Beyond Preferences: Rethinking shared decision-making through the Lens of care

Efforts to involve patients in medical decision-making have led to the development of various models for structuring clinical encounters. Among them, Shared Decision-Making (SDM) is now a cornerstone of contemporary healthcare, based on the ethical imperative to involve patients through the articulation of preferences. However, in practice, SDM often relies on a rationalist model of deliberation that prioritizes autonomy, clarity, and informed choice-often overlooking the relational, affective, and embodied dynamics of care. Drawing on ethnographic fieldwork in France, Spain, and Denmark with patients undergoing long-term anticoagulant therapy following unprovoked venous thromboembolism (VTE), this article examines the contexts in which decisions are made, as well as patients' attitudes toward those decisions and their treatment. We argue that "preferences"-the conceptual hinge of SDM-are not stable expressions of autonomous will, but rather fragile, contingent, and emergent responses. Especially as understood and operationalized by practitioners, preferences often obscure other forms through which patient agency is exercised, both within and beyond the clinical consultation. Engaging Annemarie Mol's "logic of care", we show how patient agency unfolds not as a rational choice between predefined options, but as an ongoing, situated negotiation of treatment that extends beyond the consultation. Furthermore, focusing on care, rather than choice, allows for a medical approach attentive to the patient's needs, demands, and hesitations-not solely to their stable preferences regarding treatment duration. These findings call for broadening participation beyond preference articulation, toward more responsive and context-sensitive forms of engagement.