Toward a Shared Decision: Against the Fiction of the Autonomous Individual

Abstract

Western, specifically American, medical ethicists, in a reaction against a particular narrative of medical paternalism, have called for the use of a shared decision making process. Increasingly, this process is primarily aimed at honoring the autonomy of the patient. However, the concept of autonomy invoked often assumes an isolated, idealistic, individual deciding amongst neutral options from an objective position free from all biases. However, such an individual original position is fictional. American physicians, complicit in this false assumption, have been reduced to providers of options instead of givers of guidance. This paper describes a better path to achieve a shared decision that respects and serves patients. It urges physicians to employ an appropriate degree of directiveness. Further, it argues that one may enhance the true autonomy of patients by engaging their rich contextual influences and biases. This will include communal decisions, decisions that include the family or other significant community. The common experience of communal decision making amongst certain families and religious communities in the United States are positive examples. Using the frame of end-of-life care decisions, including considerations of decision burden and bereavement, the superiority of family or community oriented decision-making is explored with arguments of inherent value and positive potential consequences.