Each of us in many ways may wittingly or unwittingly, intentionally or unintentionally, for better or worse, not only convey information but also influence those we speak to. Knowing this, conscientious individuals strive against the sources of distortion in order to enfranchise decision-makers. Therefore, that the authors think informed decision-making less important where evidence of benefit is good than where the benefits and harms are more equally balanced, as a service user I find disturbing, even where I might if they showed it to me accept that the evidence is indeed good. Even more frighteningly, they think it in these circumstances acceptable to “go beyond simply sharing information” to “endeavour to change beliefs or promote behavioural change”.

A health consultation is between relative strangers, however longstanding their association. Even my mother can’t say with absolute certainty “I knew you’d make that decision”, a fortiori the doctor can’t, and my mother would know better than to act on such a prediction, however confident she was, for the simple reason that the decision is mine, not hers. Of course she makes me tea without asking, but she doesn’t make my health decisions. A fortiori, it is not acceptable for a doctor to do so. Nothing is always good for everyone, and there are always costs; it is not for the professional to second guess my choices.

“Good evidence of the benefits of an intervention” cannot in my view license the “aim to go beyond simply sharing information and endeavour to change beliefs or promote behavioural change.” The authors themselves say that informing to facilitate decision-making “may be at odds with apparent ‘public health’ messages that may, for example, promote uptake of screening tests to achieve programme effectiveness at population levels. However, the clinician should accept that the final decision depends as much on the patient’s own values as it does on the risk information presented.” No conscientious practitioner could deny that an individual who risks harm for the sake of some benefit should be adequately informed even if doing so threatens service providers’ ambitions. Talk of “changing beliefs” is ambiguous: conscientious communication involves dispelling misconceptions, but to positively aim to change my judgments I find overbearing - communication aims to enable the other person, not to bring about an outcome the professional wants, however benign s/he may think it. If an intervention demonstrably achieves something many people want at a cost many people will stand it is likely that informing someone disinterestedly will bring about the expected decision; but this is consistent with its not doing so in some cases, and it is most important for practitioners not to disenfranchise these by presumptuous anticipation let alone by actively steering them towards their own favoured choice.

The default position must be disclosure of information that could affect decisions. How could Mrs Jones not need to know about the weakness of the research and the lack of evidence of mortality benefit? Would the authors accept less when considering health interventions for themselves?

Competing interests: Harmed by being misinformed about benefits and risks of mammography screening.

This is a useful review. However, it is a pity that the word "risk" seems to have different meanings in different sentences. This can clearly be seen in the definitions of risk and risk communication in the second paragraph: "Risk is the probability that a hazard will give rise to harm" and "Risk communication should therefore cover the probability of the risk occurring". How can a risk occur if it is a probability?

Finally, I suggest that the authors do inform Ms Jones by how much mammography reduces her risk of dying from breast cancer and not that “mammography would reduce her risk of breast cancer by 15%”; mammography evidently increases her risk for being diagnosed with breast cancer.

Competing interests: None declared