VIEWPOINT

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Evidence-Based PersuasionAn Ethical ImperativeDavid Shaw, PhDBernice Elger, MD

THE PRIMACY IN MODERN MEDICAL ETHICS OF THE

principle of respect for autonomy has led to thewidespread assumption that it is unethical tochange someone’s beliefs, because doing so

would constitute coercion or paternalism.1,2 In this View-point we suggest that persuasion is not necessarily pater-nalistic and is an essential component of modern medicalpractice.

There are at least 3 different types of persuasion. The firstis the removal of biases; the second is recommending a par-ticular course of action and providing evidence and rea-sons in favor of it; and the third is the potential creation ofnew biases, which could cross the line into unethical ma-nipulation. The first of these is always mandatory, the sec-ond is usually permissible but sometimes inappropriate, andthe third is normally impermissible but sometimes accept-able in rare cases.

Removal of BiasRemoval of bias is perhaps the most important form of per-suasion. A bias is a cognitive mechanism or mistaken beliefthat adversely affects a patient’s decision making. One ex-ample of a cognitive bias is omission bias, whereby a pa-tient prefers one option because it involves inaction, al-though this may result in greater harm than taking aparticular action.3 Another common bias occurs when pa-tients prioritize short-term desires over long-term desires,with patients refusing surgery because of fear, even thoughthe long-term consequences may be dire. A more commonexample is a patient refusing a particular treatment be-cause she believes it to be expensive, when it actually wouldbe free. Physicians can address such biases by providing cor-rect information to patients to inform them and hopefullyremove biases; in certain cases, appeals to emotion may alsobe appropriate (eg, if the patient has fears about undergo-ing an operation, the physician could ask if she also has fearsabout dying). The difference between providing nondirec-tive information and persuasion is that in the latter case thephysician not only delivers information and ensures that thepatient has understood it but also explicitly states at leastsome of the conclusions to be drawn from that informa-

tion. Removing biased interpretation of information is per-suasion because the physician is attempting to change thepatient’s beliefs to help the patient make a more rationalchoice. Simple provision of facts might not meet the crite-ria for informed consent if the patient is not also persuadedto believe them.

Recommending OptionsOnce biases have been minimized, the physician can assessthe patient’s key beliefs and desires and make a judgmentregarding which (if any) treatment option is best. A studyin Switzerland revealed that directive counseling was regardedas a form of undue influence by some health professionals,4

even though it is actually a physician’s duty to give an opin-ion to the patient. If information about a physician’s pre-ferred course of action is conveyed subtly, such as throughbody language, hints, or other clues, this could exert a pow-erful influence or lead to misunderstanding, in addition tobeing an unprofessional means of communicating with apatient. It could be argued that physicians who refuse to revealtheir recommended course of action are thereby deprivingpatients of relevant information and rendering them inca-pable of providing informed consent; thus, in attempting toavoid risks related to the voluntariness criterion for con-sent, which states that patients must not be coerced, phy-sicians might fail to fulfill the information criterion. Phy-sicians have substantial medical knowledge and should haveskill in assessing and analyzing risk, and it is unfair to denypatients access to this skill and knowledge set.

Creating New BiasesGiven the importance of transparency, the creation of newcognitive biases is unacceptable. For instance, some physi-cians may adopt the following suggestion to convince pa-tients: “When discussing mammography with patients forwhom it is indicated, frame the associated risk reductionin mortality from breast cancer in terms of relative ratherthan absolute risks.”3 However, doing this would overstatethe prospective benefit of mammography substantially, andit is best practice to use absolute risks. Using relative rather

Author Affiliations: Institute for Biomedical Ethics, University of Basel, Basel, Swit-zerland.Corresponding Author: David Shaw, PhD, Institute for Biomedical Ethics, Univer-sity of Basel, Bernouillistrasse 28, 4056 Basel, Switzerland (david.shaw@unibas.ch).

©2013 American Medical Association. All rights reserved. JAMA, April 24, 2013—Vol 309, No. 16 1689

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than absolute risks may amount to manipulation of the pa-tient and could only be permissible (if at all) in extreme in-stances; for example, in the case of a patient who has an ir-rational needle phobia and will die without intravenoustreatment.

The Importance of ContextThe appropriateness of persuasion is context-dependent. Per-suasion beyond minimization of bias is unlikely to be ap-propriate in situations of equipoise, for which no evidenceexists to favor one course of action over another. For ex-ample, in prenatal testing, persuasion can be rationally jus-tified if the testing will inform later choices or help to pre-pare a couple psychologically. Breast cancer screening isanother example of this: here, the evidence is that for eachlife saved by screening, 3 women will receive unnecessarytreatment.5 However, it is not known for any given womanwhich of these groups she will be in, representing a type ofequipoise. Similarly, some decisions ultimately will be basedon values rather than medical evidence; for example, a pa-tient might have to choose between having a long life withlower quality of life (by choosing chemotherapy) and hav-ing a shorter life with a higher quality of life (by not choos-ing chemotherapy). Physicians should clearly leave such de-cisions to patients but could state what they would do inthe same situation, given their own values and goals. De-pending on the context, it might be better to offer this in-formation only if the patient requests it, to avoid any ap-pearance of coercion.

As another example, even though the evidence for MMR(measles, mumps, rubella) vaccination of children is clear,6

many parents are still worried about risks. Here, recom-mending vaccination should be mandatory, because par-ents might have significant antivaccine bias because of mis-information provided by opponents of vaccination. Althoughnew biases could be created to persuade parents to vacci-nate their children, this could lead to parents avoiding fu-ture vaccinations if they felt their trust in the physician hadbeen violated. This illustrates that persuasion must be used

with great sensitivity; if evidence is not provided or trans-parency is not maintained, ethical persuasion can easily crossthe line into paternalistic manipulation.

In conclusion, persuasion is an essential component ofmodern medical practice, and it may be impossible to re-spect patients’ autonomy without engaging in persuasion.7

Physicians using persuasion should ensure that they meet6 criteria: (1) remove biases and access the patient’s au-tonomous wishes; (2) provide honest, impartial evidence-based information about prospective harms and benefits; (3)provide a rational interpretation of this information, includ-ing facts about the physician’s belief set and views regard-ing the best decision; (4) use reason rather than emotion,while sometimes appealing to patients’ emotions to coun-terbalance their existing emotional responses; (5) avoid cre-ating new biases; and (6) be sensitive to the patient’s chang-ing preferences, because persuasion is likely to change thepatient’s outlook and perspectives.

Published Online: April 8, 2013. doi:10.1001/jama.2013.2179Conflict of Interest Disclosures: The authors have completed and submitted theICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Elger reported re-ceiving travel and meeting expenses from the Swiss Federal Commission on Ge-netic Testing. Dr Shaw reported no disclosures.

REFERENCES

1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th ed. New York,NY: Oxford University Press; 2001:94.2. Singer P. Practical Ethics. 2nd ed. New York, NY: Cambridge University Press;1993:195.3. Swindell JS, McGuire AL, Halpern SD. Beneficent persuasion: techniques andethical guidelines to improve patients’ decisions. Ann Fam Med. 2010;8(3):260-264.4. Manai D, Burton Jeangros C, Elger B. Information et gestion des risques—regards juridiques, sociologiques et ethiques sur la grossesse. Bern, Switzerland:Stampfli; 2010.5. Independent UK Panel on Breast Cancer Screening. The Benefits and Harms ofBreast Cancer Screening: An Independent Review. Cancer Research UK website.http://www.cancerresearchuk.org/prod_consump/groups/cr_common/@nre/@pol/documents/generalcontent/breast-screening-review-exec.pdf. October 2012.Accessed February 12, 2013.6. Health Protection Agency (UK). MMR Vaccine: General Information. HealthProtection Agency website. http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/MMR/GeneralInformation/. Accessed February 12, 2013.7. Barilan YM, Weintraub M. Persuasion as respect for persons: an alternative viewof autonomy and of the limits of discourse. J Med Philos. 2001;26(1):13-33.

VIEWPOINT

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