Intended for healthcare professionals

Editor's Choice

Shared decisions

BMJ 2010; 341 doi: (Published 08 December 2010) Cite this as: BMJ 2010;341:c7089
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}

Two months ago in this journal, Angela Coulter sounded a warning bell about efforts to provide more choice for patients (BMJ 2010;341:c4989). Her main concern was the gulf between what patients say they want and what doctors think they want. Some patients may want to switch providers, but many more want greater involvement in deciding which treatment would suit them best. If competition and choice are to drive improvements in healthcare, clinicians need to engage patients in these decisions, she said.

This week, Martin Marshall and Vin McLoughlin take up the tolling of the bell (doi:10.1136/bmj.c5272). They think that competition policy is based on false assumptions about how people make healthcare decisions. In the idealised rational model of decision making beloved of traditional economists, people seek out comparative information and weigh the pros and cons of each option. But healthcare decision making is more a social process than a cognitive one. Providing good comparative information is important in its own right, the authors say. But it’s unlikely to deliver concrete or immediate improvements in quality of care.

One decision that ought to have a rational basis is when to retract a paper. But guidelines are variously inadequate, and editors differ in how they interpret them, finds Melanie Newman in her report (doi:10.1136/bmj.c6985). The paper in question has been around for some time. Published in the Journal of the American Academy of Child and Adolescent Psychiatry in 2001, it concluded that paroxetine was safe and effective for adolescents with depression. But internal documents from the drug’s manufacturer, GlaxoSmithKline, show that this rosy picture was only achieved when new secondary outcomes were analysed and reported in place of the primary ones, and that this was done in order to “minimise any potential negative impact” of the data. The paper was commissioned from a medical communications company and written by one of their employees, but this was not disclosed. It was used to support GSK’s marketing campaign before regulators banned the drug in under 18s. It has been cited more than 200 times.

The editor of the journal says the paper met best publication practices at the time it was published and sees no evidence of scientific error to justify retraction. Publishing guidelines and gurus seem to support this decision. Liz Wager, chair of the Committee on Publication Ethics (COPE) agrees that the paper is part of a “conspiracy of hope” that has tended to give new drugs the benefit of the doubt. But she warns that cases should be judged on the transparency standards of the day, otherwise, agrees her predecessor Harvey Marcovitch, “you’d be constantly retracting.” As Marcovitch’s predecessor on COPE, I think that may not be such a bad thing and I’m glad he thinks that current guidelines are “arguably…a bit feeble.” And this is where you come in. Our poll on this week invites you to vote on whether this paper should now be retracted or not. I can’t promise that your views will have any influence but it will be interesting to hear them.


Cite this as: BMJ 2010;341:c7089


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