The Clinical Experience of
Patient Autonomy and
Any attempt to characterize the dominant view of clinicians on patient autonomy and informed consent is precarious at best. On the one hand, the new ethos of patient autonomy is hardly just an outsider's fabrication, fashioned by lawyers and philosophers. Indeed, some of its most forceful and well-known advocates have been physicians—for example, Howard Brody, Eric Cassell, H. Tristram Engelhardt, Jr., Jay Katz, and Edmund Pellegrino. On the other hand, the clinical literature is replete with heartfelt attacks on the "myth of informed consent" (Ravitch, 1978), a view often echoed on the firing line.
But we are not really faced with a choice between complete rejection or affirmation. Clinicians will hopefully accept the idea that some laypersons can grasp much of the essence of the choices facing them, and some patients evolve sophisticated appreciations of their situations and prospects. Equally, the value of patient understanding for compliance, cooperation, and self-monitoring is apparent. Finally, extensive and repeated discussions are needed to enlist and maintain chronically or terminally ill patients in extended or extraordinary treatment regimens. The possibility that extraordinary treatment may result in no more than extra suffering without cure is increasingly well recognized in many families from the prior experience of a loved one. The resultant fear and reticence may require a substantial informational and counseling response.
But if we go beyond admissions that some patients are quite capable of autonomous decision making, and that patient understanding is often desirable as well as necessary, the prevailing view of clinicians still seems to involve a rejection of the most basic and revolutionary presumption underlying the new ethos and informed consent- namely, that most patients are sufficiently capable of understanding, evaluating, and making decisions about their medical situation and