A couple of weeks ago I was I was the faculty attending on Labor and Delivery. We were inducing a woman with severe pre-eclampsia and an IUGR fetus. Things went well until she was five centimeters dilated, at which point the fetal tracing went rapidly from category one to category three (reassuring to really bad). I quickly explained the situation to the patient with a resident and a nurse in the room. She heard the reasons I was recommending a cesarean section, a brief discussion of its risks, and an even briefer discussion of the alternatives (continue labor placing the fetus at risk of permanent injury or death). She had no questions, and since she had already signed a cesarean consent at the beginning of the induction, we proceeded to the operating room to perform a cesarean. She needed general anesthesia because her platelets were low, so it was too risky to give her a spinal anesthetic. During the induction but before intubation, the circulating nurse announced that she couldn’t find the “informed consent” and that we could not proceed. My response involved a reference to male cattle manure, and the comment that informed consent had just happened and that she had witnessed it herself. The anesthesiologist agreed, and the cesarean section occurred without delay.
This case exemplifies the ambiguity around “informed consent.” The nurse was referring to a document, a signed piece of paper; I was referencing a conversation, a process involving sharing information and answering questions. From a legal perspective, informed consent would seem to represent the document, whereas from an ethical perspective it is the process, not the paper that embodies informed consent. Of course, ultimately, both have a role to play, and in the case of a significant procedure it is best to have both sides of this informed consent coin documented. But what I would like to suggest is that the signed document represents an artifact—a physical symbol that two parties agree that the real nature of informed consent has been fulfilled. The piece of paper is derivative, and a signed document that lacks the ethical underpinning of a complete and valid consent discussion is meaningless. A lawyer would probably give a slightly different answer, but this is an ethics blog, not a discussion of medical malpractice.