Oleksandr Dubov is a Research Education Institute for Diverse Scholars (REIDS) Fellow with the Yale Center for Interdisciplinary Research on AIDS and a PhD candidate in healthcare ethics at Duquesne University. His most recent research is on the ethics of persuading patients to pursue certain treatments and how physicians should navigate that tricky territory. The News spoke with Dubov to hear his thoughts on standard practice of decision-making in critical care, the power of framing information and how doctors should responsibly use that power.
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What problems does your paper seek to address?
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I try to examine decision-making in the critical care context by looking at the standard decision-making theory in medical care and how it comes into reality. There are many assumptions in the [shared decision-making] model. For example, the standard assumption in medical ethics is that you provide the patient all the information and act in the best interest of the patient. If you don’t do this, you can’t protect their autonomy. However, the research in social psychology shows that there may not be consistent decision-making.
Q
Do you think there is anything that can be improved about the current decision-making model?
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Yes. I think there are two understandings of shared decision making — a narrower understanding and a broader understanding. In a narrower understanding of shared decision making, there’s a strict division of labor between the patients and the medical providers. Doctors bring medical information, families bring values and values are matched to the information. Here, the emphasis is on autonomous decisions. In the broader understanding, the emphasis is on enabling the patients and their families to participate. The division of labor is less strict, and the process is more open-ended. In the broader understanding, the doctors take the patients personally.
In the narrower understanding, you assume that the patients and the families can understand information about options, and that they can make decisions independently. In a broader understanding of shared decision making, you believe that expressing preferences is a collaborative process. This [broader understanding] is what I try to explore more.
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Are you suggesting that doctors should play a more active role and be more than information providers?
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Yes. I think what I try to do is to show that no matter whether they want it or not, clinicians always influence choice in the decision-making process. If we know that we do have an influence, why don’t we be more confident about it and use it in a more positive way? There are two types of cases when influence can be put into practice. The first type is when there is clearly one medically beneficial choice. For example, when you break an arm, there’s clearly one choice: You have to be cast. There are some other cases when it is less clear what options are more beneficial. In these cases, clinicians should be aware of the fact that patients make some predictable mistakes. They use some shortcuts in the decision-making that might, in the long run, hurt them or not be conducive to their values. While soliciting values in those cases may not be ethical [for the clinicians], what is ethical is to alert the patient of the mistakes they may make, and to help them avert biases.
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As a medical ethicist, was there a case that made a strong impression on you?
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Yes, a couple. I can think of an example of a university professor. She was 70 years old and she had a critical situation. She could recover after long rehab, and she could eventually live with her family. But she definitely could not go back to her own house because of concerns for care provision, and she was definitely not going to go back to teach. In communication with her clinician, she showed her hesitation to have the rehab. She was worried that she could no longer connect socially and intellectually to people. She rejected getting the rehab because she said that she did not want to have this kind of life. After a long consultation, she chose to have the rehab.
Q
This paper is part of your dissertation. What other areas of the patient-doctor relationship and medical ethics are you exploring? Do you want to develop this into a full model of decision making in critical care?
A
What I want to do is to examine the assumptions people make in medical ethics. For example, one of the assumptions is that people are rational, that people make rational choices. The second assumption is that patients and families know their preferences. They have values and they bring them to the table. As long as you provide the information, they can make an autonomous choice. People assume that even if patients make errors, these errors are not systematic. But behavioral economics have shown that there are some predictable errors that people make that hurt people in the long run. What I want to do perhaps is to explore those patterns and to see how they apply to medical ethics.