Patient participation and shared decision making in the consultation
Patient-professional partnership and patient-centred care have become central to government health policy and regarded as a means to the delivery of better quality and more appropriate and cost -effective healthcare (Department of Health 1 9 9 1 , 1 996, 1 998, 1 999, 2 000, 2 00 1 a, 200 1b; Hogg 1 999 ) . They reflect the emphasis on personal autonomy and institutional accountability in the modern state . The paternalism which has characterised professional delivery of healthcare from the inception of the National Health Service appears increasingly inappropriate and out of tune with the spirit of the times (Towle & Godolphin 1 999 ) . Traditional justifications for the professional to assume the role of 'perfect agent' ( Gafni, Charles & Whelan 1 998 ) of the patient in taking control of decisions about treatment and illness management have been substantially eroded. The monopoly of expert knowledge, the variability of clinical practice, the proliferation of therapeutic options, and uncertainty about their comparative efficacy and safety have undermined the social status of medical authority ( Coulter 1 997; Coulter 2002; Harrison & New 2 002; Williams & Calnan 1 996a; Williams & Calnan 1 996b ) (see Chapter 3 ) . Given the risks and uncertainties involved, it is perceived to be unethical to exclude patients from choices which fundamentally affect their wellbeing and can only be determined in the context of individual values and preferences ( Chewning & Wiederholt 2003 ; Hogg 1 999; Wennberg et al . 1 99 3 ) .