Intended for healthcare professionals

Rapid response to:

Editor's Choice

In the patient’s best interests? Who says?

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5920 (Published 05 November 2015) Cite this as: BMJ 2015;351:h5920

Rapid Response:

Patient knows best

Dear Dr. Godlee,

Thank you for this thought-provoking issue of the BMJ and in particular your insightful Editorial titled “In the Patient’s Interests. Who says?” We have been considering the very same issues for some time now (1-5) in attempting to understand what is truly patient-cented care and how it can be practised, realistically, within the constraints of our healthcare system. To this end, we have proposed a model of patient care that aims to support clinicians to deliver care that is truly in the best interests of the patient and driven by the patient themselves (4 6). We are currently testing this model out; we have found dentistry a perhaps less complicated vehicle than medicine (where e.g. important care decisions are less likely to have the far reaching life and death implications that may appear in medicine) and as such our efforts are now concentrated in this field (4 5 7).

In this model we have proposed that a combination of information and choice should be offered to all patients regardless of the condition we are treating so that the patient who, after all is an expert in their own life, can make decisions that are right for them. Given enough, high quality, unbiased information and choice and the tools to evaluate this information and options available, we have suggested that patients will make the right decision all the time every time. In putting forward this ‘controversial’ view, we have become aware of the very dilemma that you are posing in your Editorial. What do you do when the patient “is wrong”? What happens if the patient believes they want care that Health-Care Professionals (HCPs) think is not in their patients’ best interests? What do you do when patients choose the less well-suited to their condition treatment choice?

Faced with these decisions, we are reminded of the great principle of self-preservation. People are naturally tuned to make choices about their health that will ensure their survival. Taking this argument to its extreme, Dawkins’ (8) work would suggest that as machines that our genes have invented to perpetuate their own existence, there is one thing that we will universally strive for and that is, our on-going survival and withdrawal from damaging situations. Thus, on the basis of self-preservation and Selfish Gene principles we propose that patients will always make the decision that is right for them. So the difficulty does not lie with the patient’s choice. It lies, we believe, with the HCP and their, perhaps questionable belief that somehow the HCP understands the patient’s condition better than the patient themselves and as such, is the better decision-making partner in a healthcare partnership.

We say that given enough information about health and illness and realistic choice amongst all possible alternatives (to include that of choosing to decline treatment – an option that some HCPs might struggle with) patients, guided by Selfish Genes and self-preservation will always make the ‘right’ choice that is the right decision for them, within their own context.

Yours,

Dr. Koula Asimakopoulou, Reader in Health Psychology
Dr. Sasha Scambler, Senior Lecturer in Sociology
King’s College London.

References

1. Asimakopoulou K, Gilbert D, Newton P, et al. Back to basics: Re-examining the role of
patient empowerment in diabetes. Patient education and counseling 2012;86(3):281-3.
2. Asimakopoulou K. Empowerment in the self-management of diabetes: are we ready to test
assumptions? European Diabetes Nursing 2007;4(3):94-97.
3. Asimakopoulou KG, Newton P, Scambler S. ‘First do no harm’: the potential shortfalls of
empowerment in diabetes. European Diabetes Nursing 2010;7(2):79-81.
4. Scambler S, Asimakopoulou K. A model of patient-centred care - turning good care into
patient-centred care. British dental journal 2014;217(5):225-8.
5. Asimakopoulou K, Gupta A, Scambler S. Patient-centred care: barriers and opportunities in
the dental surgery. Community Dent Oral Epidemiol 2014;42(6):603-10.
6. Asimakopoulou K, Scambler S. The role of information and choice in patient-centred care
in diabetes: a hierarchy of patient-centredness. European Diabetes Nursing
2013;10(2):58-62.
7. Scambler S, Gupta A, Asimakopoulou K. Patient-centred care - what is it and how is it
practised in the dental surgery? Health expectations : an international journal of public
participation in health care and health policy 2014.
8. Dawkins R. The Selfish Gene. Oxford: Oxford Paperbacks, 1989.

Competing interests: No competing interests

06 November 2015
Koula Asimakopoulou
Reader in Health Psychology
Dr Sasha Scambler
King's College London
Floor 18 Guys's Tower, Guy's Hospital