This post by Paul Levy got me thinking about informed consent, and a case I saw recently got me to take a little time and write about an issue frequently ignored in medical school.
A bit of background for non-medical readers. Informed consent is a term in medicine for when doctors get the agreement of the patient to do something to said patient. For example, before a patient is cut open for surgery, the patient has to say, “Yes I want to be cut open and have x happen.”
Less extreme examples abound: the patient has to consent to anything from a blood draw for a lab test to a CT scan. Part of informed consent is that the patient has to be informed. It is acceptable for a patient to say, “Tell me nothing, just do it,” but the patient has to be offered information regarding their disease as well as the risks and benefits of the procedure they are consenting to. For example, “This x-ray will tell us whether or not you have pneumonia or something else, but may slightly increase your risk of cancer in the long run. I recommend you get it. Do you agree?”
But here’s the thing: I increasingly think informed consent is a chimera, a concept more than a concrete thing. I believe it is whatever the provider wants it to be.
As an example, consider this case that I recently saw on the wards.
After we left, we ran our management of the patient by the attending. Upon hearing of her blood pressures without any signs of severe problems, and then learning that she was considering a C-section after a balanced counseling, the attending promptly ordered senior resident to, “Get back in there and convince her to deliver this baby vaginally.” My senior resident did indeed go back, and talk to the patient (I was unable to be present for the conversation), and she did indeed end up having a vaginal delivery many hours later.
My senior resident was concerned with patient autonomy: He legitimately wanted to present the options to the patient. My attending was more concerned with beneficence: He felt that the women would be harmed by a C-section and that she needed to be pushed towards a vaginal delivery. In effect, he felt that the balanced counseling that was given was too pro-C-section.
Both perspectives were not incorrect: After all how one presents the options can make a huge difference. Imagine the senior resident saying either of these two things to the patient the first time around:
Both statements are entirely true statements, but imagine if you’re a relatively uninformed pregnant women; hearing those spiels, which option would you choose?
There is such a massive knowledge imbalance between doctors and patients. How can any patient who is not a doctor ever be truly informed? They would logically need to understand the amount of knowledge contained in 7-10 years of medical training in 5 minutes.
Ultimately, all patients end up trusting their doctors to some degree. What that degree is varies from provider to provider, but depends on the provider. Throw in the fact that most people don’t read what they sign (or they’ll be stuck reading a novel in most hospitals) and you get the present reality. Just because a doctor spends 5 minutes discussing risks and benefits does not make consent informed, and consent may never be truly and fully informed; and that’s not necessarily a bad thing.
After all, informed consent has always been recognized by the legal profession as no obstacle: The physician is still held liable for everything that is offered or done, unless the patient refuses everything the doctor offers. What that means is that regardless of if the patient above chose as a vaginal delivery or C-section, if anything went wrong the physician would be held liable. Only if the physician tells the patient that they absolutely need a C-section and the patient refuses it against medical advice is the physician somewhat insulated. (This creates an obvious incentive for physicians, which manifests itself in a nearly 50 percent C-section rate in high malpractice lawsuit areas like New York City.)
The real problem though is when physicians don’t realize the power that they have. Our knowledge of medicine lets us convince most patients to do anything, and it is easy to blindly use that power without realizing the biases that might influence our advice. If we fool ourselves, saying “I’m merely providing information and options,” we risk doing a serious disservice to our patients.
Vamsi Aribindi is a medical student who blogs at Follies of an Amateur Intellectual.