It is widely acknowledged that the patient's perspective should be considered when making decisions about how her care will be managed. Patient participation in the decision making process may play an important role in bringing to light and incorporating her perspective. The GRADE framework is touted as an evidence-based process for determining recommendations for clinical practice; i.e. determining how care ought to be managed. GRADE recommendations are categorized as “strong” or “weak” based on several factors, including the “values and preferences” of a “typical” patient. The strength of the recommendation also provides instruction to the clinician about when and how patients should participate in the clinical encounter, and thus whether an individual patient's values and preferences will be heard in her clinical encounter. That is, a “strong” recommendation encourages “paternalism” and a “weak” recommendation encourages shared decision making. We argue that adoption of the GRADE framework is problematic to patient participation and may result in care that is not respectful of the individual patient's values and preferences. We argue that the root of the problem is the conception of “values and preferences” in GRADE – the framework favours population thinking (e.g. “typical” patient “values and preferences”), despite the fact that “values and preferences” are individual in the sense that they are deeply personal. We also show that tying the strength of a recommendation to a model of decision making (paternalism or shared decision making) constrains patient participation and is not justified (theoretically and/or empirically) in the GRADE literature.

人们普遍承认，在决定如何管理她的护理时，应考虑患者的观点。患者参与决策过程可能在揭示和整合她的观点方面发挥重要作用。GRADE 框架被吹捧为用于确定临床实践建议的循证过程；即确定应如何管理护理。GRADE 建议根据几个因素分为“强”或“弱”，包括“典型”患者的“价值观和偏好”。建议的强度还向临床医生提供了关于患者应该何时以及如何参与临床会诊的指导，从而在她的临床会诊中是否会听到个体患者的价值观和偏好。那是，“强”建议鼓励“家长式”，“弱”建议鼓励共同决策。我们认为采用 GRADE 框架会给患者参与带来问题，并可能导致护理不尊重个体患者的价值观和偏好。我们认为问题的根源在于 GRADE 中的“价值观和偏好”概念——该框架有利于群体思维（例如“典型”患者的“价值观和偏好”），尽管事实上“价值观和偏好”在感觉他们是非常个人化的。我们还表明，将推荐的强度与决策模型（家长式或共同决策）联系起来会限制患者的参与，并且在 GRADE 文献中（理论上和/或经验上）是不合理的。