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shared decision making is a Preference-sensitive Formative Construct: the Implications

Jack Dowie


As with many constructs in healthcare (e.g., ‘evidence-based medicine’, ‘health-related quality of life’, ‘decision aid’) ‘shared decision-making’ is formative not reflective, that is, ‘it’ has no existence prior to its definition and measurement. Any particular formative construct is preference-sensitive, being based on the preferences of those who form it by their indicator selection and weighting. These preferences often reflect interests of various sorts, some material, many not (at least not directly), but often ones aligned with particular beliefs, ideologies or ideals. So cave litteras maiusculas - sdm not SDM.  Since ‘shared’ is an adjectival qualifier of ‘decision-making’, fundamental preferences relevant to decision-making are relevant in any construction of sdm. We highlight two major preferences in relation to health decisions. One is for provider-controlled, direct-to-patient intermediation (inter) as contrasted with provider-independent, direct-to-person apomediation (apo). The second is for verbal deliberative reasoning (vdr) as contrasted with numerical analytical calculation (nac). From their cross-tabulation we can see that, within both practice and research - and in legal standards and ethical guidelines for both - sdm is currently being constructed exclusively within the intermediative verbal deliberative reasoning (‘inter-vdr’) frame. We compare and contrast inter-vdr with the three other possibilities - ‘inter-nac’, ‘apo-vdr’ and ‘apo-nac’. Dismissal or disregard of the latter, especially the last, on the grounds of credibility and trustworthiness, needs to be challenged by preference-based comparative evaluations, using unbiased measurement of costs and effectiveness, in order to optimise the development and delivery of personalised support for health and healthcare decisions.


Apomediation, deliberation, formative construct, intermediation, Multi-Criteria Decision Analysis, person-centered healthcare, preference sensitivity, reflective construct, shared decision-making

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Accad, M. (2018). Is shared decision-making applicable to only a minuscule fraction of encounters? KevinMD Blog 21 December. Available at:

Kaltoft, M.K., Nielsen, J.B. & Dowie, J. (2017). Formative preference-sensitive measures are needed in person-centred healthcare at both clinical and policy levels. European Journal for Person Centered Healthcare 5 (1) 17-20.

Mikulić, J. & Ryan, C. (2018). Reflective versus formative confusion in SEM based tourism research: A critical comment. Tourism Management 68, 465469.

Fleuren, B.P., van Amelsvoort, L.G.P.M., Zijlstraa, F.R.H., de Grip, A. & Kant, I.J. (2018). Handling the reflective-formative measurement conundrum: a practical illustration based on sustainable employability. Journal of Clinical Epidemiology 103, 71-81.

Eddy, D.M. (2005). Evidence-Based Medicine: A Unified Approach. Health Affairs 24 (1) 9-17.

Wears, R.L. (2011). The hunting of the snark. Annals of Emergency Medicine 58 (5) 465-467.

Montori, V.M., Kunneman, M. & Brito, J.P. (2017). Shared Decision Making and Improving Health Care: The Answer Is Not In. Journal of the American Medical Association 318 (7) 617-618.

Gulbrandsen, P., Clayman, M.L., Catherine, M., Han, P., Boss, E.F., Ofstad, E.H. & Elwyn, G.. (2016). Shared decision-making as an existential journey : Aiming for restored autonomous capacity. Patient Education and Counseling 99 (9) 1505-1510.

Clayman, M.L., Gulbrandsen, P. & Morris, M.A. (2017). A patient in the clinic; a person in the world. Why shared decision making needs to center on the person rather than the medical encounter. Patient Education and Counseling 100 (3) 600-604.

Gerwing, J. & Gulbrandsen, P. (2019). Contextualizing decisions: Stepping out of the SDM track. Patient Education and Counseling 102 (5) 15-16.

Geessink, N.H., Ofstad, E.H., Olde Rikkert, M.G.M., van Goor, H., Kasper, J. & Schoon, Y. (2018). Shared decision-making in older patients with colorectal or pancreatic cancer: Determinants of patients’ and observers’ perceptions. Patient Education and Counseling 101 (10) 1767-1774.

Bollen, K.A. & Diamantopoulos, A. (2015). In Defense of Causal–Formative Indicators: A Minority Report. Psychological Methods 22 (3) 581-596.

Elwyn, G., Scholl, I., Tietbohl, C., Mann, M., Edwards, A.G., Clay, C., Légaré, F., van der Weijden, T., Lewis, C.L., Wexler, R.M. & Frosch, D.L. (2013). “Many miles to go …”: a systematic review of the implementation of patient decision support interventions into routine clinical practice. BMC Medical Informatics and Decision Making 13 (Supplement 2) S14.

Wyatt, K.D., Branda, M.E., Anderson, R.T., Pencille, L.J., Montori, V.M., Hess, E.P., Ting, H.H. & LeBlanc, A. (2014). Peering into the black box: a meta-analysis of how clinicians use decision aids during clinical encounters. Implementation Science 9, 26.

Schwartz, A. (2011). Medical Decision Making and Medical Education: Challenges and Opportunities. Perspectives in Biology and Medicine 54 (1) 68-74.

Gigerenzer, G. & Gray, J.A.M. (2011). Launching the Century of the Patient. In: Better Doctors, Better Patients, Better Decisions: Envisioning Health Care 2020. (Gigerenzer, G. & Gray, J.A.M. Eds.), pp. 3-27. Cambridge, MA: MIT Press.

Eysenbach, G. (2007). From intermediation to disintermediation and apomediation: new models for consumers to access and assess the credibility of health information in the age of Web2.0. Studies in Health Technology and Informatics 129, 162-166.

Charles, C., Gafni, A. & Whelan, T. (1997). Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Social Science and Medicine 44 (5) 681-692.

Charles, C., Whelan, T., Gafni, A., Willan, A. & Farrell, S. (2003). Shared Treatment Decision Making: What Does It Mean to Physicians? Journal of Clinical Oncology 21 (5) 932-936.

Scalia, P., Durand, M.A., Berkowitz, J.L., Ramesh, N.P., Faber, M.J., Kremer, J.A.M. & Elwyn, G. (2019). The impact and utility of encounter patient decision aids: Systematic review, meta-analysis and narrative synthesis. Patient Education and Counseling 102 (5) 817-841.

Elwyn, G. & Montori, V. (2016).Tools to engage patients in clinical encounters. In: Shared Decision Making in Health Care: Achieving evidence-based patient choice. (Elwyn, G., Edwards, A. & Thompson, R. Eds.), pp.57-63. Oxford: Oxford University Press.

Elwyn, G., Lloyd, A., Joseph-Williams, N., Cording, E., Thomson, R., Durand, M-A. & Edwards, A. (2013). Option Grids: shared decision making made easier. Patient Education and Counseling 90 (2) 207-212.

NICE Decision Aids. Available at:[{%22ety%22:[%22Patient%20Decision%20Aids%22]}]&q=nice+decision+aids&sp=on.

Steffensen, K.D., Vinter, M., Crüger, D., Dankl, K., Coulter, A., Stuart, B. & Berry, L.L. (2018). Lessons in Integrating Shared Decision-Making Into Cancer Care. Journal of Oncological Practice 14 (4) 229-235.

Society for Medical Decision Making. Course introduction. Available at:

Dolan, J.G. (2008) Shared decision-making - transferring research into practice: the Analytic Hierarchy Process (AHP). Patient Education and Counseling 73 (3) 418-425.

Eiring, Ø., Nytrøen, K., Kienlin, S., Khodambashi, S. & Nylenna, M. (2017). The development and feasibility of a personal health-optimization system for people with bipolar disorder. BMC Medical Informatics and Decision Making 17 (1) 102.

Dowie J., Kaltoft, M.K., Salkeld, G. & Cunich, M. (2015). Towards generic online multicriteria decision support in patient-centred health care. Health Expectations 18 (5) 689-670.

Salkeld, G., Cunich, M., Dowie, J., Howard, K., Patel, M.I., Mann G. & Lipworth, W. (2016). The role of personalised choice in decision support: A Randomized Controlled Trial of an online decision aid for Prostate Cancer Screening. PLoS One 11 (4) e0152999.

Dowie, J. & Kaltoft, M.K. (2019). The evaluation of decision support tools needs to be preference context-sensitive. Studies in Health Technology and Informatics 265, 163-168.

Kaltoft, M.K., Nielsen, J.B., Eiring, Ø., Salkeld, G. & Dowie, J. (2015). Without a reconceptualisation of ‘evidence base’ evidence-based person-centred healthcare is an oxymoron, European Journal for Person Centered Healthcare 3 (4) 496-502.

Chan, S.W., Tulloch, E. Cooper, E.S., Smith, A., Wojcik, W. & Norman, J.E. (2017). Montgomery and informed consent: where are we now? British Medical Journal 357, 10-12.

Joseph-Williams, N., Elwyn, G. & Edwards, A. (2014). Knowledge is not power for patients: a systematic review and thematic synthesis of patient-reported barriers and facilitators to shared decision making. Patient Education and Counseling 94 (3) 291-309.

Clayman, M.L. (2018). Shared decision making’s adolescence and transition into adulthood. Patient Education and Counseling 101 (10) 1723-1724.

Légaré, F., Adekpedjou, R., Stacey, D., Turcotte, S., Kryworuchko, J., Graham, I.D., Lyddiatt, A., Politi, M.C., Thomson, R., Elwyn, G. & Donner-Banzhoff, N. (2018). Interventions for increasing the use of shared decision making by healthcare professionals. Cochrane Database of Systematic Reviews 7: CD006732.

Savelberg, W., Boersma, L.J., Smidt, M., Goossens, M.F.J., Hermanns, R. & van der Weijden, T. (2019). Does lack of deeper understanding of shared decision making explains the suboptimal performance on crucial parts of it ? An example from breast cancer care. European Journal of Oncology Nursing 38, 92-97.

Elwyn, G., Durand, M-A., Song, J., Aarts, J., Barr, P.J., Berger, Z., et al. (2017). A three-talk model for shared decision making: Multistage consultation process. British Medical Journal 359, j4891.

Barry, M.J., Edgman-Levitan, S. & Sepucha, K. (2018). Shared Decision-Making: staying focused on the ultimate goal. NEJM Catalyst Available at:

McCormack, J. & Elwyn, G. (2018). Shared decision is the only outcome that matters when it comes to evaluating evidence-based practice. BMJ Evidence-based Practice 23 (4) 137-139.

Eddy, D. (1990). The Balance Sheet: Comparing Benefits and Harms. Journal of the American Medical Association 263 (18) 2493-2505.

Dowie, J. & Kaltoft, M.K. (2018). The future of health is self-production and co-creation based on apomediative decision support. Medical Sciences 6 (3) pii: E66.



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