The Role of Mutual Understanding in Shared Decision-Making

This article addresses the challenges of shared decision-making (SDM) when a patient's request conflicts with accepted medical practice, using the case of Maria, a 72-year-old patient receiving dialysis. Maria, admitted to the ICU, insists on continuing hemodialysis sessions despite symptomatic hypotension and wants to take the herbal supplement Jin Gui Shen Qi Tang (JGSQT). We argue that understanding-the mutual effort by patient and clinician to comprehend each other's reasons, goals, and values-is a foundational element of SDM, superseding the goal of reaching agreement about the preferred intervention. For the JGSQT request, a physician should approach with curiosity and epistemic humility, acknowledging the limits of medical knowledge on alternative treatments. Given the supplement's low risk and Maria's perceived benefit, allowing its use promotes a shared process. Conversely, the request to continue dialysis during symptomatic hypotension poses a significant threat of medical harm, justifying the physician in asserting professional values to stop the session. In both instances, the physician must approach the situation with curiosity and seek truly to understand the patient's perspective and also must explain thoroughly the rationale for a decision to Maria, ensuring that she understands the risks and the basis for the decision while looking for acceptable compromises. Ultimately, although SDM may not always result in a shared final decision, the shared process of mutual understanding ensures a patient-centered approach that respects patient autonomy while acknowledging the ethical limits of autonomous patient requests.