Dismissing preferences?

At the International Conference on Communication in Healthcare, which I just returned from, there was a discussion continuously coursing beneath the surface and bubbling up every once in a while. If we, acolytes of shared decision making, whether patients or providers, want to encourage decision making that has the person involved at the center, recognizing their preferences and values, does the kind of decision in question have anything to do with the relevance of those preferences?

Is it really the case that (as was said multiple times during the conference) there is “no such thing” as preference-sensitive decisions, for the reason that all decisions are sensitive to preferences? Everything, it was said in this argument, involves preferences, and countless decisions are made in the course of a day. Getting into the car to go to the doctor’s office is a decision. Taking a pill, or not, is a decision. Picking up the phone to talk to someone about your symptoms: That’s a decision too. So, the argument goes, to pick certain health care decisions as more “preference sensitive” than others is meaningless. Everything involves an exercise of wants, desires, and priorities.

I think this ignores the diverse uses of the term “decision” and the verb “decide.” Surely not all of the following are the same?
• I decided to take an aspirin to reduce my chance of heart disease.
• I decided to go to the doctor.
• I decided to take a deep breath.
• I decided to perform CPR on this bystander in the street.
• I decided to forgo resuscitation if my heart should stop.
• I decided to quit smoking.

It must be that these involve various shadings of the word decision, a different mix of voluntary, quasi-voluntary, outwardly imposed, and preference-sensitive action. If we are to further care that is consonant with peoples’ preferences, we should recognize that sometimes these preferences are at the fore in a given decision (“I decided to walk 2 miles every week!”) and sometimes not (“I decided to take time off work to take care of my mother”). There are differences that should be recognized, and eliding them runs the risk of dismissing when preferences might actually be most important.

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.