Abstract
In order to fashion a synthesis of the various agendas and perspectives that weigh upon us, we have elected to give primacy to an informed consent event in our account, however much it may need to be augmented by a surrounding process. The informed consent event has three distinct stages, each aimed at quite different, though complementary goals: (1) the comprehensive disclosure stage, which will roughly approximate the detailed presentation of risks, benefits and alternatives of a given intervention required by American law, but will be aimed at more modest goals, e.g. providing the patient the opportunity to rule in or out regarding hesitancy, ambivalence or misconceptions; (2) the core disclosure stage, which will attempt to counter the information overload tendency of the first stage and give patients something relatively simple and structured which they might minimally react to and evaluate, viz., the essential choice at hand; and (3) the assessment, clarification, and patient choice stage which will be the only necessarily interactive part of the informed consent event (unless the patient spontaneously chooses this mode at any other point), and which will focus on the patient’s level of understanding and other concerns. This stage will proceed by probing into the patient’s understanding of the information provided in the preceding two stages and will respond to this with appropriate clarification of the patient’s developing sense of the issues at hand.
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Notes
There will, of course, be instances where multiple diagnoses are at issue, particularly early on in the work up of a patient. Such situations are not rare and will surely complicate the detail of this section. Two caveats seem to bear making: (1) a balance would need to be struck between mentioning all of them, some of which may be theoretical possibilities only, and emphasizing the main possibilities. What would actually be said might be determined by the intervention at issue, especially if it is diagnostic and relates to one of the possibilities. Also, one should be hesitant to assault patients with an extended list of possibilities that will do little more than alarm them and cause needless worry. Our aim throughout is to present important information and encourage patient insight, not engage in “truth-dumping”. But (2) it is as potentially disastrous not to identify such uncertainties to the patient up front, as the clinician’s credibility, and with it trust, may evaporate if he is forced to modify treatment toward one of the other possibilities later. A good example here would be a patient who presents with shortness of breath and a temperature, but also with a x-ray containing a suspicious lung opacity. The patient probably has an infiltrate, but this may be superimposed upon a malignancy that also will need to be investigated. To neglect to mention the latter possibility early on not only will strain trust but deprive the patient of time to prepare for the latter discussions. To not even mention the possibility sets the whole process up for failure and may well cause more problems than it solves.
See especially the first section of chapter four.
E. Haavi Morreim, personal communication.
This scenario is discussed extensively in the eighth chapter regarding patient waivers of informed consent.
This designation is used in passing by Faden and Beauchamp, 1986 on pg. 315. I make no claim as to whether they would tend to accept the “operational” recommendations which I am making here.
See, for example, Doukas and McCullough, 1991.
As long as the situation is one where the clinician sees a certain treatment as “clearly indicated”, such latitude should be given to patients. To the extent important compliance issues are involved, or important personal choices are presented, such behavior by patients becomes less acceptable. In this regard, see the discussion of the “waiver exception” in chapter eight, regarding when such behavior by patients should be challenged as unacceptable.
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© 1993 Springer Science+Business Media Dordrecht
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Wear, S. (1993). The Informed Consent Event. In: Informed Consent. Clinical Medical Ethics, vol 4. Springer, Dordrecht. https://doi.org/10.1007/978-94-015-8122-6_7
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