Understanding risk and lessons for clinical risk communication about treatment preferences

Informed consent: moral necessity or illusion?

There is a professional and legal consensus about the clinical duty to obtain informed consent from patients before treating them. This duty is a reflection of wider cultural values about the moral importance of respect for individual autonomy. Recent research has raised practical problems about obtaining informed consent. Some patients have cognitive and emotional problems with understanding clinical information and do not apparently wish to participate in making decisions about their treatment. This paper argues that such research does not undermine their potential to provide informed consent. Rather, sufficient resources are required to create better communication skills among clinicians and more effective educational materials for patients. Finally, cognitive and emotional inequality among patients is maintained to be a reflection of wider social and economic inequalities. Researchers who take the right to informed consent seriously should also address these.

Understanding patients' preferences for treatment: the need for innovative methodologies

Treatment selection is now much more consumer driven than in the past. However, there is a need to develop investigative methodological approaches that are sensitive to differences in patient preferences if full account is to be taken of what the patient sees as the best option in terms of different possible treatments available for a particular condition. Previous attitude research has been criticised because it does not provide insight into reasons why people hold different preferences or beliefs. A methodology is described which allows people to describe their concerns and values associated with different treatment options in their own words. This is the repertory grid method of eliciting personal constructs used in conjunction with generalised Procrustes analysis (GPA). An example of the use of this methodology is provided, drawn from research directed towards understanding people's beliefs about genetic technologies. A possible application of the method to understanding treatment preferences related to type 2 diabetes is also discussed. It is concluded that the use of innovative methodologies is essential if our understanding of patient preferences regarding treatment options is to have a significant impact on patient quality of life.

Differences in belief about likely outcomes account for differences in doctors' treatment preferences: but what accounts for the differences in belief?

Doctors, patients, and their relatives face a complex decision when there are multiple treatment options that differ in their profiles of risk and benefit over time. Doctors from a single specialist paediatric cardiac unit participated in a correlational study that used a novel tool (subjective multi-state survival graphs) to elicit their beliefs about the likely outcome of different treatments. Doctors' preferences were more closely related to their beliefs about long term, rather than short term, outcomes. This is consistent with placing greater value on far future than on immediate life years, highlighting the importance of incorporating patients' values for these outcomes into decisions of this kind. Beliefs about likely outcomes differed with whether or not doctors encountered former paediatric patients who were now adults, illustrating the difficulty of deciding what risk information should be available when the evidence base on outcomes is limited. Some problems of risk communication are identified, and the value of multi-state survival graphs as an aid to communication is discussed.

The extent of patients' understanding of the risk of treatments

The scientific understanding of how people perceive and code risks and then use this information in decision making has progressed greatly in the last 20 years. There is considerable evidence that people employ simplifying heuristics in judgement and decision making. These heuristics may lead to bias in how people interpret information. However, much of our understanding of risk perception is based on laboratory studies. It is much less clear whether risk perception in the real world (as in the case of medical treatments) exhibits the same patterns and biases. This paper reviews the published literature on risk perception in patients who face substantial treatment risks. It examines how accurate patients' perception of risk is, what factors affect the perception of risk, and several possible explanations for why patients' risk perception is not always accurate.