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Analysis

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

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2230 (Published 09 May 2016) Cite this as: BMJ 2016;353:i2230

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

Dear Sir

We read Johansson et al’s article and found ourselves intrigued with the central notion that the process of informed choice might be generating an over-medicalisation of ordinary life and health experiences. However, we had some problems with it.

Firstly, the case scenario did not really illustrate a downside to informed choice, merely the danger of relying on a crude process of fitting a patient to a diagnostic box rather than engaging actively with him or her. We seriously question whether we would really “feel proud of ourselves” about starting with an offer of active treatment in such a case. We in the UK may sometimes feel encumbered by NICE guidelines but it is clear that for us, for both the cardiac symptoms and emotional distress presented, self-help and life-style adjustment would be the first issues to discuss. This would involve a process of information exchange, explanation and some rather un-dramatic choices for the patient to make. Over-medicalising or empowering? You tell us.

We also take issue with the notion that recording a diagnosis of depression in a person’s records necessarily has such toxic consequences that it generates an ethical problem in making the diagnosis. We don’t see that a diagnosis of “previously, medically treated hypertension,” is any more or less likely to generate inappropriate medicalisation. On a personal note, PT has had a diagnosis of depression which has been medically treated, shared with 4 million people on a television programme (watched by some of his patients) and which has proved never to be any kind of burden or difficulty.

Lastly, the notion that the answer to over-diagnosis is for the doctor to be bit more “laid-back”. We agree that doctors need to “really listen” but would argue that it is much more active than the glib invocation offered here. It involves a number of very active skills that include active listening, motivational interviewing, negotiating and the willingness to explore sensitive areas of cultural difference. Only these can generate an active and bi-directional engagement of doctor and patient. There are a few doctors who seem to do these things almost automatically - but for most of us these are skills that need to be actively learnt and maintained. Laid back? We think not.

So, aside from their stigmatising comments about psychiatric diagnosis and their naive comments about conversational interventions, it seems to us that the authors have, like Don Quixote, tilted at a windmill. The villain of the piece is not informed choice but a reliance on diagnosis to the exclusion of an active and collaborative relationship with the patient.

Dr Philip Timms FRCPsych
Consultant psychiatrist, START team, 1, St Giles House, London SE1 7UD
South London & Maudsley NHS Trust

Dr Jacob Bird MRCPsych
ST4 psychiatrist, START team, 1, St Giles House, London SE1 7UD
South London & Maudsley NHS Trust

Competing interests: No competing interests

17 June 2016
Philip W Timms
Consultant psychiatrist
Jacob Bird
South London & Maudsely NHS Foundation Trust
START team, 1 St Giles house, St Giles Road, London SE5 7UD