Then I became a doctor, and I began to realize that we provided these non-choices to patients all the time. Like today, for instance, when I asked a patient permission to refer her to gastroenterology for her fecal incontinence. (At least we talked about it - because she brought it up. Often times people don't do even that much, a fact I discuss in my book reflective of the broader reluctance of patients, and sometimes doctors, to discuss sensitive issues.)
I asked, "Is that okay with you?"
Which is BS, really. I suppose it's better than making the referral without discussing it with the person at all, but there's no choice there. Even if I were to break down the possible alternatives - refer; take care of the problem just the two of us, me and the patient; kick the can of the problem down the road - how is the patient supposed to know what might be preferable? Heck, I'm not sure I even know.
This is what makes real-world shared decision-making so complicated. I don't know what fraction of medical decisions are like the one above, but certainly a big chunk are. When the doctor doesn't know what the right answer is, and the patient doesn't know enough to have a clear preference (or no clear preference is possible), what can really be shared, after all?