Evidence and decisions: two different things

decisionmakingEvidence and decisions really are two different things, and we need to take care when we discuss this.

A short but fascinating rapid response to a recent British Medical Journal article really got my attention this week. Writing in response to an ongoing discussion about evidence, guidelines and decision-making, Michael H Stone pointed out that the role of evidence is to help clinicians to describe outcomes and make the guidelines which we know are sometimes necessary to ‘steer service provision’. In a culture which prioritises evidence (and that addition is mine rather than the original author’s), health professionals are required to then present that evidence to people making decisions about their health.

But, as Stone then points out, the people making decisions do not have to accept the treatment which is offered or recommended, and they are at liberty to “incorporate personal and non-clinical factors into their decision-making, so ‘EBM’ can never prescribe the decision-making of any particular patient (sic).”

He goes on to differentiate this even more clearly, noting that, while doctors decide what to offer, it is the recipient of health care who decides what to accept and concludes that, “I personally find it very unhelpful to describe that as ‘shared decision-making’.” (Stone 2016)

I found myself nodding as I read this. Stone has put into words something which has long bothered me. As much as I love that there are brilliant, kind and woman-centred midwives, doctors, doulas and other birth workers out there who do everything they can to facilitate women and their families being able to make the decisions that are right for them, we need to ensure that the language we use clearly differentiates the elements of this.

Information, education and advocacy are vital, but it is not for professionals to lay claim to participation in the decision-making of those who need to live with the consequences. This means, as I have long ranted, ensuring that we talk about evidence separately from decision-making, reminding ourselves that, as important as it is, evidence is not the only thing that informs decisions and, perhaps most importantly of all, never forgetting that it is women who make the decisions about their care.


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Stone MH (2016). The Evidence and the Decision are two quite distinct things. BMJ 2016: 353: i2452.

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