Many have argued that good quality health care includes involvement of patients in decisions about their care. Furthermore, care should only be judged as appropriate if, as well as meeting professional and societal safeguards and concerns, patient preferences and patient values have been incorporated within the decision making process.¹ Few would disagree with this in principle. However, despite the importance of patient views and the value of engaging patients in all aspects of care being acknowledged within mainstream health policy, the changes needed in clinical practice and delivery of health care that will move policy from lip service to a reality have yet to be made.

Indeed, the changes needed will challenge some of the assumptions of health care and will raise many complex questions. For example, patients who do not wish actively to engage in decision making, particularly in taking responsibility for decisions on their treatment, may be inadvertently …