In the healthcare context, our language can have a big impact – including a nocebo effect. Whether we are focused on risks or benefits, recommended care or alternatives…the fact remains that there is
The Decision belongs to one impacted (in maternity care, this is the pregnant woman).
The words counsel, shared, persuade and consent are ‘tricky’ words, especially where policy or bias are involved. What each of these words often means in practice is Coerce. Let’s break it down:
Counsel
The patient was counselled” is intended to mean that the risks were discussed, but for many women, this feels like being talked at until they submit. This is a process of checking a box, and relieving potential liability, rather than ensuring understanding to make a confident decision. It usually means risk-focused information, curated towards compliance, in a limited time at the critical point. Being counselled is not about supporting a maternal decision, but gaining consent. Consent given under these conditions is unreliable.
Shared
‘Shared Decision Making’ is often misconstrued to mean the decision is shared. Shared Decision Making is actually a process where care centres around the individual receiving the care. That individual alone is responsible for The Decision. It is an opportunity for care providers to understand the values and context of the individual, provide rationale for their recommendations, and offer alternatives and time to consider. In the maternity context, this process is best done as an advanced care approach, the final decisions are made as needed, but should be based on prior understanding. Within the power imbalance that occurs in a doctor-patient relationship, this process can look more like being counselled (as above). This process could be called Supported Maternal Decision Making to avoid being misconstrued.
Persuade
In the 2023 International Symposium for Communication in Healthcare, the word ‘persuade’ was used, suggesting the purpose of communicating with patients is to convince them to comply. This is fraught and disrespectful, and a barely disguised agenda, more often heard in health care contexts where the message is aimed at the population level, rather than the individual level (and where counsel is used).
Consent
The trouble with consent is the assumed yes. The Con in Consent is that a presumption is made of a correct stance – that you should want to say yes, and that doing otherwise makes you lesser, different, wrong…a dissenter. This can feel like pressure for some women, especially if they have trauma.
If we offered respectful care, we would use the words: discuss, support, listen and decide.