Intended for healthcare professionals


Shared decision making in a publicly funded health care system

BMJ 1999; 319 doi: (Published 18 September 1999) Cite this as: BMJ 1999;319:725

Policies exist to reduce the risk of conflict between individual and society

  1. Mark J Sculpher, senior research fellow, Centre for Health Economics (,
  2. Ian Watt, professor of primary and community care,
  3. Amiram Gafni, professor
  1. University of York, York, YO10 5DD
  2. Centre for Health Economics and Policy Analysis, Department of Clinical Epidemiology and Biostatistics at McMaster University, Hamilton, Ontario, Canada

    Imagine you are a general practitioner. A middle aged male patient of yours has taken a cholesterol test at a pharmacy which showed raised concentrations and wants to discuss his treatment options. Following sound evidence1 and national guidelines,2 you tell him that, because he has no other risk factors, medical intervention is not warranted. However, the patient knows that recent trial evidence shows that statins can reduce cardiac events even in populations with mildly raised total cholesterol concentrations.3 You know that such use could greatly increase the cost of such drugs—to as much as £3.5bn in England,4 from £113m in 1997.1

    You support shared decision making with patients,5 6 but you recognise the dilemma here: should you see yourself as the agent of the patient, focusing on the effectiveness of treatments, or of the healthcare system and the population it serves, focusing on affordability?

    If you choose the system perspective there is more scope for conflict between you and the patient about the treatment of choice. In some cases conflict can arise because the patient's choice is likely to affect …

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