Makins’s analysis of the philosophical justification of decision-making understates and so misinterprets the importance of patient values to ‘the deference principle.’ (Makins N,1, p1) He assesses autonomy and beneficence as two separate arguments in support of deferring to patient preferences, but they only work well considered together. Further, neither the constitutive nor the evidential view of beneficence fully recognises the importance of patient values to understanding the patient’s worldview, which in turn determines what risks and benefits matter most. Revising these arguments enables a much fuller understanding of the importance of patient values to the practice of medicine, which will in turn improve the refinement of the deference principle.

Autonomy requires beneficence, and vice versa, for either of them to be sufficient arguments for deferring to patient choices. Focusing on autonomy alone to justify deference overstates the value of choice in and of itself, as good medicine does not pursue just any choices. It seeks informed consent, which means that the choices we truly value are those made while understanding what is importantly relevant to the choice. A well-informed decision includes data about expected side effects and likelihood of beneficial effects; but it also includes knowing the patient’s values and goals. One must know what is actually valuable …