Clinging On

Mandates, Choices, and Shared Decision Making

Mandates are very much in the news this week. We’re hearing a lot of angst about vaccine mandates and mask mandates. In some situations, it seems there’s not much room for debate about what to do. Yet we find that even when reality is unyielding, people still have choices to make. So in between the extremes of unconstrained choices and absolute mandates, shared decision making seems like a pretty attractive option.

Making good decisions to protect oneself from the immediate threat of COVID might have different dimensions from decisions about the longer-term threat of obesity. But the process has some similar challenges in both cases. Shared decision making can be cumbersome, but mandates can alienate people, who then make misinformed decisions that end badly.

Shared Decision Making in Bariatric Surgery

David Sarwer and colleagues write about shared decision making in Surgery for Obesity and Related Diseases. They describe stigma and bias as a barrier to making good decisions about utilizing bariatric surgery for obesity care:

”Weight stigma also appears to impact decision making with respect to medical care more generally and weight loss treatment specifically. A recent nationwide study found that 39.1% of respondents believed that individuals who had weight loss surgery chose the ‘easy way out’; almost one in two respondents thought that people undergo weight loss surgery for cosmetic reasons.”

Sarwer describes shared decision making as an important alternative to “the traditional, hierarchical provider-as-expert approach to communication which can strain the relationship and, in turn, can lead to deferred or atypical care.” Provider bias expressed in that traditional approach is a big barrier to shared decision making in obesity care – especially in underserved communities.

When Facts Are Not Up for Debate

People sometimes resist facts, but facts turn out to be undeniable. Despite much debate, it’s clear that obesity is a chronic, progressive disease. Among the many options for obesity care, surgery can have the most profound and lasting benefit. But patients have to make choices about their own care. Many are hesitant about surgery. So shared decision making is an important tool for making good choices.

Likewise, we’ve heard much static from people trying to deny the seriousness of the coronavirus, its delta variant, and the importance of vaccination. But the facts do not yield. In communities where vaccination has been slow, hospitalization and deaths are soaring.

So now – informed by firsthand knowledge of deaths all around them – formerly reluctant individuals are choosing to get vaccinated in a hurry. More vaccine doses went into people on Friday than on any other day since July 3. Vaccination is surging in hot-spot states like Arkansas, where Chelsah Skaggs of Bella Vista had been avoiding the vaccine until now. But when the delta variant got bad in her area, she started looking a little closer at the vaccine and decided to get it. She told the Washington Post:

“Skepticism is a good thing. But to be ignorant is a different issue. My only regret is not doing it sooner.”

People always have choices to make – even in the face of a mandate. Authoritative guidance can be helpful. Authoritarian approaches can be counter-productive. But facts and reality are unyielding.

Click here for the paper by Sarwer et al and here for more on the tilt toward more vaccination prompted by the delta variant.

Clinging On, photograph © Thomas Tolkien / flickr

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July 31, 2021