I would like to thank Dr. Misra-Herbert and Dr. Kattan for their interest in my editorial. Their main point seems to be, yes, decisional conflict is a problematic endpoint, but only if you measure it in the short term. The key claim is that it “acceptable” for decisional conflict to be high if “measured soon after options have been presented”; however, “after the patient has been given the opportunity to incorporate their values and preferences into the presented options and make a decision, decisional conflict should be low.” They go on to make a methodological recommendation that the “timing of measurement of decisional conflict should allow for deliberation to occur.”
I am sympathetic to the point that decisional conflict may change over time, and might in fact reduce over time. But the authors provide no counterargument to the main thesis of the editorial, which is that although decisional regret and conflict are arguably sensitive to good decision-making processes, but they are certainly not specific. Even if we take into account the “timing of measurement”, it is entirely plausible that decisional conflict will be lower in a patient who is given biased information, or who just gives up and asks the doctor what to do, than in a patient who carefully weighs competing options. Moreover, it is not at all clear why, even with the passage of time, a rational patient would say that difficult decision such as whether to accept adjuvant chemotherapy was “easy to make” or that they were “sure what to choose”.
The authors conclude that decisional conflict “should be a temporary state that eventually leads to certainty about the final choice”. But they provide no clear reason why this should be the case. In my view, certainty is for fundamentalists and ideologues and has no role in the challenging task of advising patients about difficult, preference-sensitive decisions.