'Nudge' can be ethical choice

As patients and physicians share decision-making in choices among treatment options, decision aids such as videos, websites, pamphlets or books are coming to play an important role. However, in some cases, it may be ethical for the decision aids to provide a "nudge" toward a particular option, said researchers from Baylor College of Medicine, the Michael E. DeBakey Veterans Affairs Medical Center and The University of Texas MD Anderson Cancer Center in a report that appears in the journal Health Affairs.

In general, decision aids are meant to be even-handed, presenting information in a non-judgmental way, said Dr. Jennifer Blumenthal-Barby, assistant professor in the Center for Medical Ethics and Health Policy at BCM. However, as she began to consider different situations in which they might be used, she realized that this might not always be helpful to patients.

"There are situations in which I think it is okay for a decision aid to favor one option more," she said. In the paper, she and her colleagues described three scenarios in which such "nudges" might be the ethical choice:

-In early stage prostate cancer, active surveillance of early stage prostate cancer is a clinically viable option of which patients are often aware and are often not offered.

-Screening for colorectal cancer, which is low risk and high benefit.

-Treatment for deep vein thrombosis, which involves a choice between two alternatives that could be affected by the patient’s habits, concerns or preferences.

In using decision aids, the patient and physician are supposed to sit down together and watch a video, look at a website or go over written material that is designed to spell out the risks and benefits of each treatment for a particular disease.

"Decision aids came into being because of the concern that clinicians aren’t telling patients all the options," said Blumenthal-Barby. "Decision aids standardize things so patients get a fair view of all the options, their risks and benefits."

In some cases, however, an even-handed presentation may not give patients a fair understanding of the options. In those cases, it might be ethical to alter the playing field by placing a certain option first or help patients understand how one option might be compatible with their lives while another might not.

In the case of early prostate cancer, the data support active surveillance as a viable treatment option for a subset of patients, but many physicians do not discuss it as an option or do not go into it in depth. In that case, she said, designing the decision aid to make patients think about it more might be the best choice.

In the second case, the guidelines recommend that people ages 50 to 75 years be screened by one of four methods. In this case, said Blumenthal-Barby and her colleagues, the aid might highlight the four methods--colonoscopy, flexible sigmoidoscopy, computed tomography colonography or fecal tests--and not include a fifth option--no screening at all.

In this way, the decision aid is even-handed in its presentation of screening options but unbalanced in the decision of screening versus not screening.

Patients who have suffered deep vein thrombosis (a blood clot deep in the body) require extended treatment to prevent future blood clots. For most patients, taking an anticoagulant called warfarin by mouth or injections of low-molecular weight heparin (another anticoagulant) under the skin is equally effective.

However, the oral warfarin treatment requires that patients exclude some foods such as leafy green vegetables or alcohol from their diets and have their blood levels of the drug checked frequently. While the daily or twice daily injections of heparin may be distasteful to people who dislike needles, they do not require the dietary changes or the frequent testing of the other treatment.

In this case, said Blumenthal-Barby, the decision aid should include a "values clarification" exercise that enables the patient to consider what is most important to him or her and then the option that is most in line with that should be encouraged t.

Others who took part in this report include Dr. Heidi Voelker Russell, associate professor of pediatrics at BCM, Dr. Aanand D. Naik, of the Houston VA Health Services Research and Development Center of Excellence at the Michael E. DeBakey VA Medical Center and assistant professor of medicine--health services research at BCM, Dr. Scott B. Cantor, professor of biostatistics, and Dr. Robert J. Volk, professor of general internal medicine, both at The University of Texas MD Anderson Cancer Center.

Funding for this work came from the Greenwall Foundation, the Pfizer Foundation and the Michael E. DeBakey Veterans Affairs Medical Center.