A Call for Community-Shared Decisions

Shared decision-making in medicine is widely viewed as a collaboration between the patient and the clinician. For example, Montori et al state, 'The patient and clinician must collaborate to arrive at a useful formulation of the problem'. Patients are encouraged to evaluate care choices in light of the benefits and harms of each, state their preferences and identify the best course of action along with their doctor. Despite its broad reach, shared decision-making solely between a patient and doctor has clear limits. Over 30 years ago, Brock and Wartman cautioned that '[p]atients do not have an unqualified right to make even rational individual choices that risk serious harm to others'. Elywin et al noted that 'limits on shared decision-making will occur when… wider interests overrule individual wishes'. These authors lay out problems with shared decisions for antibiotics, opioids and vaccine hesitancy. A crucial gap is how to address these problems in practice.

Antibiotic-resistant bacterial infections, overdoses from diverted opioid pills and the resurgence of measles are all medical problems that affect an individual through actions others in the community have taken. Here cooperation has either failed or has not been attempted at all. Lack of cooperation occurs when individuals believe it is in their best interest to deviate from the action that they would like others to take. While various forms of cooperative behaviour exist in the wild (eg, a large number of individuals choose to recycle, vote, tip at restaurants and donate to charity), there are barriers to cooperation in medicine that require special attention. Two of the biggest barriers are a lack of awareness that cooperation is needed and the implementation of approaches to encourage cooperation.

To address barriers, community members benefit from working towards a resolution on a common strategy that each will follow so that each will benefit. Reaching this resolution is a 'community-shared decision'. The common strategy involves agreeing on changes to the clinical environment that will persuade individuals to behave cooperatively. Preferably, the common strategy would encourage cooperation while maintaining freedom of choice so that individual preferences are respected. A community-shared decision carries a different relationship to value than does a standard medical-shared decision. In a standard shared-medical decision, we must elicit preferences to understand value. In contrast, there are clear objectives for community-shared decisions that will increase value for the decision-maker. We know that if others increase their antibiotic use, our value goes down because our own chances of successful treatment decrease. We also know that if vaccination among others increases, our own values go up, since our own chance of avoiding disease exposure increases. What matters most from a value standpoint is that we all adopt a shared strategy to realise benefits and prevent losses.