Patient Education and Counseling 63 (2006) 262–267

www.elsevier.com/locate/pateducou

Cultural influences on the physician–patient encounter:

The case of shared treatment decision-making
Cathy Charles a,*, Amiram Gafni b, Tim Whelan c, Mary Ann O’Brien d
a
Centre for Health Economics and Policy Analysis, Department of Clinical Epidemiology and Biostatistics,
FHS, Rm. 3H5, McMaster University, 1200 Main St. West, Hamilton, Ont. L8N3Z5, Canada
b
Centre for Health Economics and Policy Analysis, Department of Clinical Epidemiology and Biostatistics, Mc Master University, Canada
c
Department of Medicine, McMaster University, Supportive Cancer Care Research Unit, Juravinski Cancer Centre, Canada
d
HRM Program, McMaster University, Supportive Cancer Care Research Unit, Juravinski Cancer Centre, Canada
Received 17 January 2006; received in revised form 15 June 2006; accepted 16 June 2006

Abstract

Objective: In this paper we discuss the influence of culture on the process of treatment decision-making, and in particular, shared treatment
decision-making in the physician–patient encounter. We explore two key issues: (1) the meaning of culture and the ways that it can affect
treatment decision-making; (2) cultural issues and assumptions underlying the development and use of treatment decision aids.
Methods: This is a conceptual paper. Based on our knowledge and reading of the key literature in the treatment decision-making field, we
looked for written examples where cultural influences were taken into account when discussing the physician–patient encounter and when
designing instruments (decision aids) to help patients participate in making decisions.
Results: Our assessment of the situation is that to date, and with some recent exceptions, research in the above areas has not been culturally
sensitive.
Conclusion: We suggest that more research attention should be focused on exploring potential cultural variations in the meaning of and
preferences for shared decision-making as well as on the applicability across cultural groups of decision aids developed to facilitate patient
participation in treatment decision-making with physicians.
Practice implications: Both patients and physicians need to be aware of the cultural assumptions underlying the development and use of
decision aids and assess their cultural sensitivity to the needs and preferences of patients in diverse cultural groups.
# 2006 Elsevier Ireland Ltd. All rights reserved.

Keywords: Treatment decision-making; Shared decision-making; Physician–patient encounter; Physician–patient communication; Culture

1. Introduction universally accepted consensus on the meaning of these

In recent years, one specific component of the medical
encounter between physician and patient, the task of
treatment decision-making, has generated considerable
conceptual and practical interest among physicians, nurses
and social scientists [1–8]. Key ‘‘pure type’’ approaches to
treatment decision-making identified in the relevant
literature include the paternalistic, the informed and the
shared approaches [3,4]. There does not seem to be, as yet, a
* Corresponding author. Tel.: +1 905 525 9140x22513;
fax: +1 905 546 5211.
E-mail address: charlesc@mcmaster.ca (C. Charles).
terms despite several attempts to clarify and define them. In
particular, the concept of shared treatment decision-making
is open to different interpretations [9]. While definitions
vary depending on the author, there does seem to be an
assumption underlying this literature that the process of
shared decision-making will operate in the same way in
different cultural and clinical contexts; i.e. it is universal or
invariant. In a similar manner, the goals of shared decision-
making and the valued outcomes are also often assumed to
be universal and to hold similar meanings in different
cultural contexts [10].
Based on what we know about the influence of culture on
health and health care attitudes and behavior more generally

0738-3991/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pec.2006.06.018
 C. Charles et al. / Patient Education and Counseling 63 (2006) 262–267
[11–17], this assumption of a ‘‘one size fits all contexts’’
model of shared decision-making and even the assumption
of a common meaning and application of the concept across
different cultural groups is unlikely to be true and requires
further investigation. In this paper, we make a beginning step
towards this end by exploring two key issues: (1) the
meaning of culture and the ways that it can affect treatment
decision-making between physicians and patients, and (2)
cultural issues and assumptions underlying the development
and use of treatment decision aids.
This paper does not provide a comprehensive review of
either the meaning of culture or its influence on treatment
decision-making. That would be far too complex an
undertaking for one paper. Our aim is more modest: first,
to highlight that, for the most part, and with some recent
exceptions [18–24], research aimed at exploring conceptual
models of shared treatment decision-making, its implemen-
tation and the development of patient decision aids has not
been culturally sensitive; second to suggest that the role of
culture in influencing physician and patient treatment
decision-making is a topic that needs more research
attention. Our perspective is both selective and focused.
The areas we will explore in this paper are not exhaustive;
neither are the examples cited within these areas.
We want to clarify at the outset that our interest in the role
of culture is analytic and conceptual rather than normative.
We do not make any claims that a given culture, or cultural
approach to treatment decision-making is better than
another. Our aim is to describe and make explicit the
cultural assumptions we carry around when thinking about
the appropriateness of various approaches to the medical
encounter, to treatment decision-making and to the kinds of
interventions that we think will assist in this process. This
stance is consistent with our earlier work [3,4,10,25]. We
also assume that culture is only one among many factors
influencing the treatment decision-making process in the
medical encounter.
2. The meaning and influence of culture on
treatment decision-making in the medical encounter
Culture is an extremely abstract and complex concept
with meanings that have varied over time and across and
within academic fields of study. The term ‘‘culture’’ is said
to be ‘‘. . . one of the two or three most complex words in the
English language. . .’’ [26, p. 1]. We are interested here in the
influence of culture primarily at the micro level of analysis,
i.e. the physician–patient encounter rather than at the macro
level, i.e. the structure and funding of health care systems,
although we recognize that values underlying the latter may
also influence the former.
In the context of this paper we use a sociological lens to
define culture as the expected (socially sanctioned or
legitimized) set of roles, attitudes, behavior and beliefs of
health care providers (in this case physicians) and patients
263
about health and health care in general and treatment
decision-making in particular. This definition does not
assume a universal value system for all society or the
supremacy of one group’s value system over another’s. It
allows for the reality of a pluralistic society in which
different groups define their own values and behavioral
expectations about health and health care. In this sense
culture, as we define it, is not an individual but rather a
collective identity composed of shared understandings
which are communicated through a common language
and will influence to a greater or lesser degree what
individuals think and do.
The idea of culture as a set of shared values is
fundamental to our definition, as it is to other social
scientists [26–28]. Eagleton, for example, in The Idea of
Culture defines culture as: ‘‘. . . that set of learned values,
beliefs, customs and behaviors that is shared by a group of
interacting individuals.’’ [26, p. 34]. Frow in Cultural
Studies and Cultural Values defines this concept as ‘‘. . . the
whole range of practices and representations through which
a social group’s reality (or realities) is constructed and
maintained.’’ [28].
There are many reasons why cultural influences are
important to reflect on when considering the process of
treatment decision-making in the medical encounter.
Cultural expectations will influence the nature of the
encounter and how it proceeds, e.g. who is involved, their
status, beliefs, role expectations (norms of interaction) and
behavior. Cultural values can be supportive or not supportive
of different types of treatment decision-making approaches,
can modify their form, or in some cases, make a particular
type of decision-making approach irrelevant.
Attention to cultural influences can also help us see our
own treatment decision-making behavior, treatment pre-
ferences and criteria for evaluating these through a different
and more relativistic lens, highlighting that our taken-for-
granted assumptions about how things should be, may not be
shared by others outside of our own cultural group. Finally,
specific barriers to and facilitators of patient participation in
treatment decision-making may vary across different
cultural groups.
The most famous example of a set of culturally
prescribed expectations serving to channel sick individuals
to physicians for treatment is Talcott Parsons notion of the
‘‘sick role’’, a concept so familiar that it has now entered the
world of everyday language as well as academic discourse
[29]. Parsons developed the concept of the sick role
explicitly to demonstrate the influence of social as opposed
to strictly psychological or biological influences on how
people behave when sick.
Writing in the 1950s, he argued that in the United States,
there existed a set of dominant cultural values, learned
through socialization, which consisted of a set of interrelated
‘‘rights’’ and ‘‘obligations’’ of the sick. These included that
the sick person: (1) not be blamed for becoming ill, (2) be
temporarily relieved from usual responsibilities in order to
264 C. Charles et al. / Patient Education and Counseling 63 (2006) 262–267
try to get well, (the ‘‘rights’’), (3) be motivated to get well
and (4) seek and follow doctors orders (the ‘‘obligations’’)
[29]. These, in turn, would channel patients to physicians
who would help them get well and to return to their usual
societal roles instead of using the illness label for secondary
gains, i.e. malingering [29]. Over the years, researchers have
empirically studied attributes of Parsons, sick role, for
example, the extent to which the sick role expectations hold
across different cultural groups, and the use of the sick role
for secondary gains [30–31].
Parsons’ sick role identified only one culturally legiti-
mated mode of interaction between patient and physician (a
paternalistic approach) which many would now consider to
be seriously lacking in appropriate patient input. Today, a
shared or informed approach to treatment decision-making
is more likely to be seen as desirable, at least in North
America, reflecting a change in cultural values about what
are thought to be the essential rights of patients [3,4].
Parsons also viewed the culturally prescribed role
expectations for physicians and patients as mutually
supportive or reciprocal. Other writers since then have
taken a different view. Mishler, for example talks about the
‘‘life world of the patient’’ and his every day contextually
embedded ways of knowing versus the biomedical world of
medicine with its technical, objective, and scientific ways of
knowing [32]. According to Mishler, these different world
views create a kind of culture clash of different physician
and patient voices such that the medical encounter has more
potential for conflict than consensus [32]. Some potential
sources of differences in perspective between physicians and
patients that can influence their ideas and preferences about
how to make treatment decisions include:
(a) Illness representations:
 ideas about the meaning and causes of illness;
 reactions to illness.
(b) Constructions of risk:
 patient values around benefits and risks of various
treatments;
 concepts of risk and ways of assessing risk.
(c) Treatment effectiveness:
 what counts as a good outcome;
 the role of biomedical science versus other influences/
healers.
(d) Treatment decision-making approaches:
 the meaning of a shared process of decision-making
and how to implement it;
 the amount and type of information that patients want
to know about their disease in order to make a
decision;
 who should be involved in making the treatment
decision and their preferences for involvement.
In previous work [3–4], we assumed that the key
treatment decision makers are the physician and patient. But
on reflection, this assumption illustrates our own cultural
bias about taken-for-granted participants in this process. In
some cultures, multiple family members may have as much
or more influence on the decision than the patient [27,33]. In
other cultures there may be only one culturally prescribed
decision-making approach which is considered acceptable
rather than several options. In fact, it has been argued that the
recent ethical emphasis on patient autonomy in treatment
decision-making is primarily a North American phenom-
enon and is not easily applied to some cultural groups [33].
In exploring the influence of culture on the process of
treatment decision-making, there are several difficult
conceptual and methodological challenges to consider such
as:
 defining and measuring the boundaries of various cultural
groups to which patients and physicians belong and the
factors (subjective, objective or both) used to define these;
 defining, identifying and measuring cultural values at
different levels of analysis, including how these might
influence ways of thinking about and preferences for
different types of treatment decision-making approaches;
 isolating and measuring the influence of cultural values
versus other factors in shaping patient and physician
attitudes and behavior towards treatment decision-
making.
While these challenges are difficult, to ignore potential
cultural influences on the way that individuals think about
treatment decision-making is to over-simplify reality. More
research is needed to explore the extent to which current
shared approaches to treatment decision-making and the
development of decision aids designed to assist patients
make decisions are, in fact, helpful and appropriate for
patients of different cultures. The default assumption that
‘‘one size fits all’’ seems unlikely to meet the needs of a
multicultural society. In our own work on shared decision-
making we have attempted in recent years to pay more
attention to contextual issues, including cultural and clinical
contexts [34,35].
3. Cultural assumptions underlying the development
and use of decision aids
3.1. Decision aid development
Decision aids have been and are being developed to help
patients in several ways: (1) to provide patients with relevant
information about their diagnosis and the available
treatment options and their potential risks and benefits,
(2) to help structure the decision-making process, and (3) to
help patients participate in the process of decision-making,
if they so wish. The motivation for developing such aids is
unquestionably laudable and many have been shown to
produce positive outcomes in terms of, for example, patient
knowledge acquisition [36–38]. The clinical contexts in
 C. Charles et al. / Patient Education and Counseling 63 (2006) 262–267
which such aids have been developed vary as do the formats
used (e.g. decision board, interactive video, booklet, etc.).
Perhaps less frequently noted is the fact that there are
fundamental and common cultural beliefs that underlie the
development and use of such aids. For example, decision
aids are firmly embedded in a biological model of illness, an
evidence-based medicine paradigm, and medical concepts
of risk. These beliefs reflect a purely ‘‘technical’’ or
‘‘clinical’’ approach to decision-making and downplay the
influence and significance of other factors, including cultural
beliefs. The use of decision aids also reflects a cultural
emphasis on the autonomy of the individual in decision-
making as opposed to a broader social framework within
which to view this process [21,33].
These common features of decision aids are not
surprising, given the clinical and research contexts in which
they have been developed. But, to what extent are such tools
appropriate for patients from different cultural groups and
how sensitive are such tools to the cultural values of different
groups? We wonder to what extent these cultural issues have
been addressed in either the research development phase of
decision aids or their implementation. Even such basic
issues as the range of treatments considered appropriate to
include as options and the type of information considered
relevant to evaluate options may vary depending on cultural
beliefs. In some cultures even disclosing to the patient the
diagnosis of a potentially fatal illness is not considered
appropriate [33]. We think that an important area of future
research is to explore the extent to which decisions aids are
sensitive to some of the above cultural issues versus
implicitly assuming homogeneity in the underlying world
view that patients bring to the treatment decision-making
process.
It would be interesting to know the extent to which
current decision aids have been tested with different cultural
groups and the results of such enquiries (as one example, see
the paper by Lawrence et al. on developing decision boards
for mammography screening for two different cultural
groups—‘‘Anglo Americans’’ and ‘‘Hispanic Americans’’
[18]). In fact, one could question the appropriateness of
using decision aids at all with certain cultural groups who
are unaccustomed to this type of structured tool designed to
assist in treatment decision-making, and who routinely rely
instead on narrative talk, negotiation and consensus building
or authority of position as key processes to help make
decisions.
There is an analogy in this discussion of cultural
sensitivity of decision aids with the recent federal
government announcements about the future content of
the Canada Food Guide. For years, this guide has set out
nutritional food guidelines for Canadians by identifying four
necessary food categories, and within these, examples of
appropriate (i.e. nutritious) food choices. In recognition of
the more multicultural composition of the Canadian
population now, compared to earlier years, the federal
Minister of State for Public Health announced that, in future,
265
different versions of the guide will be produced for different
cultural groups [39]. Each food category will continue to
contain examples of acceptable food choices but the types of
examples used will no longer be restricted to a very limited
range of mainstream selections but rather will be adapted to
reflect food choices more aligned to the eating habits of
different cultural groups.
We wonder whether it is helpful to think about the
development of decision aids in the same way, i.e. to develop
different versions that are targeted to different cultural
groups as in Lawrence’s work noted above [18]. If so, the
question then arises as to how much modification for cultural
sensitivity could be undertaken without, from the perspec-
tive of the decision aid developers, compromising the
integrity of the tool (for example, assumptions about group
probabilities of treatment benefits and risks from research
evidence as a basis for making individual level decisions).
As another example, how far would researchers be willing to
modify tools to incorporate treatments considered effective
and appropriate in certain cultures, either as adjunct or stand
alone interventions, but for which biomedical research has
not yet found much benefit?
Language adaptations may be fairly easy to address but
these will not resolve issues related to more fundamental
patient values that could be at odds with the thinking
underlying decision aids. While it is sometimes thought that
information and values are two separate factors used in
decision-making, there are, in reality, connections between
the two. Patients use cultural values to filter and weigh
information presented to them. If information is not
presented in ways that resonate with patient values, it
may make little sense. Also, evidence-based information
about, for example, the causes of an illness or treatment
benefits and risks may be sufficient to change patient’s
misconceptions of facts related to these phenomena, but as
Sabatier points out, are unlikely to change core beliefs (e.g.
religious beliefs) that are fundamental to a person’s world
view [40]
3.2. Values clarification exercises
Increasingly, as either an adjunct to or as part of decision
aids, values clarification exercises are included, ostensibly to
help patients clarify their values so that they can make
treatment decisions that are in line with these values [10,41].
Such exercises have been seen as enablers, mechanisms to
help patients define and articulate values that they are
presumed to have difficulty getting in touch with on their
own and that are relevant to treatment decision-making.
(Elsewhere we have challenged this claim on both
conceptual and feasibility grounds [10]). But what do we
mean by values? Values, as used in this context seem more
akin to the notion of preferences than to fundamental belief
systems like those alluded to above.
Typically, in values clarification exercises, patients are
provided with a structured process for evaluating trade offs
266 C. Charles et al. / Patient Education and Counseling 63 (2006) 262–267
between the risks and benefits of various treatment options
[41]. Patients then use the results of this analysis to help
determine which treatment option seems most appropriate
for them, given the trade off selections they have just made.
One assumption underlying this exercise is that patients, on
their own, cannot define and articulate their values or judge
whether their treatment choices reflect these. But where is
the research evidence to substantiate this assumption? Even
if we accept this assumption, it appears that the range of
factors typically included in current values clarification
exercises as potential influences that patients should
consider in treatment decision-making is both limited (i.e.
treatment risks and benefits) and reductionist in nature (i.e.
weighing off benefits and risks of individual treatments).
There does not seem to be a mechanism in these exercises to
incorporate broader and more fundamental cultural values,
for example, religious values. Yet, we know that these more
core belief systems can influence how patients make
treatment decisions and their preferred treatment choice.
Some might argue that the range and level of possible
values that patients hold are so complex that it would be
impossible to design a values clarification exercise to
incorporate all these or to develop algorithms that could
translate an individual’s values into a specific treatment
decision choice. We agree that that is likely the case [25]. A
major problem with current exercises is that they neither
encourage nor provide a mechanism for cultural values to be
considered as legitimate factors in making a treatment
decision. Moreover, values clarification exercises that we
have seen structure the weighing process in a single defined
way. This assumes that all patients, whatever their individual
or cultural variability use and ought to use a prescribed and
identical method (based on group treatment probabilities and
trade offs between treatment risks and benefits) to articulate
and clarify their own values around treatment preferences.
Again there seems to be no room for variation, either cultural
or otherwise in this assumed universal and invariant process.
4. Discussion and conclusions
4.1. Discussion
In this paper we have explored the meaning of culture and
its influence on treatment decision-making in the medical
encounter. We have also explored cultural issues and
assumptions underlying the development of decision aids.
We have argued that, with a few recent exceptions, the
influence of culture has been a relatively neglected topic in
the medical literature on treatment decision-making.
Cultural influences can be a major factor affecting the
dynamics of the physician–patient interaction, the type of
decision-making process used, the potential for reaching a
mutually agreed upon decision, and the satisfaction of both
parties with both the process and the treatment decision. We
think there is a need for more research in these areas.
The literature on shared decision-making incorporates
two major shifts in thinking over the past decade or so. The
first is a shift from accepting a paternalistic model of
treatment decision-making as the usual and even desirable
approach, to increasing advocacy of greater patient
participation in this process through either shared or
informed approaches. In the latter cases, two potentially
different cultural and/or world views of the patient and
physician need to be accommodated in the decision-making
process. This both complicates the process and highlights
the importance of cultural sensitivity on the part of the
physician.
Second, increasing interest in and efforts to facilitate
patient participation in treatment decision-making have
resulted in the development and use of an ever expanding
array of decision aids. Because of this growth, it is
particularly important for researchers developing such tools
to make explicit the cultural assumptions that underlie them
and to develop such aids with different cultural groups
targeted for the intervention. Intended to be helpful, it should
not be forgotten that such aids are also prescriptive in terms
of the processes defined for clarifying values and making
treatment decisions. Patients in general need to know the
specific assumptions underlying their development and use.
This is particularly the case for patients of diverse cultural
groups whose beliefs and practices may be at odds with the
processes and assumptions embedded in these tools.
4.2. Conclusions
With few exceptions, culture has been a relatively
neglected topic in the literature focusing on the development
of conceptual models of treatment decision-making,
empirical studies of treatment decision-making, and the
development and use of applied tools such as decision aids to
facilitate patient participation in treatment decision-making.
More research is needed in these areas.
4.3. Practice implications
Both patients and physicians need to be aware of the
cultural assumptions underlying the development and use of
decision aids and assess their cultural sensitivity to the needs
and preferences of diverse cultural groups.
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