How Informed Is Informed Consent and Does It Matter?
How informed is informed consent and does it matter much, or as much as medical ethicists say it does? Do doctors have a duty only to make sure that their message is sent, or also a duty to make sure that it is received, and if received that it is retained? The prayer of General Absolution in the Book of Common Prayer refers to those things which we have done and ought not to have done, and those things which we ought to have done and have not done. When it comes to informed consent, there are also those things which patients have heard and ought not to have heard, and those things which they ought to have heard and have not.
This is proven in a recent paper in the British Medical Journal. Patients with stable angina in ten hospitals in the United States were asked what they thought the benefits were of the percutaneous coronary procedures they were about to undergo. The scientific evidence on this matter is more or less universally accepted: such procedures improve angina symptoms but do not increase life expectancy or reduce the rate of heart attacks.
Only one percent of 991 patients knew this; 892 thought that the procedures would lengthen their lives, and 872 thought that they would reduce their chances of a heart attack. While 684 correctly thought that it would improve the symptoms of angina, 675 also thought that it would either lengthen their life or reduce their chances of heart attack or (as in most cases) both. Only 9 of the patients, therefore, 1 percent, gave informed consent, if “informed consent” is meant consent based upon correct understanding. As Josh Billings said, “It’s better to know nothing than to know what ain’t so.”
Twenty percent of the patients even thought that their procedures were being performed as an emergency, when none was. However, the range of ignorance about this matter varied between the hospitals, from 4 percent to 38 percent of the patients that they treated. This considerable difference of the level of understanding among the patients of the different hospitals might have been caused by differences in the ways the doctors explained the procedures in those different hospitals, or it might have been caused by differences between the patients themselves. However, it has been found, rather surprisingly, that level of education does not much affect understanding in such situations. People hear what they want to hear irrespective of their level of education.
Since the people who conducted this study did not themselves hear what the doctors said to the patients, it is not possible to know whether what the patients thought were the benefits of the procedures and what the doctors told them about them were the same, similar or completely at variance. If there is one thing that reading medical journals soon teaches you, however, especially nowadays, is that doctors deceive themselves at least as much as they deceive others. No one wants to develop a highly-technical skill, exercised in stressful circumstances, only to discover that the skill is of very limited value. It is possible, then, that the doctors conveyed an impression to the patients much at variance with the hard evidence, and as much by non-verbal communication as by words.
An editorial in the same journal about the findings of this paper cautioned that, while “questioning the benefit of accurate understanding may seem heretical… prior work shows that patients want information, not that they desire to be tested on the accuracy of their recall.” In other words, the fact of being given information is more important to them than their own accurate understanding of that information. This is strange; but then human beings are strange.