Authors' response: “Informed choice” in a time of too much medicine—no panacea for ethical difficulties
We endorse the preference of Dr Timms and Dr Bird for life-style adjustments as the first issues to discuss over what they consider “active treatment” (i.e. medication). However, the time needed to promote such a strategy is not necessarily available to the general practitioner, which makes it attractive to resort to medicalisation. Additionally, few patients succeed in lowering their blood pressure or blood lipids below the values recommended in guidelines through changes in lifestyle, at least in the longer term, and therefore eventually end up discussing medical treatment.
Furthermore, even if medical treatment is never discussed we still find the process of informed choice ethically complicated; we have still (often unrequested) informed our patient about her risk of getting a heart attack if the blood lipids are increased, or a fracture in the case of osteoporosis. We feel we as doctors do not take adequate responsibility for the possible consequences of providing such information.
We are glad to hear that Dr. Timms has not personally experienced stigmatization due to public awareness about his diagnosis of depression, but doubt that this experience can be generalized. Abundant evidence suggests that many diagnoses are associated with stigmatization and impacts personal perception of health and wellbeing. Qualitative studies indicates that being labeled with a diagnosis of asymptomatic osteoporosis,(1) hypertension,(2) hyperlipidemia(3) or abdominal aortic aneurysm(4) can have substantial effects on quality of life, and having a false positive mammogram have measurable psychosocial consequences even after 3 years.(5) Such consequences of labeling are particularly problematic since many diagnoses that we apply today are not clear-cut labels of unambiguous conditions. For example, science cannot provide an answer to whether symptoms of stressful life circumstances should be defined as depression or not, or what level of blood lipids that should be defined as hyperlipidemia, these are value-based decisions. This becomes evident when considering that according to guidelines, 84% of the adult population in Norway, one of the healthiest populations in the world, are labeled as having an increased CVD-risk, i.e. only 16% of the population have a “normal” CVD-risk.(6) In the case of depression, such aspects has also been intensively debated.(7)
We would thus respectfully disagree with Dr. Timms and Dr. Bird and assert that it is quite unlikely that our analysis paper create stigmatization. This is created by societal structures that are difficult, but necessary, to change. Not highlighting the problem of stigmatization out of concerns that this would lead to more stigmatization is a mistake.
We certainly do not argue that the process of “informed choice” is the main cause of medicalisation, only that it can inadvertently legitimize it in the mind of the therapist. There is a tendency today to provide patients and citizens with information that they have not asked for by offering “informed choices” about treatment options or screening participation.(8) Offering choices is perceived as the ultimate respect for individual autonomy. We argue that this focus on providing information and offering choices may sometimes drive doctors into a pathway of diagnostic cascades and medicalisation and that the role of “informed choice” in medicine today needs deeper analysis.
We are not arguing against the notion that doctors should facilitate informed decisions based on patient’s personal preferences or a “collaborative relationship with the patient”. “Laid back” in our paper thus refers to having a less aggressive approach to providing diagnoses and medication, not towards involvement with the patient - on the contrary. As we see it, Dr. Timms and Dr. Bird agree with this assertion.
Minna Johansson, PhD student, University of Gothenburg
Karsten Juhl Jørgensen, senior researcher, Nordic Cochrane Centre
Linn Getz, professor, Norwegian University of Science and Technology
Ray Moynihan, senior research fellow, Bond University
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Competing interests: No competing interests