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Informed consent: Commentary on the ACOG ethics committee statement
Informed Consent: Commentary on the ACOG Ethics Committee Statement Thomas E. Elkins, MD Douglas Brown, PhD Department of Obstetrics and Gynecology School of Medicine in New Orleans Louisiana State University Medical Center New Orleans, Louisiana
he word "ethics" has to do with what ought to be done, all things considered. 1 From a societal perspective, ethical reflection on health care issues focuses on the continued liberty of citizens when they are patients and on the fair distribution of resources. From a professional's perspective, ethical reflection orients clinical decisions toward the goal of enhancing the patient's well-being or easing the patient's decline. From a patient's perspective, ethical reflection measures clinical choices by the impact on one's life story, which has been disrupted by accident or illness. "Informed consent" singles out one component of the decision-making process in which this freedom is exercised by the patient in the context of health care. We believe the ACOG ethics committee has correctly recognized that "ethics" presumes that human beings are essentially free and, therefore, accountable for their actions. However, the committee took a serious risk in attempting to approach the meaning of informed consent historically, philosophically, and culturally. We fear that most physicians would prefer a more cookbook document. The committee may have written a document that may, for some physicians, create confusion about a clinical responsibility they thought was fairly straightforward. The phrase "obstetric-gynecologic ethics" suggests both commonality and distinction in decision-making pertaining to women's reproductive and sexuality health care. Obstetrics and gynecology do continue to share enough common ground for both specialties to be addressed jointly in an ethics statement (eg, both areas involve women's health care needs, relate to the same region of the body, and have reproductive and sexuality interests). However, we believe that such an ethics statement needs to demonstrate consideration of the many traits that distinguish obstetrics ethics from gynecology ethics. For instance, an obstetrician makes clinical decisions for two patients (at least from the point of fetal viability) who are interdependent, with one (the fetus) being accessible for interventions only through the other (the pregnant woman). A gynecologist practices preventive medicine. An obstetrics team includes
T
WHI Vol. 3, No. I Spring 1993
© 1993 by The Jacobs Institute of Women's Health 1049-3867/93/$6.00
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pediatricians (neonatologists), thus overlapping two medical specialities. A gynecologist faces the chronic consequences of a sexually transmitted disease epidemic. An obstetrician wrestles with beginning-of-life decisions; a gynecologist, with aging and end-of-life decisions. Obstetrics focuses on a single category of experience within a fraction of a woman's life. Gynecology includes several categories of experience that cover a woman's entire life. Such comparisons suggest that informed consent can be distinguished in obstetric and gynecologic settings. The relationships between patient and physician vary in the two settings. The types of ethical decisions differ (eg, physician-assisted death). The limitations on achieving informed consent vary (eg, diminished consent capacity due to aging). The practice of informed consent proposed by the committee is immediately applicable to clinical cases in which the woman involved has the ability and opportunity to read, has social advantage, and has significant economic power. This document and the matter of informed consent are uniquely American, where citizens claim such freedom due to a social contract and have choice because of national wealth. Unfortunately, most of the literature on informed consent we have reviewed has little clinical relevance for physicians facing either obstetric or gynecologic decisions involving patients who do not bring such privilege. The committee is to be commended for the attention given to limitations in the attainment of informed consent. However, because the committee chose (correctly, in our judgment) to present its discussion of informed consent in the broader context of a theory about being human that focuses on freedom, it seems important that the committee's proposals be clearly adaptable to women whose freedom is diminished or unstable. Otherwise, these women will appear disenfranchised. The committee is also to be commended for demonstrating that the clinical significance of informed consent is determined by the patient-physician paradigm in use. (A paradigm is a way of seeing and interpreting data in the effort to make sense of life experiences.) We agree with the committee that a third distinguishable paradigm for the patient-physician relationship has developed over the past few years. However, we are not convinced that the document has clearly delineated the three paradigms or that the committee is supporting an adoption of the newest paradigm. The committee included, as a form of the paradigm that developed in the 1970s around patient autonomy, the effort to integrate patient autonomy into the decision-making process. By presenting this option as a variation of the new paradigm, the committee did not capture, in our judgment, the tension that has existed for the clinician. We propose that clinicians, whether grudgingly or willingly, began to integrate patient autonomy (and, therefore, informed consent) into the decision-making process. We think that their response represented an amendment of the traditional paradigm. However, the discussion during the 1970s within the emerging profession of medical ethicists did indeed articulate, though not with unanimity, a new paradigm for the patient-physician relationship. This new paradigm supplanted physician paternalism with patient autonomy. 2 The ethics statements from the ACOG committee over the past 15 years have, we suggest, been written out of that paradigm. Adoption of yet a newer paradigm creates the need to reevaluate each of these statements. We propose that the newest paradigm for the patient-physician relationship has developed as a transition away from the extremes allowed by the previously dominant paradigms. The older paradigm had assumed that the physician would be able to discern the best interest of the trusting patient, leaving informed consent virtually absent from the process. In an extreme form, this paradigm put the patient in the role of victim and equated benef32
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icence with paternalism. The paradigm that emerged in the 1970s put such singular emphasis on patient self-determination that informed consent would have been more accurately called informed choice. In an extreme form, this paradigm reduced the physician to the role of technician. The most recent paradigm does, as the committee discussed in some detail, recognize limitations on patient autonomy. But the literature related to the emerging paradigm also takes into account cost constraints in the distribution of resources, global concerns about sexually transmitted disease epidemics, and the need for increased beneficent involvement on the part of physicians. In this context, beneficence implies a sense of duty or obligation on the part of the physician to advise and to act in accordance with reasonable medical indications. We believe that a contemporary understanding of medical dilemmas requires a thorough understanding of this most recent paradigm. The ACOG committee's statement on informed consent appears to us still to be working with the second (ie, patienbautonomy) paradigm, albeit amended to acknowledge limits on patient autonomy. The most telling indication is the committee's dependence on the vocabulary of "principles," "doctrines," and "concepts." The vocabulary of the newest paradigm for the patient-physician relationship expands the vocabulary to include "values," "virtue," "trust," and "gratitude." In this relationship, the "mutuality" to which the ACOG committee appeals would bring together informed consent from the patient and informed planning from the physidan. The physician would not paternalistically presume to know always what would be in the patient's best interests. The patient would retain control of his or her life story by informing and responding to the phase-by-phase judgment of the attending physician.
WHI Vol. 3, No. 1 Spring 1993
REFERENCES 1. The APGO Task Force on Medical Ethics. Exploring issues in obstetrics and gynecologic medical ethics. Washington, DC: The Association of Professors of Gynecology and Obstetrics, 1990. 2. Engelhardt T. The foundations of bioethics. New York: Oxford University Press, 1986.
ELKINS AND BROWN: COMMENTARY
33
he word "ethics" has to do with what ought to be done, all things considered. 1 From a societal perspective, ethical reflection on health care issues focuses on the continued liberty of citizens when they are patients and on the fair distribution of resources. From a professional's perspective, ethical reflection orients clinical decisions toward the goal of enhancing the patient's well-being or easing the patient's decline. From a patient's perspective, ethical reflection measures clinical choices by the impact on one's life story, which has been disrupted by accident or illness. "Informed consent" singles out one component of the decision-making process in which this freedom is exercised by the patient in the context of health care. We believe the ACOG ethics committee has correctly recognized that "ethics" presumes that human beings are essentially free and, therefore, accountable for their actions. However, the committee took a serious risk in attempting to approach the meaning of informed consent historically, philosophically, and culturally. We fear that most physicians would prefer a more cookbook document. The committee may have written a document that may, for some physicians, create confusion about a clinical responsibility they thought was fairly straightforward. The phrase "obstetric-gynecologic ethics" suggests both commonality and distinction in decision-making pertaining to women's reproductive and sexuality health care. Obstetrics and gynecology do continue to share enough common ground for both specialties to be addressed jointly in an ethics statement (eg, both areas involve women's health care needs, relate to the same region of the body, and have reproductive and sexuality interests). However, we believe that such an ethics statement needs to demonstrate consideration of the many traits that distinguish obstetrics ethics from gynecology ethics. For instance, an obstetrician makes clinical decisions for two patients (at least from the point of fetal viability) who are interdependent, with one (the fetus) being accessible for interventions only through the other (the pregnant woman). A gynecologist practices preventive medicine. An obstetrics team includes
T
WHI Vol. 3, No. I Spring 1993
© 1993 by The Jacobs Institute of Women's Health 1049-3867/93/$6.00
ELKINS AND BROWN: COMMENTARY
31
pediatricians (neonatologists), thus overlapping two medical specialities. A gynecologist faces the chronic consequences of a sexually transmitted disease epidemic. An obstetrician wrestles with beginning-of-life decisions; a gynecologist, with aging and end-of-life decisions. Obstetrics focuses on a single category of experience within a fraction of a woman's life. Gynecology includes several categories of experience that cover a woman's entire life. Such comparisons suggest that informed consent can be distinguished in obstetric and gynecologic settings. The relationships between patient and physician vary in the two settings. The types of ethical decisions differ (eg, physician-assisted death). The limitations on achieving informed consent vary (eg, diminished consent capacity due to aging). The practice of informed consent proposed by the committee is immediately applicable to clinical cases in which the woman involved has the ability and opportunity to read, has social advantage, and has significant economic power. This document and the matter of informed consent are uniquely American, where citizens claim such freedom due to a social contract and have choice because of national wealth. Unfortunately, most of the literature on informed consent we have reviewed has little clinical relevance for physicians facing either obstetric or gynecologic decisions involving patients who do not bring such privilege. The committee is to be commended for the attention given to limitations in the attainment of informed consent. However, because the committee chose (correctly, in our judgment) to present its discussion of informed consent in the broader context of a theory about being human that focuses on freedom, it seems important that the committee's proposals be clearly adaptable to women whose freedom is diminished or unstable. Otherwise, these women will appear disenfranchised. The committee is also to be commended for demonstrating that the clinical significance of informed consent is determined by the patient-physician paradigm in use. (A paradigm is a way of seeing and interpreting data in the effort to make sense of life experiences.) We agree with the committee that a third distinguishable paradigm for the patient-physician relationship has developed over the past few years. However, we are not convinced that the document has clearly delineated the three paradigms or that the committee is supporting an adoption of the newest paradigm. The committee included, as a form of the paradigm that developed in the 1970s around patient autonomy, the effort to integrate patient autonomy into the decision-making process. By presenting this option as a variation of the new paradigm, the committee did not capture, in our judgment, the tension that has existed for the clinician. We propose that clinicians, whether grudgingly or willingly, began to integrate patient autonomy (and, therefore, informed consent) into the decision-making process. We think that their response represented an amendment of the traditional paradigm. However, the discussion during the 1970s within the emerging profession of medical ethicists did indeed articulate, though not with unanimity, a new paradigm for the patient-physician relationship. This new paradigm supplanted physician paternalism with patient autonomy. 2 The ethics statements from the ACOG committee over the past 15 years have, we suggest, been written out of that paradigm. Adoption of yet a newer paradigm creates the need to reevaluate each of these statements. We propose that the newest paradigm for the patient-physician relationship has developed as a transition away from the extremes allowed by the previously dominant paradigms. The older paradigm had assumed that the physician would be able to discern the best interest of the trusting patient, leaving informed consent virtually absent from the process. In an extreme form, this paradigm put the patient in the role of victim and equated benef32
ELKINS AND BROWN: COMMENTARY
WHI Vol. 3, No. 1 Spring 1993
icence with paternalism. The paradigm that emerged in the 1970s put such singular emphasis on patient self-determination that informed consent would have been more accurately called informed choice. In an extreme form, this paradigm reduced the physician to the role of technician. The most recent paradigm does, as the committee discussed in some detail, recognize limitations on patient autonomy. But the literature related to the emerging paradigm also takes into account cost constraints in the distribution of resources, global concerns about sexually transmitted disease epidemics, and the need for increased beneficent involvement on the part of physicians. In this context, beneficence implies a sense of duty or obligation on the part of the physician to advise and to act in accordance with reasonable medical indications. We believe that a contemporary understanding of medical dilemmas requires a thorough understanding of this most recent paradigm. The ACOG committee's statement on informed consent appears to us still to be working with the second (ie, patienbautonomy) paradigm, albeit amended to acknowledge limits on patient autonomy. The most telling indication is the committee's dependence on the vocabulary of "principles," "doctrines," and "concepts." The vocabulary of the newest paradigm for the patient-physician relationship expands the vocabulary to include "values," "virtue," "trust," and "gratitude." In this relationship, the "mutuality" to which the ACOG committee appeals would bring together informed consent from the patient and informed planning from the physidan. The physician would not paternalistically presume to know always what would be in the patient's best interests. The patient would retain control of his or her life story by informing and responding to the phase-by-phase judgment of the attending physician.
WHI Vol. 3, No. 1 Spring 1993
REFERENCES 1. The APGO Task Force on Medical Ethics. Exploring issues in obstetrics and gynecologic medical ethics. Washington, DC: The Association of Professors of Gynecology and Obstetrics, 1990. 2. Engelhardt T. The foundations of bioethics. New York: Oxford University Press, 1986.
ELKINS AND BROWN: COMMENTARY
33