New article published: The counseling, self-care, adherence approach to person-centered care and shared decision making: Moral psychology, executive autonomy, and ethics in multi-dimensional care decisions

A few days ago, an article by myself and three colleagues from philosophy, psychological safety research and pediatrics that's been accepted for a long time finally came online at the journal Health Communication's website. The article explores how standard accounts of how models for increased interaction and collaboration between patients and health care professionals – often termed patient or person centred care, and shared decision-making – fit badly to a broad group of patients; namely those whose care are mostly self-administered, who suffer vulnerable decision capacities and who exhibit a weakening adherence to decided care plans. In the article we illustrate the point with a study of adolescent diabetes care, based on video-taped consultation meetings between patients and health care professionals, and develop a general argument based on broadly recognised research in decision-making and moral psychology to revise the standard approach to person centredness and shared decision-making for this group of patients, focusing less on making shared rational autonomous decisions in health care meetings, and more on emotionally empowering patients and help them to develop virtues necessary to take responsibility for the self-care they agree on in collaboration with health professionals. Here is the abstract:

This article argues that standard models of person-centred care (PCC) and shared decision making (SDM) rely on simplistic, often unrealistic assumptions of patient capacities that entail that PCC/SDM might have detrimental effects in many applications. We suggest a complementary PCC/SDM approach to ensure that patients are able to execute rational decisions taken jointly with care professionals when performing self-care. Illustrated by concrete examples from a study of adolescent diabetes care, we suggest a combination of moral and psychological considerations to support the claim that standard PCC/SDM threatens to systematically undermine its own goals. This threat is due to a tension between the ethical requirements of SDM in ideal circumstances and more long-term needs actualized by the context of self-care handled by patients with limited capacities for taking responsibility and adhere to their own rational decisions. To improve this situation, we suggest a counseling, self-care, adherence approach to PCC/SDM, where more attention is given to how treatment goals are internalized by patients, how patients perceive choice situations, and what emotional feedback patients are given. This focus may involve less of a concentration on autonomous and rational clinical decision making otherwise stressed in standard PCC/SDM advocacy.

The article itself can be found here. For those who lack access to university libraries or subscriptions, a so-called postprint of the article – i.e. the author's finally submitted manuscript after peer review, but before editorial and type setting changes, pagination and so on – can be found here. Or you can contact me, to request a pdf of the published version.

New Article on the Ethics, Philosophy and Practice of Person-centred Care and Shared Decision-making

One topic that's been part of my research activities for some years now is the ethical and philosophical implications of movements to transform health care practices towards more of what's often called a "patient-" or "person-centred" perspective, sharing clinical decisions with patients to a larger extent. I've been lucky to publish a few analytical works in this area in collaboration with, e.g., Lars Sandman and Daniela Cutas, which have attracted quite some attention, partly as an outcome of an ongoing research collaboration with the pediatric diabetes centre at the Sahlgrenska University Hospital, involving medicine, psychology, organisation, communication, care and human factors risk research, besides philosophy and ethics. Now I'm happy to announce the first of a number of planned articles coming out of empirical and multi-disciplinary investigations of communicative aspects of adolescent diabetes care undertaken in this project, authored by Anders Herlitz, myself, Marianne Törner and Gun Forsander. This article uses outtakes from a video-study of continuous doctor-patient consultation sessions forming the bulk of adolescent diabetes inpatient care (the rest is self-care performed by the younsters themselves) to question received assumptions in standard notion of what person-centredness and shared decision-making should involve, basing our arguments in received results from behavioural science and moral psychology. Instead, we advocates a new approach for patients who are at risk of suffering from weak decision capacities when performing self-care, while being in need of significant portions of such care. We also argue, that this new model exposes an hitherto ignored ethical tension within the person-centredness and shared decision-making advocacy, which needs to be adressed and managed for care to be defensible.

The article is entitled "The Counselling, Self-care, Adherence Approach to Person-centred Care and Shared Decision-making: Moral Psychology, Executive Autonomy and Ethics in Multi-dimensional Care Decisions", and has been accepted for publication in the journal Health Communication, to appear shortly. Meanwhile, interested parties may sample our final draft after the critical review that lead to acceptance (a so-called postprint), which has been made available here. In the pipeline are at least two more works based on this study, one of which on the role of parents and family in adolescent care, and one on conrete strategies to promote what in the article promoted here is called "robust decision capacity". In the future lingers further yet undecided things, as I am part of a group that has just received a nice bit of funding for continuing working on this topic.

A Bunch of Posters and Presentations on the Ethics of Person Centred Care and Shared Decision Making in Adolescent Diabetes now Online

Yea, what he said! These things are all outcomes of ongoing research in the cross-disciplinary project Organizing Person Centred Care in Pediatric Diabetes: Communication, Decision-making, Ethics and Health, where myself and some younger philosophers/ethicists collaborate with psychologists, linguists, care and organisation researchers and medical specialists. The project's original plan can be seen here. We are now a few years in and the last week has been a hectic one of delivery both at the yearly international conference of pediatric and adolescent diabetes specialists, ISPAD 2013, that was held in my town last week, and an ethics seminar at the University of Groningen that I visited this thursday.

Here's what came out:

1) An oral presentation (slides) of the main results so far of our entire project, delivered by one of the senior researchers, Marianne Törner.

2) A poster by my Ph.D. student Thomas Hartvigsson and myself, presenting results from an ongoing analysis of videotaped meetings between doctors, patients and parents on the possible value of assessing decision competence as part of a person centred consultation session. The title is Respecting the Adolescent Diabetes Patient as an Autonomous Person - What Does it Imply? Assessing and Managing Decision Capacity for Care Decisions and Self-care

3) Another poster, this time by my post doc in the project, Anders Herlitz, and myself likewise presenting results from an ongoing analysis of videotaped meetings between doctors, patients and parents, this time in the form of a general claim with regard to how person centred care and shared decision making needs to be adapted to fit patients with weak or vulnerable capacities for responsibility and conditions requiring care to be mostly self-managed. The title is The Moral Psychology of Person Centred Adolescent Diabetes Care: two potentially conflicting ethical dimensions of shared decision making for sustainable self-care

4) An oral presentation (slides) that I gave in Groningen more or less at the same time as Anders presented the one above that develops our argument that standard models of shared decision making and person centredness of care lacks a crucial virtue ethical elelment that needs to be added and that this complicates the ethical assessment of the organisation of such care. The title is the same as above.

Currently me and Anders and Thomas and the rest of the team are working hard on, first, two articles, that we hope to submit shortly, and then another batch of two following up more complications of person centred acre and shared decision making that we have discovered through our video-studies. Stay tuned!

Two Related Articles on the Ethics and Politics of Person Centred Care and Shared Decision Making

Almost back from the summer holiday, I make an easy start by informing about two recent publications of mine, coming out of my involvement in projects at the Gothenburg Centre for Person Centred Care (GPCC). The two articles, one of which appeared at the beginning of summer, and the other in the middle of it, complement each other in analysing and problematising various ethical and political aspects of ideas about so-called person centred care and its related concept of shared decision making in medical and health counselling and decision making. The aspects analysed have implications for policy, economics, research and public health and the articles jointly deepen, problematise and contribute to a sounder theoretical basis of efforts to implement and ensure the quality of person centred care and shared decision making intiatives in health care.

Christian Munthe, Lars Sandman and Daniela Cutas (2011). Person Centred Care and Shared Decision Making: Implications for Ethics, Public Health and Research. Health Care Analysis, vol. 19, DOI: 10.1007/s10728-011-0183-y . Link to journal. Link to post-print at Academia.edu.

Lars Sandman, Bradi B. Granger, Inger Ekman and Christian Munthe (2011). Adherence, Shared Decision-making and Patient Autonomy. Medicine, Health Care and Philosophy, vol. 14, DOI: 10.1007/s11019-011-9336-x. Link to journal. Link to post-print at Academia.edu. Link to post-print at the University of Gothenburg publication database.