This article addresses how health professionals should monitor and safeguard their patients’ ability to participate in making clinical decisions and making subsequent decisions regarding the implementation of their treatment plan. Patient participation in clinical decision-making is essential, e.g. in self-care, where patients are responsible for most ongoing care. We argue that one common, fact-oriented patient education strategy may in practice easily tend to take a destructive form that we call error trawling. Illustrating with empirical findings from a video study of consultations between clinicians and adolescent patients with diabetes, we argue on independent grounds that this strategy not only risks to overlook significant weaknesses in patient decision competence, but also to undermine patient capacity for decision-making and implementing care. In effect, this strategy for clinically monitoring and addressing the problem of fragile decision-making capacity brings hazards in need of address. We close by suggesting complementary and alternative strategies, and comment on how these may call for broadened competency among clinical health professionals.
We use the concept of decision competence when talking about the conjunction, or the whole, of a patient's decisional capacities. Sometimes we use the phrasing decisional capacities when we want to emphasise that there are different capacities underlying competence.
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Albeit not entirely uncontested,49 it is safe to say that this ideal nowadays enjoys strong and broad support throughout medicine, as well as healthcare ethics.
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Patients not considered competent need a surrogate decision-maker of some sort. Who might be suitable for the task is a matter of some debate, as are what requirements apply to decisions made by such a person.4,50
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We cannot on the basis of either this theoretical argument, or the empirical material used for illustration in section ‘A case in point: error trawling in adolescent diabetes care’, say anything about the actual extent or comparative prevalence or causal linkage of error trawling, neither in the general patient group we focus on, nor in healthcare in general. The arguments developed in this section does however provide us with a reason to suspect that it is to be especially expected in consultation with fringe decision competent patients. This theoretical reason, together with the illustrative cases from our empirical material, is sufficient to create a strong reason to instigate empirical studies to probe the issue further. We expand on this prospect in the final discussion.
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However, we find it equally likely that HP (unintentionally) here mostly displays his/her own frustration over the fact that P is apparently unmotivated by factual information in the way that HP would consider ideal.
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