By Stacey Kusterbeck
Although there is a consensus that shared decision-making is an ethical obligation for clinicians, there is considerable variability in how clinicians actually practice it. “Shared decision-making helps ensure that clinical decisions without a single best choice incorporate and reflect patient preferences. There is a lot of support for shared decision-making from clinicians and patients, but there is still a lot to understand about shared decision-making itself,” says Douglas J. Opel, MD, MPH, professor of pediatrics at the University of Washington School of Medicine and director of the Treuman Katz Center for Pediatric Bioethics at Seattle Children’s.
Opel and colleagues developed a tool to measure the quality of shared decision-making by capturing both the parent’s and the clinician’s perspectives.1 According to Opel, “Although there isn’t consensus on all the components of shared decision-making, there is the most consensus around two components: choice awareness and eliciting and exploring patient preferences. If these components are not done explicitly, it is very difficult to claim one is doing high-quality shared decision-making.”
In the pediatrics field, shared decision-making presents some additional ethical challenges for clinicians. “Decisions in pediatrics must accommodate multiple goals, such as protecting the child as well as respecting parental values and decision-making authority. When these goals are not aligned, it can constrain how ‘shared’ the decision-making is,” says Opel.
Physicians need to communicate in a way that respects patients’ autonomy while also respecting their own integrity as healthcare professionals, says Lauris Kaldjian, MD, PhD, director of the Program in Bioethics and Humanities at University of Iowa’s Carver College of Medicine. Kaldjian and colleagues conducted a study to learn about medical students’ experiences and attitudes about physicians using persuasion with patients.2 “Persuasion in healthcare can be understood as involving the intentional effort to change a patient’s beliefs, position, or course of action based on the strength of reasons offered by a clinician,” says Kaldjian.
Persuasion is more influential than just informing or recommending. Thus, physicians, when using persuasion, should avoid manipulating or coercing patients, cautions Kaldjian. “Persuasion is different than nudging,” adds Kaldjian. “Nudging exploits patients’ cognitive biases, whereas persuasion is based on reasoning, which provides a transparent appeal to patients’ rational capacity for goal-directed deliberation.”
Of 237 medical students surveyed, more than half (55.7%) supported physicians using persuasion for the good of the patient’s health. Students who had observed a trusted clinician use persuasion, or who had themselves participated in persuasive communication, were more likely to view it favorably. Almost half of students supported physicians using persuasion for an at-risk cardiovascular patient to follow recommendations for statin treatment or walking. Most students supported persuasion if a myocardial infarction patient wants to leave against medical advice. “Emotions may be running high with fears, hurts, misunderstandings, or frustrations. Ethically valid attempts at persuasion may be an important part of the process of shared decision-making in these tense situations,” says Kaldjian.
Ethics consults can be helpful if shared decision-making, including the use of persuasion, is causing conflict. Ethicists can facilitate an understanding of what is most important to patients, family, and clinicians. “Thankfully, in most situations, these efforts are likely to result in acceptable ways forward that respect both the decision-making freedom of patients and the conscientious practice of professionals,” says Kaldjian.
Sometimes the disagreement involves a request for inappropriate treatment or refusal of recommended treatment, such as a seriously ill inpatient who is unhappy being in the hospital and wants to leave. “A respectful attempt at persuasion would endeavor to help the patient see beyond their immediate frustrations and consider more seriously the longer-term implications of a decision that is clearly unwise from a medical standpoint,” says Kaldjian.
Physicians’ attitudes varied widely on whether nudging (subtly influencing patients’ decisions) was ethically permissible, found a recent survey.3 “We were struck by how divided pediatric intensivists were on what counts as ethically permissible nudging,” says Aliza Olive, MD, associate staff in the Division of Pediatric Clinical Care at Cleveland Clinic Children’s Institute. Olive and colleagues surveyed 132 pediatric intensivists about the ethical permissibility of various nudging techniques. Physicians were asked about framing (emphasizing specific aspects of a choice), saliency (drawing a patient’s attention to specific information), and default (presenting an option as a standard choice). Physicians varied widely in how often they used these nudging techniques and whether they perceived each technique as ethically permissible. For example, equal numbers of physicians said that negative framing was “not at all” or “extremely” ethically permissible.
Physicians’ views also varied depending on the clinical scenario. For example, negative saliency (drawing attention to information that supported not having a procedure) was found to be more ethically permissible for a traumatic brain injury case and positive saliency (drawing attention to information that supports having a procedure) was more ethically permissible for a tracheostomy. “This could reflect clinicians’ implicit assumptions about disability and long-term quality of life. These assumptions can unintentionally influence how risks and benefits are communicated and, therefore, choices made by patients and their families,” suggests Olive.
The researchers also found a mismatch between reported and observed behavior. In a prior study, Olive and colleagues observed that physicians used saliency infrequently in actual care conferences.4 Yet, in this survey intensivists reported using saliency often. Conversely, default options were reported as the least-used technique by intensivists but had been observed often by the researchers in their own clinical practice. “That disconnect raises questions about unconscious use of nudging and the limits of self-report. Clinicians should recognize that nudging is already happening, whether they intend it or not,” says Olive.
The way physicians inform patients about survival statistics, the order in which options are presented, or the tone of voice used can shape family decisions. This often happens without clinicians realizing it. “It’s critical that we reflect on how these strategies align with core principles of shared decision-making, especially patient and family values, autonomy, and trust,” says Olive. Telling a family there is a “90% chance of survival” conveys the same information as saying there is a “10% chance of death.” “But the emotional impact and decision pathway can be quite different,” says Olive. Likewise, if a doctor uses a hesitant or flat tone when discussing an option, it signals doubt. A warm, confident tone can make the same option feel more acceptable. “These influences are part of everyday communication in medicine. While they cannot be eliminated, clinicians should become more aware of them to ensure that they support thoughtful, values-aligned decisions rather than unintentionally undermining autonomy,” warns Olive.
Subtly influencing patients’ choices through “nudges” is unavoidable to some extent, according to Jenny Blumenthal-Barby, PhD, MA, associate director at the Center for Medical Ethics and Health Policy at Baylor College of Medicine in Houston, TX. Blumenthal-Barby is author of Good Ethics and Bad Choices: The Relevance of Behavioral Economics for Medical Ethics.
Moreover, nudges can support patient autonomy by helping patients make choices that are best aligned with their values and goals. “Utilizing insights from behavioral economics and decision psychology to shape medical decisions can also protect and promote patients’ interests — a central tenant of medical ethics. For all these reasons, if done well, nudges can be a helpful and critical part of shared decision-making,” asserts Blumenthal-Barby.
On the other hand, if nudges promote the clinician’s pre-determined agenda and obstruct dialogue, it can undermine shared decision-making. “Ethicists play a crucial role in supporting clinicians in terms of navigating the gray areas of influence and autonomy. The development of ethical approaches to nudging could be supported through both formal and informal mechanisms,” says Olive.
Ethicists can help to develop formal policies or guidelines outlining principles and examples of ethically permissible nudges and persuasive techniques, especially in high-stakes settings such as critical care. At the same time, informal support, such as ethics rounds, case-based discussions, and training sessions, can help clinicians reflect on their own practices in real time. “Ethicists can help ensure that the patient’s voice remains central — even in emotionally and ethically complex conversations like those in the pediatric ICU (intensive care unit),” concludes Olive.
Stacey Kusterbeck is an award-winning contributing author for Relias. She has more than 20 years of medical journalism experience and greatly enjoys keeping on top of constant changes in the healthcare field.
References
1. Opel DJ, Ayala E, Spielvogle H, et al. Development of a tool to measure the dyadic process of shared decision making in young children: The Making Decisions for Kids (MADE for Kids) survey. Med Decis Making. 2025;45(7):834-848.
2. Muckler J, Thomas JC, Shinkunas L, Kaldjian LC. Medical students’ attitudes and experiences regarding persuasion of patients by physicians: Clarifying the ethics of shared decision making. J Gen Intern Med. 2025; Sep 4. doi: 10.1007/s11606-025-09807-w. [Online ahead of print].
3. Olive AM, Wagner AF, Sherman AK, et al. Pediatric intensivists’ perspectives on nudging: A multi-institution assessment of ethical permissibility. AJOB Empir Bioeth. 2025; Jul 1. doi: 10.1080/23294515.2025.2526328. [Online ahead of print].
4. Olive AM, Wagner AF, Mulhall DT, et al. Nudging during pediatric intensive care conferences with family members: Retrospective analysis of transcripts from a single-center, 2015-2019. Pediatr Crit Care Med. 2024;25(5):407-415.
