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Letters “Informed choice” in a time of too much medicine

Informed choice involves many active skills

BMJ 2016; 354 doi: (Published 15 August 2016) Cite this as: BMJ 2016;354:i4363
  1. Philip Timms, consultant psychiatrist1,
  2. Jacob Bird, ST4 psychiatrist1
  1. 1START team, 1 St Giles House, London SE1 7UD, UK
  1. philip.timms{at}

We were intrigued by Johansson and colleagues’ notion that the process of informed choice might generate an over-medicalisation of life and health experiences. However, we had some problems with it.1

Firstly, the case scenario didn’t really illustrate a downside to informed choice, merely the danger of relying on a crude process of fitting patients to a diagnostic box rather than engaging actively. We question whether we’d “feel proud of ourselves” about starting by offering active treatment in such a case. We in the UK may sometimes feel encumbered by NICE guidelines, but, for the cardiac symptoms and the emotional distress presented, self help and lifestyle adjustment would be the first issues we’d discuss. This would involve information exchange, explanation, and some undramatic choices for the patient. Over-medicalising or empowering? You tell us.

We also question whether recording a diagnosis of depression in a person’s records necessarily has such toxic consequences that it generates an ethical problem. We don’t see that a diagnosis of “previously, medically treated hypertension” is any more or less likely to generate inappropriate medicalisation.

Regarding doctors being more “laid back,” we agree that doctors should “really listen” but would argue that this is much more active. It involves a number of very active skills that include listening, motivational interviewing, negotiating, and the willingness to explore sensitive areas of cultural difference. Only these can generate active, bidirectional engagement of doctor and patient. A few doctors seem to do these things almost automatically, but these skills mostly need to be actively learnt and maintained. Laid back? We think not.

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, collaborative relationship with the patient.



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