Consent

In the early weeks of 1961, the new president was asked to provide support to anti-Castro forces in their planned invasion of Cuba. The intelligence community told him that the chance of success was fair. After study and reflection, the invasion of the Bay of Pigs went forward; resulting in the loss of more than 200 lives and the imprisonment of over 1400 members of Brigade 2506. (Later to have their freedom negotiated by James Donovan subject of The Bridge of Spies) The CIA had calculated and then forecasted the risk described to the President as fair; internally fair was considered a 1 in 3 chance of success.

I was drawn to this because physicians forecast to our patients every day. Surgeons call their predictions, informed consents; medical forecasting is less explicit, more assumed. After all, why recommend treatment if there is not to be a ‘better’ outcome? But we face the task of translating 1 in 3 to fair or more often a 90% survival with a 15% chance of complications (requiring further care) to good.

Numerous articles point out the difficulty with numeracy – understanding numbers, especially probabilities, for physicians and patients. And numbers can be shaped and nuanced just like words; 99% survival, 1% mortality is different when you have cancer or considering breast augmentation. But numbers greatest issue is that they seem so precise; less vague than words and springing from our mouths with a certainty of 100%.

The history of ‘informed consent’ demonstrates many narrative threads, classically revolving around:

autonomy – the right to choose one’s treatment,

beneficence – acting in the patient’s best interest,

non-maleficence – Do no harm, and

justice – fairness and equality of distribution.

Surgical consents began to appear in the early 20th century and reflected a physician-centric orientation; that is, a surgeon should provide a patient the information that another physician would disclose. By mid-century and presaging what we consider today’s patient-centric care, the doctor was asked to communicate what a ‘reasonable patient’ would want to know. Communicating risk to our patients touches on all four ethical principles and is something we are asked to learn on our own. Which intern has not obtained informed consent for a procedure they were deemed not able to perform?  Parenthetically, most malpractice litigation is due to failures of communicating – 55% a discrepancy between expectations and achieved results and 30% faulty information.

I’ve been reading about the ‘end of professions’ and how many of our tasks and work are and can be assumed by very reliable machines. I get that. Assisting a patient exercise their autonomy in identifying needs requires knowledge to do no harm, and that seems something a computer can provide. Mapping a path through the ambiguity of consent; understanding risk and benefit – that requires beneficence, a human calculation. It compels us to be more than reliable; it requires us to be trustworthy.