Choose well

Several times a week as I whiz down I94, I pass an advertizing billboard with this slogan on it. "Choose well," it advises simply, next to the logo of a big local hospital. The implication is that if you're sensible you'll decide to go there next time you are in need of hospital care.

This ad is clearly targeted to people like me for whom informed decision-making is an important part of life, and it got me thinking. It's clever, because "choose well" has several implicit meanings, including "make a choice carefully", "choose to be well" and "choose the best". The conflation of these different meanings in the ad implies is that a good choice is interchangeable with a particular selection: if you choose well, you'll choose us, of course!  The slogan thus becomes a wolf in sheep's clothing, solicitation in the guise of informed decision-making.

This ad has the same undertone we sometimes experience in our encounters with medical caregivers, too -- not just when we drive past their billboards. "You'd be smart to... [let me induce you at 40 weeks/consent to the amniocentesis/come to the hospital as soon as labor starts]" implies, "You wouldn't be smart if you didn't." 

Worse, we sometimes simply hear the caregiver speak of his or her plans to treat us, as if our thoughts and feelings were not a factor at all. The thought seems to be that if we have the opportunity to object and do not, that fulfils the requirements of shared decision-making. At the other end of the spectrum, a medical caregiver may act as a partner, presenting us with a list of options with their accompanying risks and benefits, and allowing us space to make decisions ourselves. Here's the spectrum as I see it, in table form:

	Implied consent	'Informed'  consent	Informed choice	Informed decision-making
How the dilemma is presented	No choice is offered	Choice is acknowledged but the 'best' choice is pre-determined	A range of pre-selected options, benefits and risks is presented from which you can choose	You determine the range of options to consider and the caregiver helps you get the information needed
Care provider might say...	"Here's what we're going to do" (unless you object).	"You could always select Choice A but we'll be better off with B."	"Which would you prefer, Choice A or Choice B?"	"Would you like to do anything? What do you need to help you decide?"
You might say...	"Okay."	"Well, I guess we'll go for B."	"Hmm."	"I'd like to wait and see."
Relationship between parties	Novice-expert	Liability-insured	Consumer-provider	Partner-equal partner

Studies show that women are most satisfied with the birth of their children when they are most involved in decision-making (and this is a more influential factor even than whether they experience pain) (Hodnett 2002). But involvement in decision-making can take different forms. Some women want to do all their own research and specify each detail. Others prefer to outsource their medical decision-making, along with its associated responsibilities, which can sometimes be heavy. This is also a valid choice, and it can also work well, as long as the outsourcing is itself a considered decision.

What does "choosing well" look like to you?

-----------------------

"Choose well. Your choice is brief, and yet endless."

--  Johann Wolfgang von Goethe

Reference:
Hodnett, Ellen D. "Pain and women's satisfaction with the experience of childbirth: A systematic review". American Journal of Obstetrics and Gynecology Volume 186 Issue 5 (Supplement) (2002): S160-S172.