Deliberation before determination: the definition and evaluation of good decision making
Article first published online: 9 SEP 2009
© 2009 The Authors. Journal compilation © 2009 Blackwell Publishing Ltd
Volume 13, Issue 2, pages 139–147, June 2010
How to Cite
Elwyn, G. and Miron-Shatz, T. (2010), Deliberation before determination: the definition and evaluation of good decision making. Health Expectations, 13: 139–147. doi: 10.1111/j.1369-7625.2009.00572.x
- Issue published online: 26 MAY 2010
- Article first published online: 9 SEP 2009
- Accepted for publication 9 July 2009
- decision quality;
- patient involvement;
- shared decision making
Objectives In this article, we examine definitions of suggested approaches to measure the concept of good decisions, highlight the ways in which they converge, and explain why we have concerns about their emphasis on post-hoc estimations and post-decisional outcomes, their prescriptive concept of knowledge, and their lack of distinction between the process of deliberation, and the act of decision determination.
Background There has been a steady trend to involve patients in decision making tasks in clinical practice, part of a shift away from paternalism towards the concept of informed choice. An increased understanding of the uncertainties that exist in medicine, arising from a weak evidence base and, in addition, the stochastic nature of outcomes at the individual level, have contributed to shifting the responsibility for decision making from physicians to patients. This led to increasing use of decision support and communication methods, with the ultimate aim of improving decision making by patients. Interest has therefore developed in attempting to define good decision making and in the development of measurement approaches.
Method We pose and reflect whether decisions can be judged good or not, and, if so, how this goodness might be evaluated.
Results We hypothesize that decisions cannot be measured by reference to their outcomes and offer an alternative means of assessment, which emphasizes the deliberation process rather than the decision’s end results. We propose decision making comprises a pre-decisional process and an act of decision determination and consider how this model of decision making serves to develop a new approach to evaluating what constitutes a good decision making process. We proceed to offer an alternative, which parses decisions into the pre-decisional deliberation process, the act of determination and post-decisional outcomes.
Discussion Evaluating the deliberation process, we propose, should comprise of a subjective sufficiency of knowledge, as well as emotional processing and affective forecasting of the alternatives. This should form the basis for a good act of determination.