An Agenda for the Future

The cornerstone of our approach to informed consent is the belief that the right of patients to authorize their own medical treatment, usually called the right to autonomy in decision making, is a moral value worth promoting. When medical care is required, patients should be met by physicians’ openness and willingness to present and discuss a variety of options, with the clear understanding that patients can play a role, if they desire, in shaping the ultimate decision. Our instinctive assumption that most patients would endorse this approach was confirmed by a large-scale study sponsored by the President’s Commission (1). Patients do want to know about and have the option of influencing the nature of their medical care, even if they may not always exercise that option (2). Our society’s deepseated traditions of respect for the integrity of the individual reinforce the importance of protecting patients’ interests in the medical decisionmaking process. Legal initiatives by themselves are insufficient to accomplish these results (see Chapter 7). Endless proposals to refine the legal mechanisms by which the doctrine of informed consent is enforced are not likely to achieve their goals. The legal rules governing informed consent operate at a level of generality that makes it difficult for physicians to take them into account in dealing with patients. Some surveys have found that physicians are completely ignorant of the operative standard for disclosure in their state (1), and others have found that even when physicians are aware of the standard, they do not apply it properly (3). More significantly, however, the medical setting seems relatively impervious to regulation in this area. Physicians and administrators have control over the structure of medical care and over the content of physician-patient interactions. Regardless of the law of informed consent, if the structure of hospital and office practice provides negligible opportunities for doctor-patient communication, little disclosure or shared decision making will occur. If physicians are resistant to the moral imperatives of informed consent, tinkering with standards of disclosure is unlikely to affect their behavior.