Shared decision-making: why, for whom, and how?

Abstract

Almost 2,400 years ago, Hippocrates advised that "physicians as the ones who command and decide" and that "patients must place themselves fully in physicians' hands and obey commands" 1 (p. 670). This type of view, characteristic of medical paternalism, in which the duty of beneficence and non-maleficence sustains this type of passive posture of patients, has prevailed in medicine in the last 24 centuries. However, rather than making hasty judgments, it is interesting to observe the context, that is, basically all other forms of social relationship that were so common in such period. By examining law, politics, relationships between spouses, or between parents and children, we will see the same pattern 2 . And if we look into even older times, into the social relations in the human societies of hunters and gatherers, or even if we look into biology, into the social relations between primates or between canids, we will ultimately see the same pattern 3 . The individual with the highest social ranking commands, while the others obey. Coalitions among individuals with greater power ensure the maintenance of the model, where the will of the most powerful prevails.According to Norberto Bobbio 4 , one of the minds behind the Universal Declaration of Human Rights, this model begins to collapse in the Modern Age, initially with the Religious Wars. At the time, the sovereign-subject model begins to be replaced by the State-citizen model, where the right to self-determination becomes, slowly and gradually, guaranteed to citizens, who before, as subjects, did not even have the right to choose which faith to profess. Nevertheless, according to the Italian jurist: "Human rights however fundamental are historical rights and therefore arise from specific conditions characterized by the embattled defense of new freedoms against old powers. They are established gradually, not all at the same time, and not forever" 4 (p. 5). This gradual and heterogeneous change faces greater resistance in some parts of the social fabric. That is what we perceive in health and, especially, in medicine.And, thus, it was only in the 1970s that these new freedoms reached patients. It was the revolution of autonomy in the relationship between physician and patient. However, beyond that, it was the beginning of the erosion of the sovereign-subject model in medicine, in which not only patients, but also family members, nurses, legislators, among others, obeyed the orders of the sovereigns in the field of medicine. And, as in other fields of knowledge, this change was not at once, nor was it free from turbulence and problems.