Helping patients to reach decisions regarding their treatment: Do 'non-directive' approaches cause systematic bias?

OBJECTIVES: Many patients want help in considering medical information relevant to treatment decisions they have to make or agree to. The present research investigated whether focussing on particular issues relevant to a medical treatment decision (using an apparently non-directive procedure) could systematically bias a treatment decision. DESIGN AND METHODS: In a randomized design, participants (community volunteers, n = 146) were given standard information about treatment of cardiac risk factors by medication (statins). There were four experimental interventions in which the participants focussed on the likely personal relevance of subsets of the information previously given (positive, negative, or mixed aspects) or on irrelevant information. Participants were asked to rate their anticipated likelihood of accepting treatment before and after the experimental intervention. RESULTS: The rating of acceptance of treatment was significantly increased by positive focussing; negative focussing did not significantly alter the decision rating. CONCLUSIONS: The results partially replicate similar studies in health screening decisions. Reasons for the differences in results from those obtained in screening studies are considered. It is suggested that negative focussing may have less effect in decisions in which there are few risks. Statement of contribution What is already known on this subject? Decision-making in the context of health behaviour change has been widely described, but there are few experimental studies testing hypothesised strategies. 'Non-directiveness' is often regarded as desirable because it supposedly allows exploration of the decision without influencing it. Previous studies on health screening (but not treatment) have shown that health decision outcomes can be systematically influenced by the way in which a 'non-directive' intervention is implemented. This can be accounted for by a modified subjective expected utility theory previously applied to both health screening and child vaccination decisions. What does this study add? The hypothetical decision about whether or not, in future, to take statins for elevated cholesterol levels was influenced by positive but not by negative focussing. Results were consistent with the theoretical framework. This study extends previous work on influences on the decision to undertake health screening and vaccination to treatment offered as secondary prevention. 'Non-directive' approaches to helping facilitate decisions can modify those decisions, and as such cannot be regarded as non-directive.

Valuing hope.

This article argues that hope is of value in clinical ethics and that it can be important for clinicians to be sensitive to both the risks of false hope and the importance of retaining hope. However, this sensitivity requires an understanding of the complexity of hope and how it bears on different aspects of a well-functioning doctor-patient relationship. We discuss hopefulness and distinguish it, from three different kinds of hope, or 'hopes for', and then relate these distinctions back to differing accounts of autonomy. This analysis matters because it shows how an overly narrow view of the ethical obligations of a clinician to their patient, and autonomy, might lead to scenarios where patients regret the choices they make.

Position statement on ethics, equipoise and research on charged particle radiation therapy.

The use of charged-particle radiation therapy (CPRT) is an increasingly important development in the treatment of cancer. One of the most pressing controversies about the use of this technology is whether randomised controlled trials are required before this form of treatment can be considered to be the treatment of choice for a wide range of indications. Equipoise is the key ethical concept in determining which research studies are justified. However, there is a good deal of disagreement about how this concept is best understood and applied in the specific case of CPRT. This report is a position statement on these controversies that arises out of a workshop held at Wolfson College, Oxford in August 2011. The workshop brought together international leaders in the relevant fields (radiation oncology, medical physics, radiobiology, research ethics and methodology), including proponents on both sides of the debate, in order to make significant progress on the ethical issues associated with CPRT research. This position statement provides an ethical platform for future research and should enable further work to be done in developing international coordinated programmes of research.

Physicians' duties and the non-identity problem.

The non-identity problem arises when an intervention or behavior changes the identity of those affected. Delaying pregnancy is an example of such a behavior. The problem is whether and in what ways such changes in identity affect moral considerations. While a great deal has been written about the non-identity problem, relatively little has been written about the implications for physicians and how they should understand their duties. We argue that the non-identity problem can make a crucial moral difference in some circumstances, and that it has some interesting implications for when it is or is not right for a physician to refuse to accede to a patient's request. If a physician is asked to provide an intervention (identity preserving) that makes a person worse off, then such harm provides a good reason for the physician to refuse to provide the intervention. However, in cases where different (identity-altering) interventions result in different people having a better or worse life, physicians should normally respect patient choice.

The ethics of attaching research conditions to access to new health technologies.

Decisions on which new health technologies to provide are controversial because of the scarcity of healthcare resources, the competing demands of payers, providers and patients and the uncertainty of the evidence base. Given this, additional information about new health technologies is often considered valuable. One response is to make access to a new health technology conditional on further research. Access can be restricted to patients who participate in a research study, such as a randomised controlled trial; alternatively, a new treatment can be made generally available, but only on condition that further evidence is collected (eg, on long-term outcomes and adverse events, in patient registries). The National Institute for Health and Clinical Excellence (NICE), which provides guidance on which new health technologies to make available under the UK's NHS, for example, has made some research conditional recommendations, and the current interest in such options suggests that they are likely to become more prevalent in the future. This paper identifies and discusses the main ethical issues created by this distinctive range of recommendations. We argue that decisions to put research conditions on access to new technologies are compatible with widely accepted values, principles and practices relevant to resource allocation. However, there are important features of these distinctive judgements that must be taken into account by resource allocation decision-making bodies and research ethics committees, and that require new sorts of empirical data.

Intensive care triage: priority should be independent of whether patients are already receiving intensive care.

Intensive care units (ICUs) are not always able to admit all patients who would benefit from intensive care. Pressure on ICU beds is likely to be particularly high during times of epidemics such as might arise in the case of swine influenza. In making choices as to which patients to admit, the key US guidelines state that significant priority should be given to the interests of patients who are already in the ICU over the interests of patients who would benefit from intensive care but who have not been admitted. We examine four reasons that in principle might justify such a prioritization rule and conclude that none is convincing. We argue that the current location of patients should not, in principle, affect their priority for intensive care. We show, however, that under some but not all circumstances, maximizing lives saved by intensive care might require continuing to treat in the ICU a patient already admitted rather than transferring that patient out of the unit in order to admit a sicker patient who would also benefit more from intensive care. We conclude that further modelling is required in order to clarify what practical policies would maximize lives saved by intensive care.

Threats and offers in community mental healthcare.

Making threats and offers to patients is a strategy used in community mental healthcare to increase treatment adherence. In this paper, an ethical analysis of these types of proposal is presented. It is argued (1) that the primary ethical consideration is to identify the professional duties of care held by those working in community mental health because the nature of these duties will enable a threat to be differentiated from an offer, (2) that threatening to act in a way that would equate with a failure to uphold the requirements of these duties is wrong, irrespective of the benefit accrued through treatment adherence and (3) that making offers to patients raises a number of secondary ethical considerations that need to be judged on their own merit in the context of individual patient care. The paper concludes by considering the implications of these arguments, setting out a pathway designed to assist community mental healthcare practitioners to determine whether making a specific proposal to a patient is right or wrong.

Anorexia nervosa and the language of authenticity.

People with anorexia nervosa struggle with questions of authenticity. They thought about whether they were being their authentic selves, and which of their desires, emotions, and choices were authentic. More attention should be paid this important concept and its role and status--both how patients think about it, and how clinicians should think about it.

Hippocampal neurofibrillary tangle changes and aggressive behaviour in dementia.

Neuropsychiatric behaviours occur frequently in Alzheimer's disease and other dementias and are thought to arise from the neurodegenerative process. However, it is unclear whether neurodegenerative changes in the hippocampus are associated with neuropsychiatric behaviours such as aggression. In this study, semiquantitative measurements of cell loss, atrophy, neuritic plaque and neurofibrillary tangle load in the postmortem hippocampus were taken for dementia patients, prospectively assessed for neuropsychiatric behaviours. It was found that increased tangle load, but not other hippocampal neuropathological variables, was associated with increased severity of aggressive behaviours and presence of chronic aggression. This study suggests a pathogenic link between neurofibrillary tangle load and aggressive behaviours in the hippocampus of dementia patients.

Attitudes of patients with anorexia nervosa to compulsory treatment and coercion.

BACKGROUND: The compulsory treatment of anorexia nervosa is a contentious issue. Research suggests that patients are often subject to compulsion and coercion even without formal compulsory treatment orders. Research also suggests that patients suffering from anorexia nervosa can change their minds in retrospect about compulsion. METHODS: Qualitative interviewing methods were used to explore the views of 29 young women concerning compulsion and coercion in the treatment of anorexia nervosa. The participants were aged between 15 to 26years old, and were suffering or had recently suffered from anorexia nervosa at the time of interview. RESULTS: Compulsion and formal compulsory treatment of anorexia nervosa were considered appropriate where the condition was life-threatening. The perception of coercion was moderated by relationships. What mattered most to participants was not whether they had experienced restriction of freedom or choice, but the nature of their relationships with parents and mental health professionals. CONCLUSIONS: People with anorexia nervosa appear to agree with the necessity of compulsory treatment in order to save life. The perception of coercion is complex and not necessarily related to the degree of restriction of freedom.

A serotoninergic basis for hyperphagic eating changes in Alzheimer's disease.

Hyperphagia and associated eating changes occur frequently in Alzheimer's disease (AD) and lead to considerable morbidity. However, the neurochemical basis for these neuropsychiatric behaviours is at present unclear. In this study, we measured serotonin transporters, 5-HT(1A), 5-HT(2A), and 5-HT(4) receptors using radioligand binding assays in the postmortem temporal cortex of a cohort of controls and AD patients longitudinally assessed for hyperphagia. We found significant decreases in 5-HT(4) receptor densities in the hyperphagic, but not normophagic, AD group. Our data suggest that 5-HT(4) receptor deficits may be a specific neurochemical correlate of hyperphagia, and point to the potential pharmacotherapeutic utility of 5-HT(4) agonists for these behaviours in AD.