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October 30, 2012 | Posted By Michael Brannigan, PhD

Here is cardiac surgeon Christiaan Barnard's account of his conversation with Louis Washkansky just before he performed on him the first human heart transplant, in 1967:

"'We know you have a heart disease for which we can do nothing more. You have had all possible treatment, and you are getting no better. We can put a normal heart into you, after taking out your heart that's no longer any good, and there's a chance you can get back to normal life again.'

"'So they told me. So I'm ready to go ahead.'

"Washkansky said no more. His eyes remained on me but with no indication he wanted to know anything more.

"'Well, then ... goodbye,' I said.

"'Goodbye.'"

A disturbingly short-lived exchange, particularly given its profoundly momentous occasion. Indeed, as described in the late Yale law professor and physician Jay Katz's "Silent World of Doctor and Patient," it is brutally brief.

There are serious omissions. Even more crucial, Barnard downplayed any need for further conversation.

Washkansky survived another 18 days.

***

We can forgive Barnard. This was in Cape Town, South Africa, and their encounter preceded extensive hospital momentum in the U.S. to require informed consent, touted by ethics scholars as medicine's moral cornerstone. Informed consent ultimately maintains that our bodies and minds may not be justifiably intruded upon without our permission.

In substance, however, informed consent is unnerving. What qualifies as disclosure? What constitutes consent?

Each of its three requirements — that patients be sufficiently informed, free and competent — reveals a Pandora's Box of obstinate hurdles.

Here, we'll tackle only the first ingredient — disclosure.

Certainly not complete disclosure, which is impossible. Instead, it requires that patients be adequately informed regarding their condition, proposed treatment, alternative treatments including none, benefits and risks. A tall order, though one with which many of us are familiar when our physician conveys to us, in palatable language, relevant information we need to make a reasonably informed choice.

Our doctor provides the facts. We decide. But peer under the rug. This paradigm of my doctor giving me X (information) so that I can Y (decide) is stilted. It rests upon a one-sided notion of "information," about which the most prominent misconception is that it is merely some quantitative "thing," some "stuff" that is simply expressed, conveyed, and transferred.

This is only partly true. Philosophers Neil Manson and Onora O'Neill remind us that the "original meaning of 'inform' is to give form to something, to give it determinate shape, to arrange it, or to modify it." Informing comprises an intriguingly intricate process that in the clinical context involves the skill and art of conversation. And conversation is a complex, interactive dynamic of words, body language, subtleties, expectations, hidden inferences, unexamined assumptions, meaningful pauses, impressions, often disparate worldviews and colliding values — all wrapped within singular contexts.

***

Informing the patient, in other words, involves not only what is said, but, more impressively, how it is said and what's left Unsaid. This gets to the heart of the physician-patient relationship, which is anything but symmetrical but matures with meaningful conversation. Or is conversation in short supply, a dying art?

Since patients are already in compromised positions, our doctors have primary responsibility for encouraging conversation. Concurrently, we as patients have a moral duty to question and inquire further when we need to know more.

Our moral right to be informed embraces our all-compelling human need to be acknowledged, recognized and respected as persons, and to be assured that we are cared for. It is this sense of inter-human connection, or lack of, with our doctors that we recall with warm heart, cool regret, or icy resentment.

Unless we can resuscitate meaningful conversation, consent remains half-hearted, a doctrine we honor more in form, less in substance.

 

To see more of Dr. Brannigan's work, go to http://www.timesunion.com/brannigan.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

1 comments | Topics: Consent, Doctor-Patient Relationships, End of Life Care, Ethics and Morality, Patient Care

Comments

Mary Mills

Mary Mills wrote on 10/31/12 8:53 AM

Informed Consent even though defined in many State Constitutions under Civil Rights is being violated by Doctors and staff alike. Many pre-admit forms include a generalized Informed Consent, however, as a patient's illness progresses there seems to be a lack of communication between the Doctor and the patient resulting in invalidation of any Informed Consent previously signed. In some matters there seems to be complete silence and the patient places a misguided trust in the Doctor who ultimately has the advantage over the patient. Without communication, as discussed in the above article, Informed Consent cannot exist in its full measure and we become lowered to no more than animals without freedom of choice. When a Doctor imposes a procedure on a patient without Full Consent and Explanation, without explaining the Risks involved and without offering any viable Alternatives, he has violated their Civil Rights especially when trauma or death occurs because of the Doctor's actions. I speak from experience in the matter as my Mother was placed into Palliative Sedation by Hospice without explicit Informed Consent. This procedure placed her in a drug-induced coma with never a word from the Doctor or staff as to what they were doing. She died in this stupor.

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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.
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