The importance of a mutual participatory model in medical care and decision making is supported by literature that now shows a link between patient participation and an improved health outcome. Illness (and the sick role) constitutes a state of diminished autonomy and mutual participation may help patients to regain control.

Patients who participate most frequently are under 65 but above 30 years old, are better educated, have a higher income and profession and a higher socioeconomic status. Patients are keener to participate in decision making when more serious illnesses are present and when they have had prior experiences with a serious illness. They participate more fully if they feel that they are well enough, have enough knowledge and are allowed to participate. Patients are able to participate to a greater extent when they see themselves as experts in experiencing the illness. It is therefore important to encourage active participation by those patients who are less likely to participate.

It is important for health workers to have at least the following personal values and skills, which will enable them to encourage and foster active participation: humility, the ability to relinquish the role of the expert, an awareness of their position of power and the ability to value even the poor are needed to set the scene for participation.

It is important that health workers acknowledge the patients' right to self-determination and autonomy. Empathic listening, unconditional positive regard, sensitivity for the patients and their values and an ability to tolerate ambiguity create an atmosphere conducive to mutual participation.

When health workers become aware of differences in opinion or in the balance of power, this should be acknowledged and discussed and a mutual understanding should be negotiated. Health workers have the potential to manipulate “mutual decision making” with the information they give. It is therefore essential to be open and honest about biases and opinions.