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

Semantic pitfalls preclude “Informed choice”

Johansson et al’s ethical concerns for “informed choice” about healthcare warrant comment as basic prerequisites are too poorly implemented.

First, evidence-based tools providing simple pictographs that use absolute numbers with a consistent denominator (ie. /1000 persons), time frames, and visuals employing the same scale for information on gains and losses of the options are too rarely available.(2)

Second, even the simple 4-steps method is rarely implemented by healthcare professionals: 1) Indicate that all options are acceptable; 2) administer the information (as above); 3) promote active participation of the person by the expression of his or her values; 4) analyse if the person is comfortable with the decision by rephrasing.(3)

Third, a critical issue for balanced information is independency.(4) Initiatives such as the Patient-Centered Outcomes Research Trust Fund ( and the Harding Center for Risk Literacy ( must be pledged.

Last, but not least there is a major semantic misconception. Indeed, Johansson et al, in the introduction called for “open discussion of risks and benefits of different options.” This wrongly suggests that benefits are definite while harms are not. Accordingly, appropriate wording should be “risks of harm and potential for benefit” or “harm-to-benefit ratio”. This is a major problem: Pubmed searches hit 2610 for "benefit-risk ", 1218 for "benefit risk ratio", 1103 for “benefit/risk” vs only 7 for "potential benefit" AND "risk of harm", 17 for "benefit-harm ratio".

1 JohanssonM, Jørgensen KJ, Getz L, Moynihan R. “Informed choice” in a time of too much medicine—no panacea for ethical difficulties BMJ 2016; 353 :i2230.

2 Johansson M, Brodersen J. Informed choice in screening needs more than information. Lancet 2015;385:1597-1599.

3 Braillon A, Bewley S. Shared Decision-Making for cancer ccreening: Visual tools and a 4-Step Method. JAMA Intern Med 2015;175:1862.

4 Barry MJ. The prostate cancer treatment bazaar: comment on ‘‘Physician visits prior to treatment for clinically localized prostate cancer’’. Arch Intern Med. 2010;170:450-2.

Competing interests: No competing interests

12 May 2016
alain braillon
senior consultant
University Hospital. 80000 Amiens. France