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The ethics of responsibility and ownership in decision-making about treatment for breast cancer: Triangulation of consultation with patient and surgeon perspectives

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  • Mendick, Nicola
  • Young, Bridget
  • Holcombe, Christopher
  • Salmon, Peter

Abstract

Doctors are widely encouraged to share decision-making with patients. However, the assumption that responsibility for decisions is an objective quantity that can be apportioned between doctors and patients is problematic. We studied treatment decisions from three perspectives simultaneously - observing consultations and exploring patients' and doctors' perspectives on these - to understand how decision-making that we observed related to participants' subjective experience of responsibility. We audio-recorded post-operative consultations in which 20 patients who had undergone initial surgery for breast cancer discussed further treatment with one of eight surgeons in a general hospital serving a socioeconomically diverse urban population in England. We separately interviewed each patient and their surgeon within seven days of consultation to explore their perspectives on decisions that had been made. Qualitative analysis distinguished procedurally different types of decision-making and explored surgeons' and patients' perspectives on each. Surgeons made most decisions for patients, and only explicitly offered choices where treatment options were clinically equivocal. Procedurally, therefore, shared decision-making was absent and surgeons might be regarded as having neglected patients' autonomy. Nevertheless, patients generally felt ownership of decisions that surgeons made for them because surgeons provided justifying reasons and because patients knew that they could refuse. Conversely, faced with choice, patients generally lacked trust in their own decisions and usually sought surgeons' guidance. Therefore, from the perspective of ethical frameworks that conceptualise patient autonomy as relational and subjective, the surgeons were protecting patient autonomy. Studying subjective as well as procedural elements of decision-making can provide a broader perspective from which to evaluate practitioners' decision-making behaviour.

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  • Mendick, Nicola & Young, Bridget & Holcombe, Christopher & Salmon, Peter, 2010. "The ethics of responsibility and ownership in decision-making about treatment for breast cancer: Triangulation of consultation with patient and surgeon perspectives," Social Science & Medicine, Elsevier, vol. 70(12), pages 1904-1911, June.
    • Handle: RePEc:eee:socmed:v:70:y:2010:i:12:p:1904-1911
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    Cited by:

    1. Stephen L Brown & Demian Whiting & Hannah G Fielden & Pooja Saini & Helen Beesley & Christopher Holcombe & Susan Holcombe & Lyn Greenhalgh & Louise Fairburn & Peter Salmon, 2017. "Qualitative analysis of how patients decide that they want risk-reducing mastectomy, and the implications for surgeons in responding to emotionally-motivated patient requests," PLOS ONE, Public Library of Science, vol. 12(5), pages 1-13, May.
    2. Sinding, Christina & Hudak, Pamela & Wiernikowski, Jennifer & Aronson, Jane & Miller, Pat & Gould, Judy & Fitzpatrick-Lewis, Donna, 2010. ""I like to be an informed person but..." negotiating responsibility for treatment decisions in cancer care," Social Science & Medicine, Elsevier, vol. 71(6), pages 1094-1101, September.

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