Academic journal article The Hastings Center Report

Avoiding Surprises: A Model for Informing Patients

Academic journal article The Hastings Center Report

Avoiding Surprises: A Model for Informing Patients

Article excerpt

Not long ago, I heard myself saying something like the following to my medical ethics class: So, as physicians you will be morally required to provide your patients with any information they need in order to make reasonable treatment decisions. But, of course, that is not the only information you will be morally required to give them." Soon after the words left my mouth, I realized that despite what I took to be their obvious and unsurprising truth, I had never seen this fact discussed in the medical ethics literature. (1)

The issue of informed consent is vitally important, and there are many reasons why discussions regarding informing patients have tended to take place within that context. What I want to suggest, however, is that limiting discussions about informing patients to this context has had an unintended but deleterious effect on these discussions. It encourages us to talk as if physicians are required to provide all and only information necessary for securing informed consent. In fact, there are many instances when physicians should--and regularly do--provide information that obviously will not affect their patients' decisions. There is not much information that would deter a normal patient from deciding to have his broken leg set, yet there is quite a bit that any physician would, and should, tell such a patient. Among other things, she should tell him how long he'll have to wear the cast, what sort of pain he can expect, and whether and how the break might affect his leg in the future.

As the example demonstrates, physicians are already in the habit of providing much more information than patients need in order to make reasonable decisions. Nonetheless, an explicit discussion about what they should provide is important. So much of the information that physicians should present is information that no one likes to give--this procedure might result in permanent impotence or incontinence, this mended bone may continue to ache from time to time, there is a slight chance that this medication will cause your child to be born with a birth defect. If we say, time and again, that physicians must provide information for the purpose of gaining informed consent, and don't say anything more, it may be too easy to slip into thinking that a certain bit of information can be passed over because--as anyone really would agree--there is no chance that information about this fact will alter the patient's decision. Some of the models for informed consent might well provide good guidance regarding the general information physicians should provide their patients, but if so that seems to be purely accidental. Virtually all criticisms and defenses of them have been made in the context of informed consent, and none of their authors have encouraged us to use their models in a broader way.

Thus my goals in this paper are twofold. One is to introduce a model for thinking about the general information that physicians are morally obligated to give their patients. The other is to provoke discussion of this topic, in hopes that others will suggest further models. Although the model I offer does not present the information given as that which allows informed consent, if a patient is informed as my model proposes, her consent would be informed. In brief, I will argue that a patient should be informed in such a way that, no matter which rational option she chooses, she will not be surprised by what happens--unless the informing physician is himself surprised. I will refer to the principle on which my model is based as the Principle of Avoiding Surprises. (2)

Informed Consent and the Law

It is in the opinions of the courts that we find the first statements of the most commonly cited standard of what patients must be told: the "Reasonable Person" Standard. According to this standard, a physician is required to give her patient whatever information a reasonable person would want before deciding whether to consent to a particular treatment. …

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