Too Much Information: Informed Consent in Cultural Context

Joseph J. Fins, MD; Pablo Rodriguez del Pozo, MD, JD, PhD


July 18, 2011

Imagine you are doing a long-awaited rotation in laparoscopic surgery, and are asked to obtain informed consent from a patient who will undergo an elective cholecystectomy. You want the patient, a woman in her 50s, to make a truly informed decision, which logically requires that she be fully aware of every possible detail of the impending surgery.

You introduce yourself to the patient, and carefully go through the list of details you have learnt should be fully disclosed. You start with the names, positions and roles of each member of the surgical team, including the chief surgeon, anesthesiologist, nurses, and you, a fourth-year medical student. You describe the technicalities of the procedure in a clear and understandable manner, from the drugs used for anesthesia induction and muscle relaxation to the number and size of the incisions to the skin suture technique (nylon, if she doesn't mind). Naturally, you go through all the advantages and potential risks of the procedure, and explain to the patient her right to consent or reject the treatment, or simply to postpone her decision for some other day.

An exemplary approach to informed consent, correct? Not necessarily. Some patients may be happy with this approach and follow the explanation without missing a word. But others, particularly if you happen to be in a "high-context" society, will probably feel that rather than respecting their rights, you are reading them their rights. Not everyone everywhere feels informed when flooded with detailed, explicitly worded information.

In the United States and other Western societies, people communicate mainly through verbal exchange. Information flows back and forth in the form of an explicit script and not much attention is generally paid to nonverbal, contextual cues. This model of communication occurs in what cultural anthropologist Geert Hofstede calls "low-context cultures."[1]

In contrast, the Mediterranean and Arab worlds seem to be at the high end of that communication spectrum in which less discourse is better. In high-context cultures, most information is -- as Hofstede has observed -- actually delivered by the context rather than the words themselves. The message is carried not as much by what is said, but rather by who is saying it and where, when, and how it's being said. People in general don't listen or read the words as much as they pay attention to what is hinted at by the environment.

This is not to say that patients in high-context societies don't require basic information about their own illnesses and treatments. Rather, words sometimes matter more as contextual clues than as carriers of bits of information. This has direct repercussions on how to obtain a meaningful informed consent and teaching the doctor-patient communication across cultures, as we have discussed elsewhere.[2,3]

In low-context venues like the United States, most patients demand explicit, detailed information, preferably in writing. In the high-context Spanish- and Arabic-speaking world, people simply don't demand this level of detail. On the contrary, if you give too much or too explicit information, the patient may suspect that you're withholding information -- that the truth is too ugly to be told and therefore is buried deep beneath a pile of words.

These cultural peculiarities should be understood at the bedside. In the United States, as medical ethicist Robert Veatch put it, information must be comprehensive, even excessive, because whereas "the over-informed person is inconvenienced; the under-informed has his or her autonomy violated."[4]

In other parts of the world, or for immigrants to United States from varied cultural backgrounds, delivering the right information is a less straightforward, more subtle enterprise that requires a proper balance between words and environmental cues. In the United States, trust is built on explicit information; in other cultures, trust can actually be jeopardized by over-abundant, suspicion-raising details. Finding the proper mix, though, is easier said than done.

There is no single standard that defines this mix, no simple formula or protocol. Proper transmission of information needs to be gauged case by case, relying on cultural competence, sensitivity, and a clear set of informational and trust-building goals.

To avoid communication missteps you should first assess the situation by asking yourself if the patient is from a high- or low-context background and then determine whether different norms are guiding the discourse. Next, seek the counsel of cultural intermediaries, perhaps a physician or nurse colleague with whom you work who hails from the patient's home culture. Such intermediaries can provide guidance on how best to develop a useful doctor-patient relationship.

In this context, it may be tempting for doctors and doctors-in-training to seek refuge in the comfort of clear-cut US standards of disclosure. No less tempting would be to suggest that not providing extremely explicit information would be to fall prey to old-fashioned medical paternalism. Either too much or too little disclosure in the wrong context can be counter-productive, even harmful to communication and the doctor-patient relationship.

The best bet is to understand one’s cultural context and gauge the disclosure of information in light of societal norms. Remember in a high-context society, less may be more and in a low-context setting, more detail may be better. Bottom line: there is no way to know how much information to share without reference to cultural context.