Decision aids: When 'nudging' patients to make a particular choice is more ethical than balanced, nondirective content

Patient decision aids, such as instructional leaflets describing treatment options for prostate cancer, are designed to help educate patients so that they can share in decisions about their care. Developers of these decision aids strive for balance, aiming to be as neutral, unbiased, and nondirective as possible. We argue that balance should not always be a goal, and we identify three situations where it should not be. For example, men diagnosed with early-stage prostate cancer frequently are not advised by their physicians that active surveillance is a reasonable alternative to immediate surgery or radiation. It may be desirable to design decision aids that promote active surveillance as an option. We recognize that the arguments put forth in this article are controversial. But they are also justified. We challenge medical decision makers and decision aid developers to determine if and when patients should be "nudged" toward one option or another.