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.

5 comments for “Evidence and decisions: two different things

  1. Angela Red River
    May 27, 2016 at 7:47 am

    Hi Sarah, it is all very well, in the first place, saying that we need evidence-based decision-making, but it has become clear over time that the evidence of many clinical studies has later been proven to have been inadequate and inaccurate. Why is it that we need to prove a physiological process that was going on long before the medical profession co-opted childbirth and made it in to a dis-ease? All the Medical Profession is doing is proving that what they have been doing for the past 200-300 years has been ineffective at best.
    Thank you for a great article – after my own heart, as you can see. It is definitely about supporting women to make their own best decisions and assisting their own inner midwife to emerge during her entire childbirthing experience – from preparing for conception right the way through to breastfeeding and bonding and beyond! Angela Red River – Angel of the Red River

  2. May 27, 2016 at 8:58 am

    Could not agree more. I loathe the phrase “shared decision-making”. The decision belongs to the woman, and perhaps family members with whom she chooses to share it.

  3. Denise Hynd
    May 27, 2016 at 7:38 pm

    In obstetrics and therefore Maternity services Ritual and fear can often block new evidence that says what we offer was not evidence based in the first place

  4. September 6, 2016 at 7:35 pm

    Perhaps I’m missing something …but I’ve never heard that phrase before ‘shared decision making’ and certainly never considered any decisions a woman makes about her care, one that she shares with me.

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