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stances of every patient who needs informed consent. Not
to mention, how can anyone but the patient really know
the details of the patient’s life and the full spectrum of the
patient’s interests?
Perhaps the best approach to information disclosure uses
a model that combines elements of both the reasonable
standard and the subjective standard. Although the reason-
able standard has some practical advantages (it does not
oblige physicians to know more about their patients than
what would be “reasonably” expected), the reasonable stan-
dard alone does not go far enough in tailoring the process
to patient individuality. In contrast, although the subjec-
tive standard may be overly cumbersome, it more ade-
quately addresses patient autonomy and the mandate to
address the individual needs of each patient. Combining
the reasonable and subjective creates a balance between
respect for patient autonomy and individual best interest,
while reducing some of the practical limitations encoun-
tered in the subjective standard. Under a combined subjec-
tive and reasonable standard model, physicians would be
encouraged to communicate with and learn about their
patients to the greatest extent possible, but with an under-
standing that time limitations and a duty to other patients
may prevent knowing all the details necessary to giving
adequate disclosure. Adequate disclosure must be based on
a patient’s values and interests, but both physician and
patient need to identify which values and interests take
precedence over those of lesser importance to the patient,
so that decisions are practically made.
Achieving adequate information disclosure is often not
easy and requires the physician to be especially attentive to
the language used while communicating with the patient.
When disclosing information, it is not enough simply to
use lay terminology, diagrams, or similar strategies to edu-
cate the patient and evaluate the patient’s understanding.
Rather, the specific choice of words used by the physician is
critical. In disclosing information, the surgeon’s word
choice can exert an unintended influence over the patient’s
overall decision-making process, an ethically problematic
process called “framing.”
8
For example, telling a patient,
“your quality of life will be horrible if we do not do this
procedure in the near future” may reflect the honest belief
or experience of the surgeon. But framing the information
in this way may diminish the patient’s ability to synthesize
true objective data into a decision that reflects the patient’s
interests and values. Instead, telling a patient, “there is good
evidence that patients have a lower chance of full recovery
and have poor functional outcomes if they wait X amount
of time before having this procedure,” liberates the patient
from potential bias because it allows a more objective as-
sessment of the clinical situation. Each patient and the
Gestalt that accompanies the situation at the time of such a
discussion, however, have to be individualized. Although
surgeons should try to avoid “overframing” the discussion,
they do need to provide information based on their clinical
experience and expertise to help the patient make a truly
informed decision.
Framing is often unintentional, but a more intentional
type of framing can occur in which the physician provides
an unnecessarily negative outlook for a patient’s procedure
or prognosis, called “crepe hanging.”
17
Although providing
patients with accurate prognostic information is impor-
tant, painting an unreasonably bleak picture of a patient’s
chances to either appear correct if the outcomes are partic-
ularly poor or exceptional if the outcomes are good should
be avoided. Despite being rife with ethical peril, crepe
hanging may be tempting to the rare physician who seeks
protection from negative outcomes. Both this and more
subtle forms of framing that can occur during the informed
consent process must be avoided. In general, the language
used by the physician in the information disclosure process
should be as objective as possible. Of course, many patients
still want their surgeon’s more subjective opinion of their
clinical situation. In general, it is best that the surgeon
withhold an opinion until after disclosure is complete, and
only on the direct request of the patient.
Information disclosure is a critical part of informed con-
sent, but subsequent active assessment of the patient’s un-
derstanding of the disseminated information is similarly
important. Before the decision-making process can begin,
patients need to understand fully the realm of outcomes
possible with each of their therapeutic options (cognitive
understanding), and fully recognize how their beliefs and
values relate to the therapeutic options and associated po-
tential outcomes (evaluative understanding).
8,10
To ensure
cognitive understanding, it is often helpful for the surgeon
to ask patients to reiterate in their own words their under-
standing of the rationale, risks, and benefits of the proce-
dure. The idea here is not to quiz the patient, but rather to
encourage an open exchange of information and encourage
the patient to participate and to ask any necessary ques-
tions. If the patient is reluctant to ask questions or asks
questions that suggest an incomplete or incorrect under-
standing of the circumstances, the surgeon should engage
in further discussions with the patient to ensure that any
misunderstandings are rectified and that the patient’s val-
ues and interests are being respected. Surgeons should also
be aware that some patients may value not asking ques-
tions, and this should be respected within reason.
Although surgeons are responsible for engaging patients
in this dialog, patients have a similar ethical obligation.
That is, patients should be active partners in the informed
Childers et al
Informed Consent and the Surgeon
J Am Coll Surg
67