Intended for healthcare professionals


Power imbalance prevents shared decision making

BMJ 2014; 348 doi: (Published 14 May 2014) Cite this as: BMJ 2014;348:g3178
  1. Natalie Joseph-Williams, research associate1,
  2. Adrian Edwards, professor1,
  3. Glyn Elwyn, professor and senior scientist2
  1. 1Cardiff University, School of Medicine, Cochrane Institute of Primary Care and Public Health, Cardiff, UK
  2. 2Dartmouth Center for Healthcare Delivery Science and the Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, NH, USA
  1. Correspondence to: N Joseph-Williams josephnj1{at}
  • Accepted 1 May 2014

Providing information is not enough to enable shared decision making, argue Natalie Joseph-Williams and colleagues. Action is required to change the attitudes of both patients and doctors


Adoption of shared decision making into routine clinical settings has been slow.1 Large scale implementation programmes in the UK have delivered valuable lessons on how best to embed shared decision making,2 3 4 5 but few programmes have actually considered what helps or stops patients from being involved in healthcare decisions. Organisational and clinician perceived barriers are important,1 3 6 but shared decision making is unlikely to become the norm if we do not also deal with the barriers that patients perceive. Our recent systematic review of patients’ perceptions highlighted deeper rooted attitudes that need to be changed in order to prepare patients for a new type of clinical encounter.7 Here we highlight the main findings and discuss how to prepare patients for shared decision making.

Patients find it hard to speak up

There is good evidence that attitudinal barriers are hindering progress in implementing shared decision making.1 7 Even when patients are well educated and well informed, many still find it difficult to use this knowledge to participate meaningfully in decisions about their healthcare.8 The Francis report into failings at Mid Staffordshire trust revealed that patients often feel prohibited from speaking up, even when they are extremely concerned about safety or the quality of care they are receiving.9 Online blogs, publications, and social media campaigns (such as #hellomynameis)10 show that even doctors are not immune to the power imbalance when they become patients, feeling that they represent a disease rather than that they are an individual and aware of a pressure to be compliant and passive.10 11 12 How then can we expect people to express their preferences about …

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