Letter

Shared Decision Making: Whose Decision?

To the Editor: In the August Taking Issue commentary, Drake and Deegan ( 1 ) framed shared decision making as a moral imperative for mental health services. According to this view, traditional providers must move beyond paternalistic approaches to treatment and offer decision aids and supports to help people with mental illnesses choose among service options. It levels the field of interaction, so that mental health professionals set aside authority and partner with service consumers to decide about treatment options. We believe shared decision making does not go far enough. It does not convey to the person with mental illness that his or her decision "trumps" the preferences and choice of the provider—that is, the person with mental illness has ultimate control over life choices and treatment options.

Joint decision making is a relatively easy enterprise when patient and mental health professional agree on overall direction and activities. It is when they disagree that shared decision making is limiting. Consider times when the psychiatrist believes medication is needed but the individual wishes instead to stop.

Leaving the ultimate choice up to the person with mental illness makes anecdotal sense, at least in terms of general medical care. Modern medicine has broadened physician roles to include those of educator and counselor, providing information patients need to decide about treatments and offering support as these treatments proceed. For example, the person treated for lymphoma is fully informed about the cancer's prognosis as well as the medical, surgical, and alternative approaches to the illness. In many cases, a single health care professional is unable to fully present the broad range of related information. The patient weighs the costs and benefits and then selects a treatment. In mental health care, self-determination is fundamental to a recovery-oriented system. Sometimes the mental health professional's role is limited to providing information and support while the person opts to move in a different direction. Professionals can be uncomfortable on the sidelines because they know that relapse and failure are not infrequent outcomes for persons with serious mental illnesses. But forestalling failure robs individuals of the dignities of risk and discovery.

Our point is by no means foreign to Drake or Deegan. Patricia Deegan has been writing eloquently about personal empowerment and recovery for more than 30 years ( 2 ). Robert Drake is a leading innovator in practices that promote recovery. Individual Placement and Support (IPS), an example of supported employment developed and championed by Becker and Drake ( 3 ), is a model of leaving the ultimate choice to the person with mental illness. The IPS participant has primary authority in deciding on vocational goals and the methods to achieve these goals. For example, when Mr. Smith opts for law school but has only a high school diploma, the IPS job coach may believe that the goal exceeds Mr. Smith's capacities but nonetheless provides comprehensive support and guidance about pursuing and obtaining a law degree. Research on IPS shows that this kind of final determination is fundamental to successful vocational rehabilitation.

At the core, we may be framing shared decision making and leaving the ultimate choice to the patient as categorically distinct when there is clear overlap. An additional moral imperative, therefore, is a research agenda that examines the intersection of the two constructs.