Abstract

The aim of the paper is to consider the potential and challenges regarding the implementation of the shared decision-making approach in the Polish health care system, also taking into account the moral and communicative-discursive advantages of such a change. The paper consists of several sections, in which the author: defines the objectives and method of the paper (Sections 1, 2), presents the theoretical background of changes in health care (Section 3), and outlines the characteristics of Polish health care and the legal-institutional framework in Poland after the democratic turn in 1989 in terms of the ongoing communicative crisis in the relations between patients and health providers (Section 4). Next, the author distinguishes the ethical essentials of shared decision making, also presenting its affinities with J. Habermas’ communication and discourse ethics, as an approach which can be applied in the clinical practice of medicine (Section 5), including the shared responsibility principle (Section 6). The next step was to name reasons for which health and medical values, SDM and practical discourse ethics can be linked together (Section 7). Then the author considers how the SDM model could be implemented through sampling cases from other countries (Section 8). Subsequently, she describes structural and normative potentials to adapt SDM and practical discourse ethics for Polish public health care (Section 9). A discussion follows.

1. Objectives

The main purpose of the paper is to consider the potential and challenges regarding the implementation of shared decision-making (SDM) in the Polish healthcare system, taking into account the moral and communicative-discursive advantages of such a change. The paper consists of several sections which outline the SDM approach, revisit the core communicative-discursive arguments that support it, weigh up the advantages and challenges of improving the SDM (also in terms of institutional framework and competencies), and provide examples of its application to clinical practice.

While scholars highlight the need for patients’ involvement in clinical decision-making and report on related developments that have taken place in countries across Central Europe, including Poland, after the democratic turn in 1989, some different developments can be observed: structural and competence-related barriers to communication and sharing clinical agreements and decisions with patients, and discouraging patients from contributing to clinical decision-making. Even though allowing patients to voice their concerns and expectations is increasingly present in healthcare contexts, as is the practice of healthcare providers listening to these perspectives, this alone is not equivalent to SDM, reciprocity and agreement. It is not the aim of this chapter to evaluate these practices for economic value or effectiveness within healthcare.¹ However, they certainly contribute to an area of shared health-related values among patients and health professionals. How these values are understood still remains a problematic question.²

2. Methods

The article reports on authors’ investigations, supported by the topic-related international literature, with a focus on the participation of patients in clinical decision-making in the Polish context. The literature was used to 1) advocate for the need of SDM and reciprocal agreement in clinical contexts and to 2) describe and introduce the SDM approach as a socially inclusive method for involving specific values, priorities and interests related to patients’ health, which already has the generally and publicly recognised status of one of the core goods.

The data and selected literature on SDM are compared with Polish scholarship on the subject, within the specificity of Polish healthcare, and subsequently discussed. It is worth noting that the applicability of SDM varies with the types of medical care (outpatient or inpatient care) and medical specialisations. Critical healthcare, for example, leaves little space for reciprocity, SDM and agreement, and refers more to healthcare providers’ expertise and responsibilities. This paper revisits scholarship mainly referring to outpatient care, with the background of healthcare in general. The theoretical framework developed by the author focuses on communicative and discourse competences, actions and interactions as being supportive for SDM and agreement based on a shared episteme, the mutual understanding of the participants involved, and jointly discussed, weighed up, argued and justified outcomes, i.e. valid decisions and arrangements related to diagnosis, treatment and prophylaxis.

Within the framework of the communicative-discursive paradigm, the researcher intends to extract and analyse those moments of the communication situation where there is an exchange of arguments between at least two rational subjects who are able to speak to each other. One of the basic conditions for the occurrence of communicative and discourse interactions between the participants of clinical situations in which medical decisions, arrangements and agreements are made is that only such justifications that can be acceptable to all parties and reach an agreement are considered, while all the validity claims are maintained. The extensive international scholarship addressing the topic and reporting on developments and practices implemented elsewhere only confirms that the communicative and discursive ‘state-of-the-art’ in the Polish healthcare context is stunted when compared to other countries. However, the topic still remains a priority for international researchers and practitioners interested in the improvement of medical communication. Simultaneously, communication, discourse-based and SDM are becoming increasingly marginalised by new, technologically and digitally supported systems which tend to ease but also minimalize and marginalise the participation of human subjects. Unlike the recent technological approaches promoting electronic health (Gordon et al., 2020; Sutton et al., 2020),³ this paper advocates improving the human and interhuman values and qualities of the practice of medicine.

3. Background

The primary goal of a healthcare system is to ensure that citizens have access to health services. From an ethical point of view, health is a special kind of good situated on the (social) border between the private and public, which makes it susceptible to institutional supervision, which is, in fact, necessary. Health as a social good and value is the subject of academic discussion, and each of the authors of this volume refers to it in some way.⁴ The idea of fair and equal access to health services does not generally in itself raise moral objections. The problem arises when we try to clarify what ‘health’ and ‘healthcare’ mean, and what kind of health services people actually need and how to provide them.⁵ Moreover, the specific organisation of the health-care system constitutes specific interpersonal relationships and social qualities between patients and medical professionals. In particular, chronic and long-term diseases have become a growing problem in Western societies. The distribution of goods in such diseases’ related situations is often extremely challenging for decision makers.⁶ However, the prevalence of chronic diseases also leaves some open room for models to involve patients’ activism as decision makers. The area of inter-subjective interactions in medicine is particularly sensitive from the moral point of view and should be given careful consideration if a model of SDM, or something similar to it, is to be adopted.

The healthcare sphere is essentially that of interpersonal interactions and co-operation. This sphere differs from other social interactions and cooperation for several reasons. Firstly, it is the vulnerability of a living, human person into whose life healthcare providers make interventions through diagnosis and treatment. Such interventions are both actions and interactions: patients are not malleable material objects; their status and contributions are those of subjects who have their own personality, autonomy, rights, priorities and vital interests. Doctors’ influence on patients might seem one-sided, as the former embody professional expertise and responsibilities, while the latter are laypeople, the passive recipients of healthcare provision and the charges of health providers. However, above and beyond such asymmetries, patients are very much involved in co-operating with these professional healers and carers. Co-operation is not just mechanical and economic (though contemporary healthcare systems improve marked-like relationships between healthcare contractors and purchasers). Interhuman co-operation implies that interaction is immediately managed by subjects in the process of communicating with another, to recognise the other, to understand each other and to make agreements and decisions at least with the patients’ informed consent – if patients’ active participation on medical decision-making is limited. The elements discussed above create a space for shared health-related values and preferences in medical contexts. According to the tradition and assumptions of the author of this chapter, these are values created and established through discourse and communication tools which will be described in more detail in the following paragraphs.

The participants of such interaction (patients and their family members, healthcare providers, nursing personnel and further entitled agents) constantly have to manage a large and complex area of issues oscillating between life, health and well-being, one the one hand, and illness, pain, suffering, quality of life,⁷ risk and mortality, on the other. Managing such a far-reaching and sensitive area which, additionally, touches patients’ emotional and experiential sphere and their involvement in social reality (various life-worlds and life forms) seems to be unusually hard. Healthcare should, therefore, not only be reduced to the delivery of health services but should also embrace humanistic, social and communicative-discursive dimensions to allow the sharing of all kinds of related episteme and to open up an epistemic field or horizon within which healthcare professionals and patients meet together to communicate and develop decisions based on reciprocity and agreement. Within this intersubjective field, not only the existing scientific knowledge and medical expertise, evidence and technai are to be properly selected, agreed upon by subjects and applied. Novel knowledge, called “getting to know the patient” (Kępiński, 2002), which seems scarcely possible without the patient's contribution, is also produced here. Last but not least, clinical agreements and decisions rooted in this new knowledge should be shared, argued, justified and recognised by subjects who co-create their common field and intersubjective relationship within the field. The field is about reclassifying “a social logos into a communicative dialogos“ (Siemek, 2000, p. 36), following M. J. Siemek, one of the leading advocates of applied intersubjectivity and practical discourse in Poland. “Effective doctor-patient communication is a central clinical function in building a therapeutic doctor-patient relationship, which is the heart and art of medicine. This is important in the delivery of high-quality health care” (Ha and Longnecker, 2010, p. 38).

A specific change can be identified as having occurred within the relationship patterns of healthcare providers and patients both on the international level and in Poland, reflecting changes that took place in bioethical reflection in the 20th century: a shift from the paternalistic model to informative or informed models and, finally, to deliberative or deliberation-supported modes.⁸ Current models, taking into account practical needs, more or less fulfil the postulate of patient participation in the treatment process. However, the approach based on SDM seems to be closest to a full realisation of this postulate. Moreover, it has a number of advantages from the point of view of its therapeutic effectiveness and in terms of improving communicative-discursive quality, which will be presented later in the paper. Considering primary care, several important issues may be highlighted. As Cheraghi-Sohi et al. noticed,

Responding to the preferences of patients concerning, the delivery of health care is an important aspect of current health policy worldwide. This is especially relevant to primary care, which has traditionally been viewed as health care, which is oriented to the needs of patients rather than focused on technology. (Cheraghi-Sohi et al., 2006, p. 276)

As a part of primary care, medical professionals first contact patients (starting with the reception desk), which often sheds light on the rest of the therapy and treatment process (Légaré et al., 2011; Meijers et al., 2019).

4. Polish healthcare as an institution after the 1989 democratic turn

The Polish healthcare system is a part of the bigger sphere of public healthcare. According to the Polish Constitution, everyone has the right to have access to health care services, irrespective of their ability to purchase such services⁹ (which may also be regarded in terms of A. Sen and M. Nussbaum's Capabilities Approach).¹⁰ Health, as one of universally important social and individual values, goods and interests, is, thus, enshrined in the centre of social interest-sensitive legislation. On the one hand, health belongs to the key personal goods, however, on the other and, public supervision and protection is exercised over it. Models of healthcare are aimed precisely at such supervision and ensuring health protection as a value. However, the Polish healthcare system itself underwent radical reforms after 1989. A large number of social, economic, ethical, cultural and institutional factors have influenced its modernisation, including the democratic transformation in Poland, an unstable economic situation typical for post-communist countries, and the social and living conditions of the citizens during the transformation period.¹¹ Under the 1999 reform, the previous budget system (based on local health authorities, in Polish: kasy chorych) was replaced by the centralised insurance-budget system, which was based on the principle of social solidarity and the principle of universality.

Established in 2004, the National Health Fund provides partial financing of health services from the taxpayers’ public funds. The Polish healthcare system is currently based on general and mandatory social health insurance, but health services are increasingly simultaneously financed from private funds. Providing publicly financed health services (through the National Health Fund) is carried out through procedures. Service providers (medical facilities) could buy specific procedures that meet the health needs of the patients. However, it is assumed that there is no traditionally understood “healing process” within procedures (e.g. Piechota and Piechota, 2012; Śliwiński et al., 2013). The complexity and quality of the treatment/healing process depends not only on the type of procedures purchased and implemented by the facility. The issue is how these services are delivered: the emphasis is increasingly placed on efficiency and effectiveness and on efficient communication with patients.

It may be justified to refer to the changes which took place in Polish healthcare at the turn of the 20th and the 21st century as a communicative–discursive ‘turn’. Not only have the organisational structures and methods of financing health services changed but also – perhaps above all – the relationships with stakeholders. There is a noticeable lack of encouragement to improve collaborative communication, reciprocity and shared agreement and decision-making in the Polish healthcare system, particularly regarding services financed from public funds. Scholars even report that there is a communication crisis or, at least, stagnation in the clinical relationships between healthcare providers and patients (Kuskowski, 2019; Schütte et al., 2018). Among the reasons for this, we could mention the arduous transition from the traditional (i.e. paternalistic) to modern (i.e. participatory) and patient-involving models of healthcare delivery (Emanuel and Emanuel, 2004; Sasz and Hollender, 1956), and deficits in the sphere of communicative-discursive models, practices and competences.¹² Communicational standards and decision-making practices have failed to keep up with modernisations and transformations triggered by the democratic turn after 1989. Although constantly undergoing reforms, healthcare provision in Poland shows that it lacks the capability and willingness to open itself to SDM and the emerging professional medical knowledge horizon with the social horizons represented by patients (DiMatteo, 1998; Greenfield et al., 1985; Lee and Garvin, 2003).

One of the most developed participatory models of the doctor-patient relationship is the SDM approach, which will be described briefly in the next section of the paper. The author recommends considering how such an approach could also work in the Polish healthcare area.

5. Ethical essentials of SDM with relations to discource ethics

Shared decision-making has been defined as “an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences” (Elwyn et al., 2012, p. 1361).

Firstly, taking into account autonomy as one of the most important ethical principles of modern medical ethics (Engelhart, 1986), priority is given to self-determination in this model. In the context of SDM, self-determination does not mean that individuals are abandoned.¹³ Within this approach, the need to support autonomy is based on building good relationships, respecting both the individual competence and interdependence of others, and our intrinsic tendencies to protect and preserve our well-being. Elwyn and colleagues also use the term “relational autonomy” to articulate the statement, according to which “we are not entirely free, self-governing agents but that our decisions will always relate to interpersonal relationships and mutual dependencies” (Elwyn et al., 2012, p. 1361). Elwyn and colleagues’ statement depicts communicative intersubjectivity as always being essential for, sensitive to and respecting other subjects’ freedom and rights, which are fundamental for the practice of medicine as a social practice among autonomous and rational subjects – and crucial for patients’ empowerment.

Secondly, SDM empowers patients’ agency by providing high-quality information and supporting the decision-making process, for example, by means of deliberation,¹⁴ There has been increasing emphasis on patient participation in the medical (clinical) decision-making process over the last few decades, (Frosch and Kaplan, 1999, p. 285).¹⁵ Participatory models began to appear as an alternative to the paternalistic one in which the doctor makes all the treatment decisions. The patient's inclusion in the decision-making process began to be seen as necessary due to the emerging discursiveness of medicine (Rothman, 1991). This tension between paternalistic and participatory models of healthcare delivery and the practice of medicine is particularly apparent in countries that have undergone political transformation (Antoun et al., 2011). A strong hierarchy in public services and asymmetry between ‘laypeople’ and ‘professionals’ was observed prior to the transition.

The principle of the patient's empowerment should not be confused (or be equated) with obtaining informed consent from a patient. As Frosch and Kaplan observed:

While ethical guidelines mandate informed consent, especially when a recommendation involves a potentially harmful intervention, shared decision making goes several steps further. Beyond presenting the patient with facts about a procedure, shared decision making is a process by which doctor and patient consider available information about the medical problem in question, including treatment options and consequences, and then consider how these fit with the patient's preferences for health states and outcomes. After considering the options, a treatment decision is made based on mutual agreement. (Frosch and Kaplan, 1999, p. 285)

The communicative and discursive competencies of both the doctor and the patient are essential in the SDM process outlined above (Newton-Howes et al., 2019). There can be no question of formulating arguments as to a particular treatment path if the doctor is unable to formulate the judgments clearly and communicate them to the patient. Similarly, it is not possible to reach agreement on treatment if patients are unable to articulate their interests, preferences and needs.¹⁶

However, and this is the fourth point, this very basic, linguistic competence cannot be regarded as a communicative competence in Habermasian terms.¹⁷ To Habermas, “language performance is an element of a monological capability” (1970) and, yet, not of a communicative ability or competence, respectively. To Habermas, communicative competence is originally and by definition intersubjective and dialogical.

The “basic qualifications of speech and symbolic interaction (role-behaviour) which we may call communicative competence” are required to develop communicative competence. “Thus communicative competence means the mastery of an ideal speech situation” (Habermas, 1970, p. 367) or – according to Habermas’ concept of anticipating or approximating an ideal speech situation by real, socially embedded and world-situated participants – a skill to communicate interactively and consensually, i.e. oriented towards an agreement (Verständigungsorientiertes kommunikatives Handeln), within a communicative interaction with other subjects. Communication needs speech acts (Sprechakte), not just linguistic acts (Sprachakte). Furthermore, “I call interactions communicative when the participants coordinate their plans of action consensually, with the agreement reached at any point being evaluated in terms of the intersubjective recognition of validity claims” (Habermas, 1990, p. 58) of the proposed plans. Clarifying all ‘yes’ and ‘no’ statements, pros and cons, and the conditions of a rationally motivated agreement belongs to communicative interactions.

The uneven communicative skills of subjects (or their unequal rights to communicate) have dramatic consequences for communicative intersubjectivity: the “deformation of the intersubjectivity of mutual understanding which is built into the social structure” (Habermas, 1970, p. 372), including medical communication and the decision-making framework collaboratively made by patients and healthcare providers. Such a deformation implies further negative consequences for the reciprocal sharing, understanding and recognition of related interests, values and priorities and their validity (and validity claims).

It is worthwhile recalling Habermas’ statement from the same book for the better inclusion of patients’ cognitive perspectives and their interdependencies on their life-worlds and life forms as an integral content thematized within a communicative-intersubjective situation in clinical and medical contexts:

The process of reaching an understanding between world and lifeworld. The lifeworld, then, offers both an intuitively preunderstood context for an action situation and resources for the interpretive process in which participants in communication engage as they strive to meet the need for agreement in the action situation. Yet these participants in communicative action must reach understanding about something in the world if they hope to carry out their action plans on a consensual basis, on the basis of some jointly defined action situation. (Habermas, 1970, p. 135)

Considering all four of the arguments in the check-list above, attention should also be given to the educational potential of communicative action and interaction, in Habermasian terms, for the implementation of the SDM approach in clinical contexts. According to Rusiecki and colleagues,

Shared decision-making is a core competency in health policy and guidelines. Most U.S. internal medicine residencies lack an SDM education curriculum. A standardized patient (SP)-based curriculum teaching key concepts and skills of SDM was developed (Rusiecki et al., 2018, p. 1).¹⁸

On the one hand, this kind of communicative interpersonal practice is very suitable for recommendation in the practice of medicine as such, and the related skills should be implemented during the training of prospective medical professionals. On the other hand, patients should also be better trained in their communicative skills, so that they are enabled and empowered to participate in clinical communicative situations, such as SDM, whose outcomes require their agreement, usually practiced as simplified and under-considered forms of informed consent.

6. When A, then B? From shared decisions to shared responsibilities

Finally, both of the following are essential components of SDM: 1) communication and discourse ethics, with its key values and respect for patients’ rights to voice their interests and priorities, to communicate in order to seek understanding, recognition and consensus, to participate in medical decisions and arrangements closely related to their health, etc., and 2) the ethical principle of responsibility (‘shared responsibility’). Sharing responsibility unavoidably accompanies SDM, in the form of being actively engaged and participating in decision-making, achieving agreements and arrangements by means of communicative skills, and within intersubjective communication between healthcare providers and patients. All these activities can also be regarded as forms of self-determination and -governance assisted and supported by medical professionals’ best expertise, evidence and scientific knowledge.

However, the principle of shared responsibility in medical decision-making contexts is also strictly connected to medical uncertainty, which is tied up with clinical practice. Responsibility belongs to the core values of healthcare delivery and medicine. However, one might ask if – and if so why – responsibility for choosing treatment and treatment outcomes should be shared between the doctor and the patient. The evaluation of available options for treatments and therapies must be based on the assessment of the patient's health condition (diagnosis). However, a patient also brings an important contribution to the discussion about the treatment options. Healthcare providers cannot access such information without conversation, i.e. knowing and properly understanding (and clarifying with a patient if necessary) the preferences regarding, for example, a patient's beliefs on well-being, health and risk, indications that someone leads an unhealthy or healthy lifestyle, their personal tolerances for pain and discomfort, their future plans and long-term health expectations, and prospects related to the therapeutic process and its dynamics, to prophylaxes, to plans (such as pregnancy), to professions, cultures and religions. (Frosch and Kaplan, 1999, p. 287). The communicative-discursive approach allows health professionals to learn more – and to become more mindful – about patients’ individual value and goal preferences (see Section 9).

Responsibility in the healing process can manifest itself in various ways. In some cases, it may be limited to following the doctor's instructions (following a special diet, physical activity, taking prescribed medications regularly). In other cases, it concerns responsibility for the choice of treatment itself. The issue, particularly in the light of healthcare transitions, is the following: how to teach patients and sensitise them to this kind of shared responsibility? It is also one of the ethical issues in all relationship-centred models.¹⁹

To sum up this section, it should be stressed that the SDM approach is advantageous for several reasons. It requires the active participation and engagement of both the doctor and the patient, which is also relevant within the communicative-discursive paradigm. When patients actively participate in the treatment process, they are better prepared for following directions and have a better understanding of their health condition. From a medical point of view, it allows for better data collection and, thus, establishing optimal and effective treatment plans (it forces the doctor to consider all the treatment alternatives, therefore, the quality of decisions may be enhanced). Moreover, the SDM approach strengthens patients’ autonomy through making them aware of the treatment decisions and the results and helps to develop shared responsibility for the treatment.

7. The appreciation of health and medical values in comparison to SDM in comparison to practical discourse

Since they deserve appreciation for their health-related values, patients involved in SDM (especially when linking this involvement with communication and discourse ethics) obtain a favourable opportunity to reorient healthcare providers’ awareness and mindfulness – from the institutionalized and impersonal level of health and medical values ‘in general’, to the level of values (value preferences, respectively) which are to be actually determined for individual patients.

This opportunity would improve patients’ health-related activism (Zoller, 2005) and, thus, their ability to express, co-determine and co-decide what matters or what is valid (in German “was gilt”) for them, since for Habermas, the decision-making process is value preference- and prior goal determinationladen. In communities with multiple values in which all subjects are potential patients, health-related preferences belong to the “strong preferences […] that concern not merely contingent dispositions and inclinations but the self-understanding of a person”. Unlike “weak or trivial preferences,” strong preferences not only require “value decisions” but also “require justification” and “strong evaluations” and judgments, Habermas argues (1993, p. 4).²⁰

As a consequence, the justification of patients’ value and goal preferences necessarily implies patients’ moral right to justification. Such a right is defended, for example, by R. Forst (2011). This right corresponds to the core premise of SDM, according to which SDM (similar to evidence-based medicine) aims at “the integration of best research evidence with clinical expertise and patient values” (Bae, 2017, s. 1.; Sackett et al., 2000). Improving that right through SDM and practical discourse may advance the nature of clinical decision-making.

In this regard, the shared decision-making model (SDM) is intended to replace the traditional style of asymmetrical one-way communication between physician and patient that has been handed down for centuries by medical tradition. (Kasper et al., 2012, pp. 3–11)

The actualised and justified value preferences remain in resonance with the impersonal and universal values already framing healthcare – as one of the common social institutions. Additionally, involving both sides in SDM, i.e. healthcare providers and patients, combined with the communicative and discourse situation would provide more symmetry between the healthcare providers and patients’ axiological perspectives regarding health improvement,²¹ but also in the light of the unity of intersubjectively situated practical reason, pre-originally interested in sharing the_values and normativities upon which subjects agreed or achieved an intersubjective Verständigung (understanding), respectively. The latter seems to be the very – and even only – source of values, regardless of these values to which a similar social agreement had already come into being previously (and still persists).²² Finally, the appreciation of values by subjects involved in reciprocal, communicative and discourse relationships occurs through actual and factual confirmation vs. the questioning and disconfirmation acts performed by subjects with reference to their experience and practice (“der Faktizität der kontextabhängigen und handlungsrelevanten Ja-/Nein-StellungnahmeI”) (Habermas, 1988, p. 182), especially from a patient. Maintaining a link to a patient's lived and actual values and their vital interests is essential for applying SDM and practical discourse in order to make the treatment as appropriate and beneficial for them as possible, i.e. to balance health values between the needs and demands arising from someone's actual health condition, on the one hand, and the health, well-being and further common values upheld by the healthcare system as a common social institution serving all, on the other hand. The intersubjective aspect of value appreciation within medical and clinical contexts gives saliency to what Habermas names “solidarity” (solidarisches Zusammenwirken) among the subjects making up a society and being concretely (nicht in abstracto) oriented towards relieving the plights of fellow creatures and implementing their intended priorities.²³

In the following section I will consider in which clinical circumstances it may be possible and adequate to implement SDM (and related elements of practical discourse ethics) within clinical practice.

8. How can SDM and practical discourse models be implemented? Sampling cases

Generally, given the possibility of implementing relationship-centred models (in the broad sense) for clinical practice, the following question emerges: do we have any framework for this? According to Frosch and Kaplan,

several conditions must be met for shared decision making to occur. First, the atmosphere must be conducive to active patient participation. The attending physician must make patients feel that their contributions are valued. Patients in turn need to be frank about their preferences and goals for treatment. The physician then helps the patient determine how these goals and preferences fit with the available treatment options and a shared decision is reached. (Frosch and Kaplan, 1999, p. 285)

These conditions should also include the communicative-discursive competences which are essential for functioning in public life area in general.

The most important issue for many practitioners is how the idea of SDM can work in daily clinical practice. Elwyn et al. (2012) formulated a three-step, simplified model for clinical practice which consists of several parts: choice, option and decision talk. As the authors observe,

Choice talk refers to the step of making sure that patients know that reasonable options are available. Option talk refers to providing more detailed information about options and decision talk refers to supporting the work of considering preferences and deciding what is best. The model outlines a step-wise process, although it is important to recognise that the model is not prescriptive – clinical interactions are by necessity fluid. Decision support tools provide crucial inputs into this process. (Elwyn et al., 2012, p. 1363)

There is still no guidance in Polish healthcare on how to implement SDM elements in medicine. However, it could be interesting to consider in what clinical circumstances the doctor can really makes decisions with the patient.

As a meaningful example, one may consider hypertension as one of the conditions that is typical and widely present in the literature.²⁴ This is a condition in which close co-operation between the doctor and the patient is necessary. The therapy will have no effect without patient involvement: elimination of drugs, changes in lifestyle and taking medication. However, this is not all that can be said about the patient's participation in the treatment process in this case. Some interventions may have long-term benefits while reducing the quality of life in the short term. Recalling Frosch's example, a patient with mild hypertension may experience no symptoms now, but taking anti-hypertensive pharmacotherapy may cause symptoms in the form of side effects. However, this therapy may lead to overall better life expectancy. Reducing the long-term morbidity associated with the consequences of hypertension is the aim of such therapy. On the other hand, reduced blood pressure does not necessarily imply certain long-term health benefits. As a result, the gain from taking anti-hypertensive medication is delayed and probabilistic (Frosch and Kaplan, 1999, p. 285). In a case like this, it is necessary for the doctor to be able to talk to the patient and present all the possible side effects and the expected effects of the therapy exhaustively. However, it is also important for the patient to bring information into the discussion about their preferences, life plans that may affect therapy and any significant claims about the treatment.

More straightforward and readable examples from oncology can be found. In the already classic article on the subject, Charles and colleagues outline three scenarios in which a patient with newly diagnosed early breast cancer shares the best treatment options with her physician (Charles et al., 1997, p. 691). As a part of this model example, we can see how the doctor guides the patient through the decision-making process, taking her concerns, preferences and wishes into account. In this case, effective decision-making is recommended because of the need to choose the treatment path quickly. It will be completely different, for example, in the case of chronic diseases, such as diabetes.

9. SDM meets Polish healtcare system: open questions

Considering the implementation of SDM elements in such systems as Polish healthcare, two basic research questions can be posed: firstly, are patients sufficiently encouraged and empowered and competent (in terms of Habermas’ communicative competence and related competences described in this article) to actively and effectively participate in and contribute to clinical and medical decisions concerning their health?

Secondly, and this may be even more relevant, do doctors want patients to make decisions? As far as the former question is concerned, one can once again notice the tension between the paternalistic and participatory models in medicine. Patients sometimes simply do not want to participate in the treatment process for various reasons. They intuitively feel, for example, that the doctor should be the only decision maker because of his/her expertise and professional skills or, alternatively, they are afraid of taking the responsibility that would emerge with participation in the treatment process. According to Elwyn's general findings,

some healthcare professionals express doubts, saying that patients don't want to be involved in decisions, lack the capacity or ability, might make ‘bad’ decisions, or worry that SDM is just not practical, given constraints such as time pressure. Others claim they are ‘already doing it’, though data from patient experience surveys indicates that this is not generally the case. It is therefore clear that the first step for those advocating the uptake of SDM is to ensure that clinicians and others support the underlying rationale. (Elwyn et al., 2012, p. 1362)

Similarly, in Polish society, the tension between citizens’ participatory needs and their ‘paternalistic’ habits or expectations can be observed, especially in elderly people who still remain mentally rooted in the past reality (predemocratic, social, political and institutional) which was much less favourable for an individual's participation in decision-making. Polish people are becoming more active when communicating with doctors due to open access sources on the Internet, the availability of medical knowledge and their health awareness. However, both reliable research on the issue and in-depth reflection in interdisciplinary teams are still needed. When it comes to the second question – do doctors want patients to make decisions? – the attitudes of doctors can vary significantly (Hall et al., 2018).

Several difficulties may be identified within the public part of the healthcare system including the lack of time for consultation, staff shortages, financial limits for tests, long waiting time for highly specialised care and difficulties in accessing specialised tests. In turn, another group of issues involves the limited discursive competences of stakeholders (limited discursive competences in the public sphere in general), communication disturbances and interaction misunderstandings. It is also worth noting that there is general dissatisfaction regarding the public healthcare system. The majority of patients are dissatisfied with the quality of services. The number of patients’ grassroots initiatives (Borek and Chwiałkowska, 2014) has also been increasing in recent years.

The question remains open regarding what kinds of clinical decision-making (considering the difficulties mentioned above) are most amenable to being transformed into decision-making that involves patients. Is the Polish healthcare system itself suitably designed to enable SDM? One of the ideas for improving the quality of services was the legal act on primary care in 2017.²⁵ According to this idea, the primary care physician (family doctor or internist) was to play the role of a patient's ‘guide’ in the world of the complex dependencies of health services (this is particularly useful when a doctor meets a patient for the first time). The continuity and comprehensiveness of activities for the patient was emphasised within this idea. The diagnostic and therapeutic procedure offered the opportunity to get to know the patient better and share some decisions.

Apart from a group of factors directly related to the provision of medical procedures (diagnostic and therapeutic), one can consider the challenges that Polish healthcare has to face in order to be able to implement more patient- or relationship-centred solutions, such as SDM. One of the important, broader issues is how to share responsibility among doctors and patients. This happens when doctors motivate patients, to make them empowered and mobilized, not passive and dependent; when patients have the opportunity to verbalise and define their emotions, the patients’ concerns are taken into account in the diagnosis and establishing the treatment plan, and when doctors accept that there is a need for equal communicative competence between themselves and their patients, because the expert knowledge of doctors is not enough to make the decision that is best for their patients.

Finally, one should consider, especially in the light of intensive changes in healthcare, how to educate doctors and patients in the area of communicative and moral-discursive competences. Medical simulation centres are a relatively new method of educating physicians in terms of communication with patients. Thanks to training involving role-playing in specific clinical situations, medical students and professionals can acquire the practical skills necessary to provide information to patients and their families. However, it should be noted that providing information is only one aspect of communication with patients. Communicative-discursive competences require the equal participation of the doctor and the patient in the treatment process, which is also important in the SDM approach. This aspect should be given more attention in future research.

10. Conclusions and further research perspectives

Shared decision-making is an advantageous and valuable approach, widely described in international scientific scholarship and successfully implemented in clinical practice in several countries. Its implementation requires meeting basic institutional and organisational conditions, and the competences of the participants of clinical interaction. As a result, this approach would contribute to strengthening patients’ empowerment and self-determination. Moreover, from the ethical point of view, it could help to create a common area of shared, health-related values in medicine. Many elements of practical discourse are implemented within SDM. The participants of the interaction can learn from each other how to understand the other person's views and how to agree upon value and goal preferences. Both the expertise and axiology of health professionals differ (or may differ, as shown above) from the expertise, and value and goal preferences embodied by patients (Leanza et al., 2013). Including the latter in clinical decision-making supported by SDM and practical discourse ethics would improve patients’ right to justification and their participatory contributorship, which was the subject of Section 7.

When considering SDM elements in daily clinical practice in Poland, several challenges must be considered: (1) have we already achieved sufficient institutional and infrastructural conditions for relationship-centred approaches? (2) How can the communicative-discursive competences of patients and healthcare providers be improved to increase the participatory and dialogical style of communication in clinical contexts, as communication resulting in shared decisions, justifications and agreements being made. (3) In what clinical circumstances would patients’ more active contribution to the treatment, diagnosis and prophylaxes-related decisions be most appropriate and which systems and procedures would support it, as healthcare has many sectors and organisational and management levels.

It is difficult to answer these questions and to estimate the chances for the adoption of SDM in the Polish healthcare system. Episodic pathbreaking activities undertaken by patients can be observed (Drozd-Garbacewicz, 2015; Molęda, 2011; Napiwodzka, 2020 in process; Nowak et al., 2020, in process). In the light of the communicative-discursive and participatory-deliberative turn in healthcare delivery systems observed in numerous countries (though not in all), the SDM approach has been underrepresented in Polish medical-ethical scholarship until now. I hope that this article makes a preliminary contribution to its consideration in Poland and discussing challenges related to this subject in the international context.

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