When a ‘nudge’ may be ethical for patient decision aids

By Christopher Walsh, medwireNews Reporter

There may be some scenarios in which patient decision aids should be designed to "nudge" patients toward a particular treatment option, according to a report by US researchers.

This controversial hypothesis is at odds with the ethical standard of providing patients with "balanced" decision aids to help them make informed decisions.

However, it is not always possible to present options in a neutral, unbiased, and non-directive manner, and nor should it always be the goal, say Jennifer Blumenthal-Barby (Baylor College of Medicine, Houston, Texas) and co-authors in Health Affairs.

"It might sometimes be appropriate for the developers of decision aids to 'level the playing field' by bringing underused options more to the forefront," they write.

When a viable treatment option is not usually considered by a patient or even presented to them as an option, it may nevertheless be ethical to nudge them toward that option, say the authors.

For example, when designing decision aids about the management of early-stage prostate cancer, it may be ethical to promote active surveillance over surgery and radiation. Developers can do so by including favorable but factual patient testimonies, by ordering materials to highlight active surveillance, or by emphasizing the particular risks of surgery and radiation.

Similarly, an "unbalanced" patient decision aid may be ethical when clinical evidence strongly supports a particular treatment option as being of high benefit and low risk, but when the norm is to present that option with equal weighting alongside other, less favorable options.

In the USA, for example, colorectal cancer screening is recommended for adults aged 50-75 years, and yet patient decision aids present no screening as a viable alternative. In this scenario, Blumenthal-Barby et al recommend the complete removal of the no-screening option.

Finally, when a patient's lifestyle does not suit a particular treatment option, the authors suggest that it is justifiable to first guide the patient into recognizing this and to then recommend alternatives that can be more easily and successfully incorporated into their day-to-day life.

For example, patients who have deep vein thrombosis but who find it difficult to consistently meet weight-loss targets or to schedule regular blood tests may be more suited to anticoagulation treatment with low-molecular-weight heparin than with warfarin, and so decision aids should guide those patients toward that option, say the authors.

They conclude: "The challenge for medical decision makers and decision aid developers is to address the difficult question of whether, under what circumstances, and how patients should be nudged toward one option or another."

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