Evidence-Based Persuasion: An Ethical Imperative
Published online April 8, 2013
The primacy in modern medical ethics of the principle of respect for autonomy has led to the widespread assumption that it is unethical to change someone's beliefs, because doing so would constitute coercion or paternalism.1- 2 In this Viewpoint we suggest that persuasion is not necessarily paternalistic and is an essential component of modern medical practice.
There are at least 3 different types of persuasion. The first is the removal of biases; the second is recommending a particular course of action and providing evidence and reasons in favor of it; and the third is the potential creation of new biases, which could cross the line into unethical manipulation. The first of these is always mandatory, the second is usually permissible but sometimes inappropriate, and the third is normally impermissible but sometimes acceptable in rare cases.
Removal of bias is perhaps the most important form of persuasion. A bias is a cognitive mechanism or mistaken belief that adversely affects a patient's decision making. One example of a cognitive bias is omission bias, whereby a patient prefers one option because it involves inaction, although this may result in greater harm than taking a particular action.3 Another common bias occurs when patients prioritize short-term desires over long-term desires, with patients refusing surgery because of fear, even though the long-term consequences may be dire. A more common example is a patient refusing a particular treatment because she believes it to be expensive, when it actually would be free. Physicians can address such biases by providing correct information to patients to inform them and hopefully remove biases; in certain cases, appeals to emotion may also be appropriate (eg, if the patient has fears about undergoing an operation, the physician could ask if she also has fears about dying). The difference between providing nondirective information and persuasion is that in the latter case the physician not only delivers information and ensures that the patient has understood it but also explicitly states at least some of the conclusions to be drawn from that information. Removing biased interpretation of information is persuasion because the physician is attempting to change the patient's beliefs to help the patient make a more rational choice. Simple provision of facts might not meet the criteria for informed consent if the patient is not also persuaded to believe them.
Once biases have been minimized, the physician can assess the patient's key beliefs and desires and make a judgment regarding which (if any) treatment option is best. A study in Switzerland revealed that directive counseling was regarded as a form of undue influence by some health professionals,4 even though it is actually a physician's duty to give an opinion to the patient. If information about a physician's preferred course of action is conveyed subtly, such as through body language, hints, or other clues, this could exert a powerful influence or lead to misunderstanding, in addition to being an unprofessional means of communicating with a patient. It could be argued that physicians who refuse to reveal their recommended course of action are thereby depriving patients of relevant information and rendering them incapable of providing informed consent; thus, in attempting to avoid risks related to the voluntariness criterion for consent, which states that patients must not be coerced, physicians might fail to fulfill the information criterion. Physicians have substantial medical knowledge and should have skill in assessing and analyzing risk, and it is unfair to deny patients access to this skill and knowledge set.
Given the importance of transparency, the creation of new cognitive biases is unacceptable. For instance, some physicians may adopt the following suggestion to convince patients: “When discussing mammography with patients for whom it is indicated, frame the associated risk reduction in mortality from breast cancer in terms of relative rather than absolute risks.”3 However, doing this would overstate the prospective benefit of mammography substantially, and it is best practice to use absolute risks. Using relative rather than absolute risks may amount to manipulation of the patient and could only be permissible (if at all) in extreme instances; for example, in the case of a patient who has an irrational needle phobia and will die without intravenous treatment.
The appropriateness of persuasion is context-dependent. Persuasion beyond minimization of bias is unlikely to be appropriate in situations of equipoise, for which no evidence exists to favor one course of action over another. For example, in prenatal testing, persuasion can be rationally justified if the testing will inform later choices or help to prepare a couple psychologically. Breast cancer screening is another example of this: here, the evidence is that for each life saved by screening, 3 women will receive unnecessary treatment.5 However, it is not known for any given woman which of these groups she will be in, representing a type of equipoise. Similarly, some decisions ultimately will be based on values rather than medical evidence; for example, a patient might have to choose between having a long life with lower quality of life (by choosing chemotherapy) and having a shorter life with a higher quality of life (by not choosing chemotherapy). Physicians should clearly leave such decisions to patients but could state what they would do in the same situation, given their own values and goals. Depending on the context, it might be better to offer this information only if the patient requests it, to avoid any appearance of coercion.
As another example, even though the evidence for MMR (measles, mumps, rubella) vaccination of children is clear,6 many parents are still worried about risks. Here, recommending vaccination should be mandatory, because parents might have significant antivaccine bias because of misinformation provided by opponents of vaccination. Although new biases could be created to persuade parents to vaccinate their children, this could lead to parents avoiding future vaccinations if they felt their trust in the physician had been violated. This illustrates that persuasion must be used with great sensitivity; if evidence is not provided or transparency is not maintained, ethical persuasion can easily cross the line into paternalistic manipulation.
In conclusion, persuasion is an essential component of modern medical practice, and it may be impossible to respect patients' autonomy without engaging in persuasion.7 Physicians using persuasion should ensure that they meet 6 criteria: (1) remove biases and access the patient's autonomous wishes; (2) provide honest, impartial evidence-based information about prospective harms and benefits; (3) provide a rational interpretation of this information, including facts about the physician's belief set and views regarding the best decision; (4) use reason rather than emotion, while sometimes appealing to patients' emotions to counterbalance their existing emotional responses; (5) avoid creating new biases; and (6) be sensitive to the patient's changing preferences, because persuasion is likely to change the patient's outlook and perspectives.
Published Online: April 8, 2013. doi:10.1001/jama.2013.2179
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Elger reported receiving travel and meeting expenses from the Swiss Federal Commission on Genetic Testing. Dr Shaw reported no disclosures.
Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th ed. New York, NY: Oxford University Press; 2001:94
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Manai D, Burton Jeangros C, Elger B. Information et gestion des risques—regards juridiques, sociologiques et éthiques sur la grossesse. Bern, Switzerland: Stämpfli; 2010
Independent UK Panel on Breast Cancer Screening. The Benefits and Harms of Breast Cancer Screening: An Independent Review. Cancer Research UK website. http://www.cancerresearchuk.org/prod_consump/groups/cr_common/@pol/documents/generalcontent/breast-screening-review-exec.pdf. October 2012. Accessed February 12, 2013
Health Protection Agency (UK). MMR Vaccine: General Information. Health Protection Agency website. http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/MMR/GeneralInformation/. Accessed February 12, 2013