The decision-making process for breast reconstruction after cancer surgery: Representations of heterosexual couples in long-standing relationships

Behaviour, barriers and facilitators of shared decision making in breast cancer surgical treatment: A qualitative systematic review using a 'Best Fit' framework approach

BACKGROUND

Due to the diversity and high sensitivity of the treatment, there were difficulties and uncertainties in the breast cancer surgical decision-making process. We aimed to describe the patient's decision-making behaviour and shared decision-making (SDM)-related barriers and facilitators in breast cancer surgical treatment.

METHODS

We searched eight databases for qualitative studies and mixed-method studies about breast cancer patients' surgical decision-making process from inception to March 2021. The quality of the studies was critically appraised by two researchers independently. We used a 'best fit framework approach' to analyze and synthesize the evidence.

RESULTS

Twenty-eight qualitative studies and three mixed-method studies were included in this study. Four themes and 10 subthemes were extracted: (a) struggling with various considerations, (b) actual decision-making behaviours, (c) SDM not routinely implemented and (d) multiple facilitators and barriers to SDM.

CONCLUSIONS

Patients had various considerations of breast surgery and SDM was not routinely implemented. There was a discrepancy between information exchange behaviours, value clarification, decision support utilization and SDM due to cognitive and behavioural biases. When individuals made surgical decisions, their behaviours were affected by individual-level and system-level factors. Therefore, healthcare providers and other stakeholders should constantly improve communication skills and collaboration, and emphasize the importance of decision support, so as to embed SDM into routine practice.

PATIENT AND PUBLIC CONTRIBUTION

This systematic review was conducted as part of a wider research entitled: Breast cancer patients' actual participation roles in surgical decision making: a mixed method research. The results of this project helped us to better analyze and generalize patients' views.

Contralateral Prophylactic Mastectomy Decision-Making: The Partners' Perspective

BACKGROUND

The rate of contralateral prophylactic mastectomy (CPM) continues to rise despite no improvement in survival, an increased risk of surgical complications, and negative effects on quality of life. This study explored the experiences of the partners of women who undergo CPM.

METHODS

This study was part of an investigation into the factors motivating women with early-stage unilateral breast cancer and low genetic risk to opt for contralateral prophylactic mastectomy (CPM). Participating women were asked for permission to invite their partners to take part in interviews. In-depth interviews with partners were conducted using a semi-structured topic guide. A thematic analysis of the data was performed RESULTS: Of 35 partners, all men, 15 agreed to be interviewed. Most perceived their role to be strong and logical. Some hoped their wives would choose a bilateral mastectomy. All felt strongly that the final decision was up to their partners. The partners often framed the decision for CPM as one of life or death. Thus, any aesthetic effects were unimportant by comparison. The male partners had difficulty grasping the physical and emotional changes inherent in mastectomy, which made communicating about sexuality and intimacy very challenging for the couples. In the early recovery period, some noted the stress of managing home life.

CONCLUSIONS

The experiences of the male partners provide insight into how couples navigate complex treatment decision-making, both together and separately. There may be a benefit to including partners in pre- and post-surgical counseling to mitigate miscommunication regarding the expected oncologic and emotional outcomes related to CPM.

Caregiving and Shared Decision Making in Breast and Prostate Cancer Patients: A Systematic Review

BACKGROUND

A cancer diagnosis can impact patients' and caregivers' lives, posing different challenging situations. In particular, breast cancer and prostate cancer are two types of cancer involving families and especially spouses in challenges linked with the diagnosis and treatment process. Caregivers are usually involved in the treatment decision-making (TDM) process concerning patients' clinical pathway, cancer treatment, and ongoing therapies. To date, no contributions provide an exhaustive overview of the role of caregivers in cancer care and their involvement in the TDM process related to the therapies.

METHODS

We performed a systematic review of caregiver and patients experiences and perceptions of caregiver involvement in cancer TDM. Articles were searched on Public/Publisher MEDLINE (PubMed), Excerpta Medica Database (Embase), Medical Literature Analysis and Retrieval System Online (Medline), and American Psychological Association APA PsycINFO.

RESULTS

17 studies were included, 10 on prostate cancer and 7 on breast cancer. According to the reviewed studies, patients and caregivers experienced the cancer diagnosis with a sense of unity. Most patients preferred to have an active or collaborative role with caregivers in TDM, feeling it was important to consult or share the decision made with their caregivers. Caregivers preferred to collaborate with patients or let patients decide by themselves after considering their opinions. Caregiver involvement could have a positive influence on the patient's medical decisions, even if cancer diagnosis and treatments overwhelmed patients and caregivers.

CONCLUSIONS

These findings highlight the importance of using a perspective that focuses on the relationship between a patient and caregivers when they receive a cancer diagnosis and have to make a treatment decision. Targeting caregiver-patient dyads, rather than individuals, is important since a supported relationship could have a protective effect on psychological distress, quality of life (QOL), and relationship satisfaction. Moreover, dyads may benefit from interventions that focus on the needs of both the patient and caregiver.

Novel Patient-Reported Outcome Measures for the Assessment of Patient Satisfaction and Health-Related Quality of Life Following Postmastectomy Breast Reconstruction

BACKGROUND

Patient-reported outcome measures (PROMs) have become an integral part of the evaluation of reconstruction surgery outcomes. However, there are limitations in current PROMs when it comes to the assessment of well-being during inpatient stay, patient perception of health, relationship with partner, and vitality (i.e., mood and ability to work and pursue hobbies, carry out daily tasks, and sleep) following breast reconstructive surgery. The aim was to develop a novel set of measures to compare patient satisfaction and health-related quality of life following different types of postmastectomy breast reconstruction.

METHODS

A novel questionnaire was created and refined through cognitive interviews with patients and expert feedback. A field test study was conducted, including patients who had undergone delayed postmastectomy breast reconstruction with implant, autologous tissue, or combination of implant and autologous tissue. Based on the results, confirmatory factor analysis and examination of reliability of the questionnaire were conducted. Results of patient responses were analyzed using Chi-square test, Kruskal-Wallis test, and Mann-Whitney U test.

RESULTS

Confirmatory factor analysis showed good model fit, and Cronbach's alpha indicated high internal consistency of the questionnaire. Besides that, patients with combination reconstruction reported significantly lower vitality than patients with implant and autologous reconstruction (p = 0.048).

CONCLUSIONS

This novel questionnaire expands the current knowledge base of postmastectomy breast reconstruction PROMs. Results of the field test study showed that combination reconstruction was associated with lower patient vitality than other reconstruction types.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Couples' Experience of the Decision-Making Process in Breast Reconstruction After Breast Cancer: A Lexical Analysis of Their Discourse

BACKGROUND

One in 3 women with breast cancer will have a mastectomy and face the decision of whether to have breast reconstruction (BR). This decision is shared by the women and their physician, as well as discussed with her partner.

OBJECTIVE

This study aimed to understand the decision-making process of BR through a lexical analysis of the women and their partners' discourse. A secondary aim was to identify the differences between the couples when the woman had, or did not have, BR.

METHODS

We conducted semistructured interviews with 9 women, and their partners, who underwent a mastectomy after a first episode of breast cancer. A lexical analysis using IRaMuTeQ software was carried out.

RESULTS

The analysis yielded 3 classes, each one being more represented by one of the different BR categories. Class 1 contained words reflecting a preoccupation with body modification. Class 2 was related to the surgery and its consequences. Words contained in class 3 were about the couples' issues regarding surgeries, treatments, and medical care. The question of temporality emerged particularly in classes 2 and 3.

CONCLUSIONS

This study underlines the differences in the discourse of couples when talking about BR decision-making. Furthermore, it shows the importance of giving women time to think about BR and discuss its issues.

IMPLICATION FOR PRACTICE

Decisions about BR are difficult to make and should always be discussed between the women and health professionals, as BR is not always possible or desired by women. Partners need to be included in treatment decision-making.

A Decision Tree Model for Breast Reconstruction of Women with Breast Cancer: A Mixed Method Approach

The number of breast reconstructions following mastectomy has increased significantly during the last decades, but women are experiencing a number of conflicts with breast reconstruction decisions. The aim of this study was to develop a decision tree model of breast reconstruction and to examine its predictability. Mixed method design using ethnographic decision tree modeling was used. In the qualitative stage, data were collected using individual and focus group interviews and analyzed to construct a decision tree model. In the quantitative stage, the questionnaire was developed questions based on the criteria identified in the qualitative stage. A total of 61 women with breast cancer participated in 2017. Five major criteria: recovery of body image; impact on recurrence; recommendations from others; financial resources; and confirmation by physicians. The model also included nine predictive pathways. It turns out that the model predicted 90% of decisions concerning whether or not to have breast reconstruction. The findings indicate that the five criteria play a key role in decision-making about whether or not to have breast reconstruction. Thus, more comprehensive issues, including these five criteria, need to be integrated into an intervention for women with breast cancer to make their best decision on breast reconstruction.

Women and Partners' Information Need, Emotional Adjustment, and Breast Reconstruction Decision-Making Before Mastectomy

OBJECTIVE

Our aim was to explore the differences between women and their partners on information need, emotional adjustment, and breast reconstruction (BR) decision-making after breast cancer diagnosis. A second aim was to explore these differences regarding surgery type (mastectomy vs immediate BR).

METHODS

Women newly diagnosed with a first nonmetastatic breast cancer and having a mastectomy were invited to fill out online questionnaires, in conjunction with their partners, before mastectomy. Questionnaires assessed their information need (Patient Information Need Questionnaire), emotional adjustment (Profile of Mood States), motivations to have BR or not, shared decision-making (Shared Decision-Making Questionnaire), and partner influence in BR decision-making.

RESULTS

Thirty (15 women and their partners) people took part in the study. Women and partners had similar levels of information need, emotional adjustment, and shared decision-making. However, partners did not entirely perceive why BR is wished or not by the women. Furthermore, partners of women having a mastectomy alone had higher scores of mood disturbance and a greater need for information, compared to partners of women having an immediate BR (P < .05). Likewise, men expressed a greater need for disease-oriented information than their loved ones (P < .05).

CONCLUSIONS

This is the first study to highlight differences in couples' experiences of breast cancer diagnosis and BR decision-making before mastectomy. Partners express an important need for information and do not entirely perceive why BR is wished or not by their loved ones. An online tool providing information to both women and partners could help them in breast cancer care pathway and BR decision-making.

Understanding breast cancer survivors' information-seeking behaviours and overall experiences: a comparison of themes derived from social media posts and focus groups

OBJECTIVE

Using two different analysis techniques, this study explored differences and similarities in information-seeking discourse and overall breast cancer experiences between posters to a Reddit board and breast cancer survivor focus groups.

DESIGN

This study incorporates two qualitative methods for determining themes in breast cancer survivors' information-seeking behaviours and overall cancer experiences. First, posts from a breast cancer-specific Reddit community were extracted and analysed using the meaning extraction method (MEM) to determine core themes. Then, investigators performed a thematic analysis of two focus groups of breast cancer survivors (N = 18). Finally, themes derived from each analysis method were compared.

MAIN OUTCOME MEASURES

Outcome measures include themes extracted from Reddit posts and themes generated from breast cancer survivor focus groups.

RESULTS

Findings between qualitative methodologies represent similar yet nuanced themes in survivors' discourse. The MEM resulted in seven themes: diagnosis, treatment process, social support, existentialism, risk, information-seeking and surgery. Focus groups revealed the same initial four MEM themes plus the following: disclosure, coping and fears.

CONCLUSIONS

The MEM is a cost-effective research mechanism for informing common themes of experiences of cancer patients and survivors and may offer initial data to guide psychosocial oncology research design and recruitment.

Psychosocial well-being at time of diagnosis of breast cancer affects the decision whether or not to undergo breast reconstruction

OBJECTIVES

Numerous studies have shown that breast reconstruction after mastectomy improves QoL in breast cancer survivors. However, still about half of the patients does not opt for reconstruction. In order to accommodate suitable counseling, we should elucidate the factors that play a role in the decision-making process. This study aimed to evaluate the influence of QoL, among women diagnosed with breast cancer before the start of any treatment, on their decision whether or not to undergo breast reconstruction.

MATERIALS AND METHODS

BREAST-Q surveys were provided to breast cancer patients at the specialized breast care outpatient clinic after their first consultation with a surgical oncologist, between June 2017 and March 2019. The Q-scores of the subdomains physical well-being, psychosocial well-being, sexual well-being, and satisfaction with breasts of patients that underwent mastectomy were statistically analyzed.

RESULTS

Sixty-seven patients, undergoing mastectomy, completed the questionnaire. Fifty-four percent received reconstructive surgery. Mean age of patients seeking breast reconstruction was significantly lower than patients who did not opt for a reconstruction (53.5 vs. 63.7). Mean follow-up after mastectomy was 18.1 months. Except for satisfaction with breasts, mean Q-scores were higher in the group of patients who did not choose for reconstructive surgery. Psychosocial well-being was significantly higher in the non-reconstruction group (p = 0.012).

CONCLUSIONS

Psychosocial well-being at time of diagnosis of breast cancer was significantly higher in patients refraining from breast reconstructive surgery after mastectomy. Psychosocial characteristics might be essential for the decision-making process as well. Further prospective research should evaluate this.

Multiple health literacy dimensions are associated with physicians' efforts to achieve shared decision-making

OBJECTIVES

Shared decision-making (SDM) in health care is widely encouraged. However, for SDM to occur patients need to be able to obtain, understand and apply medical information. Our aim was to assess the relationship between health literacy (HL), numeracy and SDM (using French translations of validated measures).

METHODS

A cross-sectional survey using a self-administered online questionnaire was proposed to all members of the Seintinelles association. Several scales were used to measure HL (FCCHL and 3HLQ/SILS), numeracy (SNS-3), the SDM process (CollaboRATE) and explore their inter-relationships.

RESULTS

Data from 2 299 respondents (96.7% women, 46.1% with a history of cancer) were analysed. All measurement scales showed adequate psychometric properties. Functional HL, communicative HL and numeracy were positively associated with SDM while no significant relation was observed between critical HL and SDM. Furthermore, perceived difficulties in asking physicians' questions and deprivation were negatively associated with SDM.

CONCLUSION

Patient support to reach SDM requires high levels of HL, particularly in the functional and communicative domains. Efforts must be made to improve access and understanding of health information.

PRACTICE IMPLICATIONS

Brief self-reported measures could be used to screen for low levels of health literacy, tailor information accordingly and improve patient involvement in healthcare decision-making.

"Waiting for breast reconstruction": An interpretative phenomenological analysis of heterosexual couples' experiences of mastectomy for breast cancer

PURPOSE

Treatment decisions, such as breast reconstruction is made by the dyad patient-physician, but close others can have an influence on the process. Shared decision-making models include close others but current studies generally investigate physician-patient interactions only. Moreover, little is known about couples' interactions throughout the breast cancer journey and treatment decision-making. Thus, the aim of the present study was to explore couples' experiences of mastectomy and breast reconstruction decision-making, the month following the mastectomy.

METHOD

Ten unstructured individual interviews, with five couples facing mastectomy for breast cancer, were conducted. A dyadic interpretative phenomenological analysis (IPA) was carried on the data set.

RESULTS

Eight super-ordinate themes emerged from the data. Couples' experiences were marked by the experience of the disease, the mastectomy and the impact they produced. The relationships with health professionals and partners were also important. Partners were not only supportive and protective, but directly (i.e., couples talk about treatments) and indirectly influenced (i.e., women make a decision taking into consideration how it will impact their couple) the women in their decision to have or not a breast reconstruction. The interpretative accounts underline how women and partners cope with the disease thinking about the aftertreatment.

CONCLUSIONS

This study explains for the first time how intimate partners influence breast reconstruction decision-making and how couples cope individually with the disease immediately after mastectomy. Health professionals need to involve partners more in the treatment decision-making process as the women consider and talks to them about the choices they have to make.

Opportunities for personalised follow-up care among patients with breast cancer: A scoping review to identify preference-sensitive decisions

INTRODUCTION

Current follow-up arrangements for breast cancer do not optimally meet the needs of individual patients. We therefore reviewed the evidence on preferences and patient involvement in decisions about breast cancer follow-up to explore the potential for personalised care.

METHODS

Studies published between 2008 and 2017 were extracted from MEDLINE, PsycINFO and EMBASE. We then identified decision categories related to content and form of follow-up. Criteria for preference sensitiveness and patient involvement were compiled and applied to determine the extent to which decisions were sensitive to patient preferences and patients were involved.

RESULTS

Forty-one studies were included in the full-text analysis. Four decision categories were identified: "surveillance for recurrent/secondary breast cancer; consultations for physical and psychosocial effects; recurrence-risk reduction by anti-hormonal treatment; and improving quality of life after breast cancer." There was little evidence that physicians treated decisions about anti-hormonal treatment, menopausal symptoms, and follow-up consultations as sensitive to patient preferences. Decisions about breast reconstruction were considered as very sensitive to patient preferences, and patients were usually involved.

CONCLUSION

Patients are currently not involved in all decisions that affect them during follow-up, indicating a need for improvements. Personalised follow-up care could improve resource allocation and the value of care for patients.

The Influence of Marital Status on Contemporary Patterns of Postmastectomy Breast Reconstruction

BACKGROUND

Marital status is known to influence quality of life, survival, and treatment decision-making after breast cancer diagnosis. We aimed to determine whether relationship status impacts contemporary patterns of immediate breast reconstruction.

METHODS

Surveillance, Epidemiology, and End Results (SEER)-18 was used to identify females undergoing mastectomy for stage 0-III breast cancer from 1998 to 2014. Multivariate logistic regression was used to estimate the association of relationship status with the likelihood of postmastectomy reconstruction. Patients were grouped by diagnosis year to assess change in the reconstructed population with time. Among younger patients ≤45 years, a generalized logistic model was used to predict reconstruction subtype.

RESULTS

Among 346,418 patients, reconstruction after mastectomy was more likely to occur in women with relationship support in the form of a marriage or partner [odds ratio (OR) 1.31; 95% confidence interval (CI), 1.28-1.34; p<0.001]. Women who were separated (OR 0.76), single (OR 0.73), or widowed (OR 0.56) were significantly less likely than married women to undergo reconstruction (all p<0.001). During the 17-year study period, change in reconstruction rates with time varied by relationship status (interaction p=0.02), with reconstruction rates among divorced patients increasing more slowly than those among married and partnered women. Among younger women, subtype patterns varied by relationship status (p=0.004), with divorced women less likely to receive autologous over implant reconstruction (OR 0.87; p = 0.03).

CONCLUSION

Relationship status may influence decision-making regarding pursuit and type of postmastectomy reconstruction. Consideration of support networks of patients with breast cancer could facilitate tailored preoperative counseling by reconstructive surgeons.

The influence of partner involvement in the decision-making process on body image and decision regret among women receiving breast reconstruction

PURPOSE

This study examines the influence of partner involvement in decision-making for breast reconstruction (BR) on women's body image and post-BR decision regret.

METHODS

A cross-sectional and correlational approach was used in a convenience sample of 105 women in Taiwan who had breast cancer (BC) whose partners were involved in decision-making for BR. A structured questionnaire including the Involvement in the Breast Reconstruction Decision-Making Process Scale, the Body Image Scale, and the Decision Regret Scale was administered. Pearson's r and path analysis were used to examine the relationships among the dyadic BR decision-making process, women's body image, and decision regret.

RESULTS

The greater the amount of medical information women had, the better their body image and the less decision regret they experienced. Moreover, partner involvement was not related to women's body image, though it was inversely related to women's decision regret. The final path model showed that the amount of medical information women obtained was directly related to body image and decision regret, while body image also directly influenced decision regret. Overall, the amount of medical information women obtained and their body image explained 45% of the variance in decision regret.

CONCLUSIONS

Medical teams should provide female BC patients with complete medical information, and through partner involvement, women can be supported to make an appropriate decision regarding BR to achieve optimal levels of body image and lower levels of decision regret.

'It's a silver lining': A template analysis of satisfaction and quality of life following post-mastectomy breast reconstruction

OBJECTIVE

In the United Kingdom, the number of women undergoing post-mastectomy breast reconstruction is increasing. Consequently, exploring patient-reported outcomes in breast surgery has become increasingly important. This study investigated satisfaction and quality of life following post-mastectomy breast reconstruction.

DESIGN

Qualitative research design.

METHODS

In-depth, semi-structured telephone interviews were conducted with 25 women (age, M = 53.08, SD = 8.41) following breast reconstruction in the United Kingdom. Data were analysed using template analysis which produced three-first-level, 13 second-level, and 19 third-level themes.

RESULTS

Following reconstruction, women reported improved emotional functioning, although this was often accompanied by deterioration in physical, sexual, and/or social functioning. Women positively appraised their breast appearance, although some reported a decline in satisfaction over time, attributing this decline to their chosen reconstructive technique. Many women accepted the inevitability of scarring and most perceived their scars as a representation of their journey, signifying survival. Generally, women were satisfied with the outcome of their reconstruction, although on reflection some would not have opted for reconstruction. Following breast reconstruction, women were increasingly likely to experience the fear of recurrence, attributed to no longer being able to have a mammogram on the affected breast(s).

CONCLUSIONS

This study provides new insights into post-mastectomy breast reconstruction and is a novel application of template analysis. The analysis demonstrates only slight variation in some categories of experience among women, despite a heterogeneous sample. The findings allow researchers and clinicians to focus on specific dimensions of satisfaction and quality of life to support the needs of women following reconstruction. Statement of contribution What is already known on this subject? Patient satisfaction and quality of life are key patient-reported outcomes of breast reconstruction, although relatively few studies distinguish between types of satisfaction. The number of women electing to undergo reconstructive surgery is steadily increasing. As a consequence, exploring patient-reported outcomes in reconstructive breast surgery has become increasingly important for research and clinical practice. It is often suggested that breast reconstruction offers psychosocial benefits, although within the literature some mixed findings have been reported. Therefore, a qualitative exploration has the potential to add some clarity to the experiences of women following post-mastectomy breast reconstruction. What does this study add? To our knowledge, this is the first study to employ template analysis to explore the experiences of women following post-mastectomy breast reconstruction. Template analysis demonstrated that there was only slight variation in some categories of experience among women, despite a heterogeneous sample. This study distinguishes between the patient-reported outcomes breast satisfaction and outcome satisfaction to identify the key factors that are involved in determining satisfaction. The findings allow researchers and clinicians to focus on specific dimensions of satisfaction and quality of life which require improvement to support the unmet needs of women following breast reconstruction. The study presents two novel findings. Women attributed the fear of cancer recurrence to no longer being able to have a mammogram on the affected breast(s). Women also reported a decline in appearance-related satisfaction over time due to either the ptotic nature of autologous-based reconstruction or the fuller projected breast implant-based reconstruction affords.

Validation of the French version of the Functional, Communicative and Critical Health Literacy scale (FCCHL)

Background

Health literacy is a key asset, defined as the capacity to acquire, understand and use information in ways which promote and maintain good health.

Objectives

To assess the reliability and validity of the French translation of the Functional, Communicative and Critical Health Literacy (FCCHL) scale.

Methods/participants

A cross-sectional survey using an online questionnaire was proposed to all members of Seintinelles association. Exploratory and confirmatory factorial analyses were conducted.

Results

Data from 2342 respondents (45.8% had cancer history) were analysed. The FCCHL scale was well-accepted (missing value by item ≤0.7%). Factor analysis revealed an acceptable fit of three-factor model (comparative fit index = 0.922, root mean square error of approximation = 0.065 and standardized root mean square residual = 0.052). The FCCHL showed satisfactory reliability (α = 0.77) and scalar invariance was reached for education and deprivation, but not for age. Known group validity was verified as mean scale scores differed according to education, deprivation and age, as expected.

Conclusion

The French version of the FCCHL provides a brief reliable and valid measure to explore the dimensions of health literacy. It could be used by health professionals to screen for health literacy level in order to develop this skill and to tailor health communication.

Electronic supplementary material

The online version of this article (10.1186/s41687-018-0027-8) contains supplementary material, which is available to authorized users.

Autonomy and couples' joint decision-making in healthcare

BACKGROUND

Respect for autonomy is a key principle in bioethics. However, respecting autonomy in practice is complex because most people define themselves and make decisions influenced by a complex network of social relationships. The extent to which individual autonomy operates for each partner within the context of decision-making within marital or similar relationships is largely unexplored. This paper explores issues related to decision-making by couples (couples' joint decision-making) for health care and the circumstances under which such a practice should be respected as compatible with autonomous decision-making.

DISCUSSION

We discuss the concept of autonomy as it applies to persons and to actions, human interdependency and gender roles in decision-making, the dynamics and outcomes of couples' joint decision-making, and the ethics of couples' joint decision-making. We believe that the extent to which couples' joint decision-making might be deemed ethically acceptable will vary depending on the context. Given that in many traditional marriages the woman is the less dominant partner, we consider a spectrum of scenarios of couples' joint decision-making about a woman's own health care that move from those that are acceptably autonomous to those that are not consistent with respecting the woman's autonomous decision-making. To the extent that there is evidence that both members of a couple understand a decision, intend it, and that neither completely controls the other, couples' joint decision-making should be viewed as consistent with the principle of respect for the woman's autonomy. At the other end of the spectrum are decisions made by the man without the woman's input, representing domination of one partner by the other.

CONCLUSIONS

We recommend viewing the dynamics of couples' joint decision-making as existing on a continuum of degrees of autonomy. This continuum-based perspective implies that couples' joint decision-making should not be taken at face value but should be assessed against the specific cultural, ethnic, and religious backgrounds and personal circumstances of the individuals in question.