Warranting the decision-maker, not the decision: How healthcare practitioners evaluate the legitimacy of patients' unprompted requests for risk-reducing mastectomy.

Abstract

Shared decision-making exists to reconcile healthcare practitioners' responsibilities to respect patients' autonomy whilst ensuring well-made decisions. Patients sometimes make unprompted requests for procedures that carry medical and other risks, such as risk-reducing mastectomy (RRM). Faced with pre-formed decisions into which they have had little input, it is unclear how practitioners can reconcile respecting autonomy with ensuring well-made decisions. Qualitative study of linked patient-practitioner interviews in a breast unit in North-West England. We examined how 10 practitioners addressed 19 patients' unprompted requests for RRM. Practitioners empathised with patients' distress about cancer risk, regarded RRM as legitimate to help, but were wary of choices made 'emotionally'. Practitioners did not seek to establish whether choices were well-made but, instead, 'warranted' patients by satisfying themselves that patients were 'sensible' and 'informed' decision-makers, and thus their decisions could be trusted. Practitioners provided information, and tested patients' resolve by delaying decisions and presenting 'what if' scenarios depicting failure or harm from RRM. Patients who present emotionally and with resolution can receive RRM without evidence of a well-made decision. Argumentation theory proposes an ethically robust and clinically practicable approach, whereby practitioners elicit, examine and, where appropriate, challenge arguments underpinning patients' decisions.