Informed Consent in the Information Age

Informed Consent in the Information Age

For patients, there are no guarantees attached to the services we render as physicians. Actually, as a surgeon I would semi-seriously “guarantee” my patients three things, and three things only: a scar where an incision was made; some transient discomfort at the operative site; and the best job I knew how to do. Having thereby opened the discussion surrounding a recommended surgical intervention, I would begin the time consuming, complex and risky process of informed consent. Informed consent is quite literally the legal contract for care. The physician receives remuneration from the patient in exchange for providing a service. Moreover, because the service carries with it both deliberate injury (for example, any surgery, or administration of chemotherapeutic agents that target living cells) along with the risk of unintended injury, there is both a moral and legal obligation to inform the patient of the benefits, risks and alternatives available and to obtain legal permission prior to intervention. Failures to properly inform, along with negligence, form the only grounds for malpractice lawsuits. Physical intervention in the complete absence of consent can be grounds for criminal assault and battery. A few plaintiffs’ attorneys have tried the latter approach in recent years, though I’m not aware of successful prosecutions. On the other hand, Lawyers Weekly (July, 2000) reported that “med-mal lawyers are bringing more ‘lack of informed consent’ claims” to increasingly sympathetic juries. The traditional approach to informed consent—“Here! Read this! Sign it! Thanks.” —no longer suffices. Through the 1990s, more than $50 million per year was awarded for medical malpractice claims alleging failure to inform. Recently, a Florida jury awarded $3.8 million...
Technological Darwinism and the Social Contract

Technological Darwinism and the Social Contract

Article by Terry R. Knapp, MD This is truly a golden age of innovation and technological success in medicine. We can define and catalogue the genetic blueprint of the individual patient. We can replace hearts, and corneas, and livers, and lungs, and more. We can install an artificial pancreas that uses microelectronics to meter and infuse insulin as metabolic requirements change throughout the course of a diabetic’s day. We can cure cancers by wiping out the entire immune system, and then replacing it. Why, we can actually go far beyond prolonging life—we can, and do, prolong death. We can also violate patient privacy without patient knowledge. We can exploit the economic basis of health care delivery by recommending tests, treatments and interventions with marginal, or even negative, individual benefit. And we tend to justify it all based on obeisance to innovation and technology. The stark truth that constitutes the ugly underbelly of technology and innovation is that we have failed to reconcile technological advances with the social contract between the individual patient and the health care industry. My ninety-year-old mother-in-law has late-stage Alzheimer’s disease. In a mirror, she does not recognize the person looking back at her. This spring, she had a small lump in her breast diagnosed on excisional biopsy (local anesthesia, outpatient) as low grade carcinoma. The recommendation: modified radical mastectomy with consideration of follow-up chemo and/or radiation therapy. The decision: No thanks. The conclusion: the physician made a recommendation whereby technology triumphs over common sense. Sometimes we seem to forget that life, after all, is a finite condition. Just what responsibilities to the social contract do...