"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.
posted by Maurice Bernstein, M.D. @ 5:38:00 PM
9 comments
9 Comments:
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.
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.
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.
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 ?
Hospitals must disclose "non-standard" or religious practices to the patient and/or family promptly for immediate and ongoing informed consent. ..Maurice.
The following is a posting by Belinda which was written today but to another thread. I find it is more appropriate for it to be located here on "nudging" and so I have copied it and published it below. ..Maurice.
What happens when a patient can't be nudged? I have had two doctors telling me I should have a procedure that is a major surgery, requiring a heart/lung machine and coming off blood thinners in order to perform a certain kind of biopsy. There is a 30% chance they will get a diagnosis based on statistics of the type of disease process that is going on in the body.
I ask you, and have asked them, would you do this procedure on someone who has a blood clotting disorder, diseased lungs, and an upper airway paralysis and some kind of neuromuscular disease that has no diagnosis?
I said no. Then, I went for another opinion from a doctor who comes from a major research hospital who feels that I should NOT got through the procedure--too risky, and with too low a ratio for a diagnosis and little they can do anyway. Additionally, he sees no progression on the part of the body they are testing, yet my function is plumeting especially when there are other methods that are less invasive.
Then, I get accused of doctor hopping even though I've been with several docs for more than 15 years.
They don't know what's wrong, don't what to do, and want to subject me to a procedure that could well have been end up with a stroke and in worse shape. I do not want a transplant as they really don't work and fail.
I wonder what planet they are living on especially when I've already been told that the medications used to treat the disease process probably won't change.
How's that for nudging? I'm tired, disgusted by a system that is only trying to make money and mainly, a system that doesn't listen to the patient. I told docs more than 11 years ago I had a smooth muscle and regular muscle problem. I was told that's impossible. Guess what, it's not. I have proven it by requesting certain protocols on examination.
Have I disclosed too much about myself. Quite frankly I don't care anymore. I'm ready to stop going when you have a disease process that is ongoing, no hope of recovery and the only thing that will make me feel better are steroids leaving you with cataracts, osteoporosis, huge weight gain. I already told them if I have to pick between two diseases, either lung disease or stroke, I pick lung disease.
When there are multiple disciplines involved, they simply are not equipped to deal with them. Where's Dr. House when you need him?
What's really upsetting to me that while I don't have an MD next to my name, I'm a financial analyst by trade and have a keen mind and understand what's happening to my body. Then they wonder when I go to a new doctor with 15 minutes to explain what's wrong. I'm actually laughing at this because it's ridiculous.
What I do know is that this researcher has never seen a case like mine, is rare and knowing my psycho social issues feels that being a guinea pig at NIH or somewhere else won't benefit me.
belinda
I didn’t have the right language to describe it before reading this article but now I can say I was nudged into a tranesophageal echocardiogram last year. I had a simple external ultrasound of my heart which reading between the lines was not done quite right by a new inexperienced employee. The result was inconclusive. They told me we could do it again but that a T.E.E. would give better results. It was the way they said it. It came across as those external ultrasounds aren’t real good anyway and that a T.E.E. was really in order. If so why did they have me do the initial external ultrasound? Just an extra billing event perhaps?
The above was just an inconvenience (and expense). Nudging could have far more serious implications. One of my mother’s friends had bad knees. She was also very morbidly obese and in her 60’s. Not exactly a good candidate for general anesthesia and surgery. She had a heart attack during surgery, never regained consciousness and died a month later. Back when this happened I wondered was she truly informed of the risks and was she nudged into this surgery. For sure the fine print on the consent form said she gave informed consent but did she really? Between the surgery and a month in the ICU there was certainly a massive billing event. It was a win for the hospital, but it didn't work out so well for the patient.
You can see here that my thinking is that nudging is generallybdone for financial gain.
Biker, echocardiogram performed by inexperienced tech certainly can fail to give the adequate answer to a cardiac abnormality since the position of the patient and the proper placement of the ultrasound transducer in the acoustic windows could affect the value of the results. Since a transesophageal echocardiogram is "invasive" (inserted through the mouth into the esophagus or stomach ), certainly a repeat transthoracic echocardiogram would be worth trying first with a more experienced technician or simply repeating the exam with the initial tech might be a better attempt at diagnosis.
It is the words "give better results" which is the "nudge" rather than "let's repeat."
However, the "better results" is also dependent on the specific pathology the cardiologist is looking for. ..Maurice.
Here is the link to the 2015 PhD thesis by Dominic King, participant in the creation of the description of the anatomy and function of the "nudge" described as a mnemonic "MINDSPACE" (Messenger,Incentives, Norms, Defaults, Salience, Priming, Affect, Commitments,Ego)
https://spiral.imperial.ac.uk/bitstream/10044/1/28411/3/King-D-2015-PhD-Thesis.pdf
..Maurice.
Post a Comment
<< Home