“Sapere Eum Aude” –
Multiple-Criteria Decision Analysis 
as one way to the empowerment of patients

by

Martin Schilling

Freie Universität Berlin
Institut für klinische Psychologie

10. Juni 2004

Summary

Multiple-Criteria Decision Anyalysis (MCDA) can serve as one mean to foster the empowerment of patients in clinical contexts. This paper introduces MCDA as a method to incorporate the expertise of the physician and the values of the patient to reach “informed consent” in therapy decisions. The physician thereby does not simply give advice (“Advice Giving and Taking”), but works together with the patient to find a suitable therapy solution.

Firstly, the paternalistic, the expert and the shared decision-making approach in the clinical context are compared. Secondly, two decision-analytic methods are applied to a therapy decision. A decision-tree model is useD to for a simple eye surgery decision. The more applicable Multiple-Criteria Decision Analysis is applied to solve a pregnancy prevention decision. Finally, the relevance of a qualitative MCDA approach in clinical contexts is discussed.

 

1. Introduction

“Sapere Aude” – dare to use your mind was one of the core ideas of the famous philosopher Immanuel Kant. Born in the time of “enlightenment” more than 280 years ago, he supported radical changes in the political system towards more freedom for citizens to think, talk and act. Whereas changes in the relationship between state and citizen were revolutionary, relationships in another area remained almost unchanged in the last centuries: the relationship between physician and patient.

Many patients still treat physicians as “gods in white”. The sick and help-seeking often see themselves as depending sub-ordinates ready to receive their sovereign’s decision. Many patients are unwilling or unable to reflect about the doctors’ recommendation and decisions. However, especially in the psychiatric area this relationship begins to change. The so-called empowerment movement aims to help patients regaining influence on decisions affecting their lives (Knuf and Seibert, 2000). Ideally, subjective values of the patient and expertise of the physician are incorporated in the decision-making process.

2. Decision-making in clinical contexts

Many authors agree on the existence of three different decision relationships between physician and patient: The paternalistic approach, the informed (expert) approach and the shared decision-making approach (Zaumseil, 2000; Charles, Gafni and Whelan, 1997; Charles, Gafni and Whelan, 1997).

The paternalistic approach

In this century-old, traditionalist style, the physician observes the symptoms of the patient, asks diagnostic questions and prescribes a therapy. The therapist selects one option, explains the reasons and the patient accepts or rejects the recommendation.

The expert approach

In this information-based model, the patient asks the physician for information about a specific health problem. The therapist informs the patient about the different treatment options, who decides independently of the expert.

Shared decision-making approach

When physician and patient share information about the disease and possible therapeutic options and decide jointly, they pursue a share decision making approach. The physician provides relevant expertise regarding effects and risks of the therapies, the patient communicates his values and concerns about these options.

Opinions about the applicability of these approaches in the clinical context differ. Jungermann (1999) argues that due to the differences in expertise physicians should propose one single treatment option. This “advice giving and taking approach” has four stages:

1. The patient describes the problem and provides relevant information about symptoms and about his/her needs.



2. The physician selects one best option, suitable to solve the client’s problem. The physician thereby categorizes the client and recommends the option, which is according to his expertise best for this class of patients (categorization-and-matching strategy).



3. As next step the therapist offers the identified option as advice, justified by arguments.



4. Finally, the patient evaluates this advice based on his values and the trust in the therapist. Patients either accept or reject the advice.

Multiple-Criteria Decision Analysis as one way to the empowerment of patients Contrary to this paternalistic “advice giving and taking” approach, Zaumseil (2000) suggests to “empower” patients by sharing the decision making process. This co-operative and participative relationship expresses a respectful way of dealing with the interests and preferences of patients. Zaumseil (2000) as well describes four stages.

1. The patient and the physician share information about the disease and possible treatment options.



2. Both discuss advantages and disadvantages of different treatments and the relevance of these consequences for the patient.



3. Patient and physician decide jointly for one therapy option.



4. After having executed the treatment patient and physician may meet again to share information about the effectiveness of the therapy. Especially in decision contexts, when a commitment of the patient to the recommended therapy is of high importance (as in medication decisions or in psychiatric contexts) this shared decision-making approach can be beneficial.



3. Decision Analysis as a method to reach informed consent

In medical decision situations often considerable uncertainty about the consequences of the different treatments occurs. In addition, the patient often has multiple, conflicting objectives regarding the consequences of the therapy. Decision-analytic tools were developed to aid decision makers in these kinds of decision situations (Keeney, 1992).

Decision Analysis (DA) provides methods how to deal with decision problems involving uncertainty and/or conflicting multiple objectives. If a patient needs to decide whether to agree to a surgery of an eye with blur vision, the situation involves uncertainty. With a certain probability his sight can be restored, with a certain probability his vision gets lost completely. If a woman needs to decide which pregnancy prevention method she will apply, the decision situation might involve multiple objectives. She may want to minimize the probability of getting pregnant, to minimize the price and to maximise the ease of handling.

To help decision makers in these situations involving uncertainty and/or multiple objectives, decision-analytic researchers develop a variety of decision aiding tools (Goodwin and Wright, 1998). Decision analysts thereby offer decision makers a structured framework to think and to decide. The tools serve the decision maker. Core benefit is the possibility to create new insights in complex situations and foster commitment to solutions. The proposed solution is therefore a piece of advice, based on the values of the decision maker, it is not a deterministic, to-be-executed  duty. Most of these methods are based on expected utility theory. The next example illustrates this theory.

[...]