarding the approaches toward diagnosis and treatment of some medical conditions along with institutional or physician opportunities for self-interest, Sagoff ends the article with "the doctor should never even nudge the patient to one view rather than another as constituting the recommendation of medicine itself. The only paternalistic act which is justified may also be required---to advise the patient with a difficult diagnosis to get a second opinion."
Do you think, whatever the degree of trust is present, you would simply say to the doctor in a TV "Dragnet" type expression: "Just the facts, Doc"? ..Maurice.

 
At Sunday, July 14, 2013 3:07:00 PM, Anonymous Anonymous said...

don't like the idea at all... to begin with, the doctor might be plain wrong. If so, "nudging" just gets the patient farthest from the right (or better) course of action to treat his/her ailment.

 
At Sunday, July 14, 2013 3:41:00 PM, Blogger Maurice Bernstein, M.D. said...

Anonymous, would you think it is best for the patient to enter the doctor-patient relationship with the view that the "doctor might be plain wrong". So, would you recommend that the patient say "Just the facts, Doc" with the patient then turning in the direction based on their own decision? And then would you be comfortable that the doctor was telling you "all the facts". But couldn't the doctor be blurring some as a mechanism for a "nudge"?

What I am getting at is that trust is an essential component of the doctor-patient relationship and without trust you are the patient to the wrong doctor. ..Maurice.

 
At Thursday, February 06, 2014 2:49:00 PM, Blogger darkstar said...

What happens in an ER situation when the patient has no choice in choosing the doctor ? And what if you end up in say a religious institution where the beliefs and practices of the institution are inconsistent with your own ? If you were a pregnant mother whose life would be ended if you went through with childbirth ?

 
At Thursday, February 06, 2014 5:00:00 PM, Blogger Maurice Bernstein, M.D. said...

Hospitals must disclose "non-standard" or religious practices to the patient and/or family promptly for immediate and ongoing informed consent. ..Maurice.

 

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