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tient. It is critical that surgeons bear in mind that although
disclosing information may sometimes be mundane and
routine to the surgeon, the process is novel and frequently
confusing to the patient. As such, information should be
presented as clearly as possible and include a discussion of
the diagnosis, treatment options, and alternatives to treat-
ment including nonsurgical management or noninterven-
tion. Selective truth telling must be avoided, and surgeons
should make honest admissions of variables that are not
well controlled and other factors that are not well under-
stood by the medical profession or the surgeon.
8,10
The process of disclosure has been plagued by the ethical
question of how much information the surgeon should
disclose. In general, information related to the patient
should include explanation of the procedure; explanation
of risks, benefits, and potential consequences of the proce-
dure; and discussion of alternatives. Few would disagree
that it would be impossible to completely inform every
patient in every circumstance, that is, to take the time to
relay every detail of every risk, side effect, or potential out-
come of a given therapeutic intervention. The imbalance in
medical knowledge between the physician and patient may be
prohibitive to allow full disclosure. As such, there has been
much discourse about the amount of information that is nec-
essarily adequate in the informed consent process. Over time,
three main models of informed consent have emerged that
attempt to articulate what an adequate disclosure of informa-
tion to patients really means (
Table 1
).
2,3,11,12
One model of information disclosure is the professional
standard. The professional model reflects a traditional,
Hippocratic approach in which physicians disclose to pa-
tients no more (and hopefully no less) than what other
physicians would disclose in similar circumstances. In this
model, the standard of disclosure is measured by what
other competent health care professionals in similar cir-
cumstances would disclose. The professional standard
model has been criticized by some as being too physician
centered; in this model, information disclosure is measured
by what the physician—not the patient—deems impor-
tant. As such, this approach reduces individual patients to
generalized clinical scenarios, and physicians similarly are
reduced to performing a task that could be managed by an
informative brochure or checklist.
Another model of information disclosure is the reason-
able person standard. In this model, rather than the ade-
quacy of information disclosure being measured by what
the “reasonable” physician would disclose, the metric is
what the “reasonable” patient would want to know. The
legal standard in this model of disclosure is the “material-
ity” or significance of information to the patient’s decision-
making process. This model requires that a physician dis-
close any information that is “material” to a reasonable
person’s decision. Several court decisions in the 1970s up-
held the reasonable person standard, once called the “rea-
sonable man standard.”
2,3
Despite this, many within the
medical community have argued that the reasonable per-
son standard is ambiguous and difficult to satisfy. Specifi-
cally, the concept of what constitutes a “reasonable” person
has largely gone undefined, leaving indeterminate the prag-
matic implications of this standard. Although this model
more adequately addresses patient autonomy, it leaves open
for interpretation what it means to be “reasonable.”
13
In
addition, what a “reasonable” person may want to know
about a given medical intervention can vary depending on
the unique characteristics of his or her disease, values, and
life goals.
Because of the limitations of both the professional and
reasonable person standards, a third information disclosure
standard has been advocated by some ethicists.
14-16
This
third standard is known as the subjective standard. The
subjective standard requires the physician to disclose what-
ever information is material to the particular patient being
treated. That is, the subjective standard holds that the
amount of information disclosed should fit with the life
plan and interests of each particular patient. Although the
subjective standard has been hailed as an improvement over
the professional and reasonable person standards because it
values a patient’s right to information specific to their per-
sonal situation, the standard has been criticized as being
overly onerous to physicians. Specifically, critics have ar-
gued that it is unfair to expect physicians to be able to
discern the particular values, interests, and life circum-
Table 1.
Models of Informed Consent
Model
Definition and problems
Professional model
Disclosure and discussion based on what
other physicians would disclose in similar
circumstances
Problem: Promotes generalizations and
diminishes importance of individual
patient values and interests
Reasonable model
Disclosure and discussion based on what a
reasonable patient would want to know
Problem: What is reasonable to one patient
may be unreasonable to the next
Subjective model
Disclosure and discussion based solely on
specific interests, values, and life plan of
patient
Problem: Difficult to know every important
detail of patient’s life; cumbersome to
implement consistently
Balanced model:
reasonable and
subjective
Disclosure and discussion based on the most
important and relevant interests, values,
and goals of patient, as identified by both
patient and physician
Informed
Consent
and
the
Surgeon
Vol. 208, No. 4, April 2009
Childers et al
66