Letter

Shared Decision Making

To the Editor: In their November Open Forum, Deegan and Drake ( 1 ) call for a shared decision-making process in prescribing medication instead of the traditional authoritarian compliance process. They argued that deciding to take medication is a complex decision that needs to be processed with the patient. They even mention that clinicians who make decisions for patients may be acting unethically unless it is an emergency.

Although these authors state that there may be situations such as emergencies in which shared decision making may not fully apply, they seem to ignore situations in which it should generally not apply at all. Specifically, patients from some cultural backgrounds expect the physician to tell them what medication to take. In such cases, should the physician ask them for their opinion, they may view the clinician as incompetent ( 2 ). Hmong patients who are not acculturated to mainstream values in the United States constitute one such group. The same is true of other recent immigrants or refugees who are used to a paternalistic society. In some cultural groups, it is also common for certain people in the family to make health decisions for others in the family.

Therefore, although Deegan and Drake's strategy may well apply to most mainstream, acculturated Americans (perhaps with the exception of those who have strong dependent personality traits), it will not be applicable cross-culturally. Cultural competence will call for a more adaptable prescribing practice. Individual prescribers can try to adjust their level of paternalism on the basis of their cross-cultural knowledge and an assessment of the degree of acculturation of the individual patient. A question as simple as "Would you like to know more about this medication?" may help.

Medication prescribing is even more complicated than Deegan and Drake indicate if cultural background is taken into account.