The Ethical Question - Informed Consent

Jennifer Wider, MD

Disclosures

January 18, 2000

In This Article

Informed Consent

The phrase "informed consent" first appeared in the medical literature in the 1950s. Discussion of the concept escalated in 1972 surrounding the first and most influential of the landmark informed consent cases, Canterbury v. Spence.[1]When physicians failed to disclose possible complications of back surgery, a patient sued when he was left paralyzed. The court ruled that the patient can effectively exercise autonomy only if given full information by the physician.[2]

The December 30, 1999 issue of The New England Journal of Medicine featured an article about inserting femoral-vein catheters into patients for practice during a code. The study authors surveyed 234 house officers from three internal-medicine residencies, which included both university- and community-based training programs in Connecticut. The results of the study revealed that 34% of the house officers believed that it is sometimes appropriate to insert a femoral-vein catheter for practice during CPR, 26% had observed someone insert a femoral-vein catheter for practice during CPR, and 16% had attempted this procedure themselves.[3]

When asked in an interview whether students and residents receive proper training on the concept of informed consent, Dr. Lauris Kaldjian, lead author of the NEJM article, remarked: "I believe the topic is spoken of very frequently; how realistic those discussions are needs to be confronted seriously. We need to engage a patient in dialogue about their expectations of procedures; the degree of time it takes to do this properly is uncommon with busy schedules, and the degree to which it's applied in a vigorous way is open to discussion." (Personal communication. January 4, 2000)

In the Canterbury case, Dr. Spence stated that if patients were made aware of all of the possible complications, many would opt not to undergo necessary surgeries. His view suggests that emotional distress and anxiety caused by being informed might prevent patients from making rational decisions about their treatment. The court did not agree. Instead, they made it clear that all potential risks need to be elucidated including those that would result from a patient's choice to abstain from treatment.[4]

Treatment decisions are often complex, necessitating substantial doctor-patient dialogue in which patients are active participants in the care of their own bodies. The practice of involuntary and nontherapeutic procedures for the purpose of education is unacceptable and unethical. Physicians have an obligation to respect the dignity and autonomy of their patients. Without that, the trust between physicians and patients could be permanently lost.

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