Thursday, December 14, 2017

A. Informed Consent

      The doctrine of informed consent, which is based on the notion of individual autonomy, has guided virtually all modern physician-patient interactions concerning treatment decisions and has paved the way for the formulation of new patient-centered approaches to medicine. The doctrine evolved as a means of addressing abuses and the fundamental knowledge differential between physician and patient that underlies the inequalities inherent in the treatment relationship.

      Until the middle of the twentieth century, the treatment received by patients in hospitals was far from ideal. According to George Annas, the hospital was “a human rights wasteland,” where the care of patients ranged from benign paternalism to medical experimentation without consent or the possibility of therapeutic benefit. During this period, medical professionals operated under the assumption that medicine was primarily a scientific endeavor, and that physicians--because of their knowledge, experience, and expertise--were uniquely positioned to make decisions regarding their patients' best interests. According to this ethos, patients had neither the interest nor the ability to participate in medical decisionmaking. Thus, physicians routinely refused to counsel patients about important medical treatment options, did not inform patients of their prognosis, particularly when the chance of survival was low, ignored patients' refusal of life-sustaining treatment, and failed to consult patients when exams, tests, or procedures were conducted primarily or solely to educate medical students.

      These abuses were particularly pronounced for African American patients, who, until the 1960s, received health services primarily at large public hospitals, which were the training grounds for inexperienced medical students, interns, and residents. People of color and members of disadvantaged or vulnerable groups were also often used as training material. One particularly infamous example is the Tuskegee syphilis study, in which nearly four hundred African American men with syphilis were systematically denied known, effective medical remedies and were not informed that they were treated for research, rather than diagnostic, purposes. Sustained from 1932 to 1972, the Tuskegee study was the longest experiment in withholding treatment from human subjects in medical history. Ultimately, this and several other shocking examples of physician paternalism and deceit led to the emergence in the late 1960s and early 1970s of the patients' rights movement and the advent of the modern doctrine of informed consent, which has empowered patients and changed the attitude of a new generation of physicians toward their patients.

      Today, physicians are required to obtain a patient's informed approval prior to performing treatment and must disclose information about the risks of the proposed treatment, the alternatives, and the risks of the alternatives. This mandatory information transfer from physician to patient not only safeguards the patient's interests and autonomy but also protects the patient's essential status as a human being, prevents fraud and duress, encourages healthcare providers to consider their decisions carefully, and fosters rational decisionmaking by the patient. By rendering the physician-patient relationship less hierarchical and more dialogic, the informed consent mandate enables healthcare providers to perform with increased sensitivity to a patient's emotional needs, cognitive ability, and actual comprehension.

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