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cal team with his or her personal signature or the signature
of the surrogate decision-maker.
8,10
This signature is of con-
siderable import because it indicates that authorization is
separate but necessary to the “consent” component.
Informed consent: other considerations
Patient refusal
There are a number of ethically problematic situations re-
lated to the informed consent process that can arise in
surgery. For example, a patient may refuse an operation
because he or she is unable to make a decision, despite the
surgeon having engaged the patient in the informed con-
sent process as outlined earlier. The surgeon should recog-
nize that the patient has the right to refuse an operation,
and explain to the patient that no offense has been caused
as a result of the refusal.
10
The surgeon should explore with
patients the reasons for refusing an operation; this gives the
surgeon some insight into the patients’ thought process,
and demonstrates to the patients that their refusal does not
mean that they lose the care or support of their surgeon. In
addition, patients who refuse elective surgery should un-
derstand that their refusal does not necessarily prevent an
opportunity for a later procedure.
Diminished capacity
Not infrequently, surgeons may encounter patients with
diminished decision-making capacity secondary to cogni-
tive dysfunction, psychiatric illness, etc. Surgeons should
not automatically assume that these patients are incompe-
tent and deny them a role in the informed consent process.
The surgeon has a responsibility to personally engage the
patient to determine the patient’s level of understanding.
Although the capacity to participate in decision-making
can be made by a physician, determination of incompe-
tence is more a legal issue requiring psychiatric testimony
and a judicial process. If consultation with psychiatrists,
lawyers, or other physicians is necessary, the surgeon
should be upfront with the patient about this plan.
8
Ulti-
mately, the goal between the surgeon and any consultant
should be to improve the patient’s decision-making capac-
ity when possible, and not to simply obtain affirmation
that a patient needs a proxy decision-maker.
There will be patients, however, who are incompetent to
make their own decisions. Patients deemed incapable of
making decisions require a proxy decision-maker. The
proxy decision-maker can be someone previously chosen
by the patient when the patient was in a competent state, or
someone appointed by the court. Often proxy decision-
makers are family members or close friends who have been
chosen because they are believed to have the best percep-
tion of the patient’s values and interests.
10
In those occa-
sional circumstances in which the surgeon disagrees with
the surrogate decision, the hospital ethics committee
should be consulted.
Cultural and familial issues
Respect for autonomy and the judicious application of in-
formed consent are cornerstones of modern medical prac-
tice in the United States and reflect the largely individual-
istic approach to patient care embodied in Western
medicine. The concept of illness and how therapeutic de-
cisions are made may differ in certain cultures. Surgeons
and other physicians who practice within the Western
medical paradigm can encounter difficult ethical dilemmas
when caring for patients with varying cultural values. Sur-
geons need to pay increased attention during the informed
consent process to ensure that cultural values are identified,
valued, and respected.
On occasion, balancing the requirements of the tradi-
tional, Western informed consent process with the appro-
priate respect for the culture in question can be challeng-
ing. Perhaps one of the biggest challenges to surgeons in the
United States is dealing with patients and families from
cultures in which the principle of individual autonomy is
not the primary driving principle of decision-making. For
example, Korean Americans, Japanese Americans, and
Mexican Americans are examples of cultural groups who
may generally more frequently believe that terminal diag-
noses and information relevant to treatment should be
withheld from the patient and instead communicated only
with the patient’s family.
20,21
These situations raise obvious
ethical dilemmas and challenges for the treating surgeon.
For example, when the surgeon is asked to communicate
more directly with the family rather than the individual
patient, the direction of communication can be displaced
away from the patient, which may prevent the surgeon
from establishing an effective physician-patient relation-
ship. Second, the surgeon loses the ability to fully assess the
patient’s understanding of the disease and the available
therapeutic options in the context of the patient’s unique
values and interests. Third, and perhaps most significantly,
the surgeon may have difficulty recognizing whether any
given patient agrees with his loss of autonomy, or whether
he is instead heteronomously acting under the pressures,
values, or demands of others.
22
There are no easy solutions to these concerns. Surgeons
should approach each patient as a unique individual re-
gardless of cultural influences, and avoid making assump-
tions based on race, religion, or family influences (
Fig.
2
).
19,22
The most effective way to approach patients from
cultures in which individual autonomy may not be the
dominant ethical principle involves, from the beginning, a
heightened attentiveness for subtleties in the interactions
between the patient and the family. Discrepancies between
Childers et al
Informed Consent and the Surgeon
J Am Coll Surg
69