Intended for healthcare professionals


“Informed choice” in a time of too much medicine—no panacea for ethical difficulties

BMJ 2016; 353 doi: (Published 09 May 2016) Cite this as: BMJ 2016;353:i2230
  1. Minna Johansson, PhD student1 2,
  2. Karsten Juhl Jørgensen, senior researcher3,
  3. Linn Getz, professor4,
  4. Ray Moynihan, senior research fellow5
  1. 1Department of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
  2. 2Research Unit and Section for General Practice, FoUU-centrum Fyrbodal, Vänersborg, Sweden
  3. 3Nordic Cochrane Centre, Rigshospitalet, Copenhagen, Denmark
  4. 4General Practice Research Unit, Norwegian University of Science and Technology, Trondheim, Norway
  5. 5Centre for Research in Evidence Based Practice, Bond University, Australia
  1. Correspondence to: M Johansson minna.johansson{at}

Providing information to enable informed choices about healthcare sounds immediately appealing to most of us. But Minna Johansson and colleagues argue that preventive medicine and expanding disease definitions have changed the ethical premises of informed choice and our good intentions may inadvertently advance overmedicalisation

The idea of informed patients who make reasoned decisions about their treatment based on personal preferences is appealing in a Western cultural context, with its focus on the autonomous individual. Rightly, many doctors now reject paternalism if the patient does not specifically ask for it. They prefer to elicit the patient’s preferences and embrace an open discussion of risks and benefits of different options within a shared decision making approach.1 However, the rise of preventive medicine, the transformation of risk factors and common life experiences into diseases, and the lowering of diagnostic thresholds have changed the ethical premises of informed choice by pushing responsibility on to often ill prepared citizens.2 3 4 5 We call for careful reflection on the potential downsides of trusting informed choice to resolve ethical problems and complex value judgments in an era of “too much medicine.”6

New pathways to informed choices

When the clear cut needs of a patient to solve a health problem set the framework for the medical consultation, the ethics of informed choice can be fairly unambiguous. A patient with osteoarthritis consulting a doctor because of serious, long lasting knee pain that inhibits daily function may exemplify this. Most of us would appreciate being informed about the pros and cons of knee replacement surgery and other options, including doing nothing, and thereby being enabled to make an informed choice based on personal preferences. In such situations, informed choice is clearly better than previous paternalistic approaches. However, in medicine today, the path towards an informed choice is often far more tortuous. …

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