What Does the Evolution From Informed Consent to Shared Decision Making Teach Us About Authority in Health Care?

This article examines the legal doctrine and ethical norm of informed consent and its deficiencies, particularly its concentration on physician disclosure of information rather than on patient understanding, which led to the development of shared decision making as a way to enhance informed consent. As a vague and imprecise rubric, shared decision making encompasses several different approaches. Narrower approaches presuppose an individualistic account of autonomy, while broader approaches view autonomy as relational and hold that clinician-patient relationships grounded in good communication can assist decision making and foster autonomous choices. Shared decision making faces conceptual, normative, and practical challenges, but, with its goal of respecting, protecting, and promoting patients' autonomous choices, it represents an important cultural change in medicine.

From Doctors' Stories to Doctors' Stories, and Back Again.

Stories have always been central to medicine, but during the twentieth century bioscience all but eclipsed narrative's presence in medical practice. In Doctors' Stories, published in 1991, Kathryn Montgomery excavated medicine's narrative foundations and functions to reveal new possibilities for how to conceive and characterize medicine. Physicians' engagement with stories has since flourished, especially through the narrative medicine movement, although in the twenty-first century this has been challenged by the health care industry's business-minded and data-driven clinical systems. But doctors' stories-and Montgomery's text-remain crucial, schooling clinicians in reflection, ethical awareness, and resilience. Physicians who write even short, 55-word reflective stories can hold to humanistic and ethical understandings of patient care and of themselves as healers even as they practice in systematized settings and employ evidence-based expertise.

Samuel Beckett's "Rockaby": dramatizing the plight of the solitary elderly at life's end.

Irish playwright Samuel Beckett's spare, compact, and provocative play Rockaby (1981) is a study in old age, isolation, and disengagement from life. In it, an elderly woman rocks in a chair while the audience hears a distant voice remembering her lifelong search for human contact or communion. The play dramatizes the woman's intense physical and psychological isolation and the last sputterings of her impulse to narrate. Such radical isolation may be a necessary precondition for a person relinquishing the narrating that Beckett equates with being, and surrendering unto death. Despite its apparent simplicity, the play powerfully explores the nature of aging in contemporary society, quality-of-life issues for the frail, solitary elderly in our communities and health-care institutions, and how the elderly prepare for life's end in a death-denying culture. Rockaby is thus a text that can help clinicians and other caregivers appreciate the predicament of solitary elderly persons nearing life's end and better understand how we all must manage one day the lonely, self-abnegating yet also paradoxically self-assertive act of dying.