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PERSPECTIVE

A Typology of Shared Decision Making, Informed Consent, and Simple Consent

Simon N. Whitney, MD, JD; Amy L. McGuire, JD; and Laurence B. McCullough, PhD

6 January 2004 | Volume 140 Issue 1 | Pages 54-59

Enhancing patient choice is a central theme of medical ethics and law. Informed consent is the legal process used to promote patient autonomy; shared decision making is a widely promoted ethical approach. These processes may most usefully be seen as distinct in clinically and ethically important respects. The approach outlined in this article uses a model that arrays all medical decisions along 2 axes: risk and certainty. At the extremes of these continua, 4 decision types are produced, each of which constrains the principal actors in predictable ways. Shared decision making is most appropriate in situations of uncertainty, in which 2 or more clinically reasonable alternatives exist. When there is only 1 realistic choice, patient and physician may gather and exchange information; however, the patient cannot be empowered to make choices that do not exist. In contrast, informed consent does not require the presence of clinical choice; it is appropriate for all decisions of significant risk, even if there is only one option. When a clinical decision contains both risk and uncertainty, shared decision making and informed consent are both appropriate. For decisions of lower risk, consent should still be present, but it can be simple rather than informed. Clinicians may use this analysis as a guide to their own interactions with patients. In the continuing effort to provide patients with appropriate decisional authority over their own medical choices, shared decision making, informed consent, and simple consent each has a distinct role to play.

Author and Article Information

From the Department of Family and Community Medicine, Baylor College of Medicine, Houston, Institute for the Medical Humanities, University of Texas Medical Branch, Galveston, and Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas.

Acknowledgments: The authors thank Jana Davis for assistance and support; Pamela Paradis Tice, BA, ELS(D), for skillful editing; and Charles W. Lidz, PhD, Alan Meisel, JD, Robert J. Volk, PhD, and Susan C. Weller, PhD, for guidance and advice in developing this project.

Grant Support: By grant K08 HS11289 from the Agency for Healthcare Research and Quality (Dr. Whitney).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Simon N. Whitney, MD, JD, Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Drive, Suite 600, Houston, TX 77098; e-mail, swhitney{at}bcm.tmc.edu.

Current Author Addresses: Dr. Whitney: Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Drive, Suite 600, Houston, TX 77098.

Ms. McGuire: Institute for the Medical Humanities, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-1311.

Dr. McCullough: Center for Medical Ethics and Health Policy, Baylor College of Medicine, IREL Room 401, One Baylor Plaza, Houston, TX 77030-3498.

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