2017 HSC Section 2 - Practice Management
Vol. 208, No. 4, April 2009
Informed Consent and the Surgeon
Childers et al
tient. It is critical that surgeons bear in mind that although disclosing information may sometimes be mundane and routine to the surgeon, the process is novel and frequently confusing to the patient. As such, information should be presented as clearly as possible and include a discussion of the diagnosis, treatment options, and alternatives to treat- ment including nonsurgical management or noninterven- tion. Selective truth telling must be avoided, and surgeons should make honest admissions of variables that are not well controlled and other factors that are not well under- stood by the medical profession or the surgeon. 8,10 The process of disclosure has been plagued by the ethical question of how much information the surgeon should disclose. In general, information related to the patient should include explanation of the procedure; explanation of risks, benefits, and potential consequences of the proce- dure; and discussion of alternatives. Few would disagree that it would be impossible to completely inform every patient in every circumstance, that is, to take the time to relay every detail of every risk, side effect, or potential out- come of a given therapeutic intervention. The imbalance in medical knowledge between the physician and patient may be prohibitive to allow full disclosure. As such, there has been much discourse about the amount of information that is nec- essarily adequate in the informed consent process. Over time, three main models of informed consent have emerged that attempt to articulate what an adequate disclosure of informa- tion to patients really means ( Table 1 ). 2,3,11,12 One model of information disclosure is the professional standard. The professional model reflects a traditional, Hippocratic approach in which physicians disclose to pa- tients no more (and hopefully no less) than what other physicians would disclose in similar circumstances. In this model, the standard of disclosure is measured by what other competent health care professionals in similar cir- cumstances would disclose. The professional standard model has been criticized by some as being too physician centered; in this model, information disclosure is measured by what the physician—not the patient—deems impor- tant. As such, this approach reduces individual patients to generalized clinical scenarios, and physicians similarly are reduced to performing a task that could be managed by an informative brochure or checklist. Another model of information disclosure is the reason- able person standard. In this model, rather than the ade- quacy of information disclosure being measured by what the “reasonable” physician would disclose, the metric is what the “reasonable” patient would want to know. The legal standard in this model of disclosure is the “material- ity” or significance of information to the patient’s decision- making process. This model requires that a physician dis-
close any information that is “material” to a reasonable person’s decision. Several court decisions in the 1970s up- held the reasonable person standard, once called the “rea- sonable man standard.” 2,3 Despite this, many within the medical community have argued that the reasonable per- son standard is ambiguous and difficult to satisfy. Specifi- cally, the concept of what constitutes a “reasonable” person has largely gone undefined, leaving indeterminate the prag- matic implications of this standard. Although this model more adequately addresses patient autonomy, it leaves open for interpretation what it means to be “reasonable.” 13 In addition, what a “reasonable” person may want to know about a given medical intervention can vary depending on the unique characteristics of his or her disease, values, and life goals. Because of the limitations of both the professional and reasonable person standards, a third information disclosure standard has been advocated by some ethicists. 14-16 This third standard is known as the subjective standard. The subjective standard requires the physician to disclose what- ever information is material to the particular patient being treated. That is, the subjective standard holds that the amount of information disclosed should fit with the life plan and interests of each particular patient. Although the subjective standard has been hailed as an improvement over the professional and reasonable person standards because it values a patient’s right to information specific to their per- sonal situation, the standard has been criticized as being overly onerous to physicians. Specifically, critics have ar- gued that it is unfair to expect physicians to be able to discern the particular values, interests, and life circum-
Table 1. Models of Informed Consent Model
Definition and problems
Professional model
Disclosure and discussion based on what other physicians would disclose in similar circumstances Problem: Promotes generalizations and diminishes importance of individual patient values and interests Disclosure and discussion based on what a reasonable patient would want to know Problem: What is reasonable to one patient may be unreasonable to the next Disclosure and discussion based solely on specific interests, values, and life plan of patient Problem: Difficult to know every important detail of patient’s life; cumbersome to implement consistently Disclosure and discussion based on the most important and relevant interests, values, and goals of patient, as identified by both patient and physician
Reasonable model
Subjective model
Balanced model: reasonable and subjective
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