14Consent to Medical Care:The Importance of Fiduciary ContextSteven Joffe and Robert D. TruogAn eminent bioethicist visited his dermatologist to discuss the management ofa lump on his back. The lesion had recently been diagnosed by biopsy as abasal cell carcinoma, a benign skin cancer that is easily treatable by surgicalremoval. After stating, ‘‘Here’s what we are going to do,’’ the dermatologistdrew a picture of the proposed minor surgical procedure and mentionedsutures and the probable appearance of the scar. The physician then asked thebioethicist if he had any questions, and finally gave him a generic consentform for subsequent perusal and signature. At no time did the physicianmention any risks of or alternatives to the proposed surgery.As a bioethicist, the patient recognized that what transpired during thisvisit was minimally informed acquiescence rather than true informed consent.Nevertheless, he denied feeling any substantive offense at the nature of theinteraction. As he later noted, ‘‘If I didn’t happen to be a bioethicist, andhadn’t gone into it with an eye to observing how the doctor handled theprocess, the encounter would probably have seemed perfectly appropriate andunremarkable.’’IntroductionAccording to the standard conception of medical ethics, informed consent isfundamental to ethical practice because it is the mechanism by which patients347autonomously authorize medical interventions or courses of treatment.1Thisprerogative to control one’s medical destiny, which functions as a constrainton physicians’ power and a curb to their paternalistic instincts, is elemental.2As the President’s Commission for the Study of Ethical Problems in Medicineand Biomedical and Behavioral Research stated, ‘‘Informed consent is rootedin the fundamental recognition—reflected in the legal presumption of com-petency—that adults are entitled to accept or reject health care interventionson the basis of their own personal values and in furtherance of their ownpersonal goals.’’3Or, as Justice Cardozo famously declared almost a centuryago in Schloendorff v. Society of New York Hospitals, ‘‘Every human being ofadult years and sound mind has a right to determine what shall be done withhis own body.’’4The case of the bioethicist with the basal c ell carcinoma illustrates abasic problem for the standard conception of informed consent for treat-ment. Physicians often do not live up to their obligation to facilitateautonomous authorization. More important, patients often do notdemand the robust decision-making responsibility that the concept ofautonomous authorization presupposes, and in fact frequently prefer alesser decision-making role.5Should ethics and policy seek to educate andexhort patients to assume, and physicians to encourage, greater patientresponsibility for medical decisions? Or, taking into account the psycholo-gical realities of illness and the nature of the physician–patient relationship,is current practice normatively defensible? In light of the magnitude andpersistence of t he gap between the theory and practice of informed consent,answering this question constitutes a critical challenge for contemporarybioethics.The Fundamentals of Informed ConsentWhen is a patient’s consent to a course of medical treatment valid? Ethical andlegal commentators have identified five elements that together establish theconditions for valid consent.6First, the patient must be situated so as to beable to make a voluntary decision. A decision that is substantially coerced isincompatible with valid informed consent. Second, the patient must becompetent to make the decision. Significantly diminished consciousness orcognitive ability, among other impairments, invalidates a patient’s apparentconsent. Third, the patient must receive sufficient disclosure of the relevantfacts, typically from the physician or another member of the medical team, tobe able to reach a considered decision (note, however, that informed consent348 DOMAINS OF CONSENTcan occasionally be valid in the absence of disclosure, such as in the case of thephysician-patient who is already an expert on his or her condition1). Elementsto be disclosed include the nature and purpose of the procedure or interven-tion, its risks and potential benefits, and the available alternatives to theproposed course of action.7Fourth, the patient must achieve an adequatedegree of understanding of the disclosed facts, as well as of the nature ofconsent as authorization, to form the basis of his or her decision.1Finally, thepatient must authorize (informed consent) or decline (informed refusal) theproposed course of treatment.Because most patients must rely on their physicians’ assistance to gatherand interpret the relevant facts, the process of autonomous authorizationalmost always requires professional input. How, then, should patients andclinicia ns work together to ac hieve the goal of informed consent? ThePresident’s Commission, Jay Katz, and many others have advocated aprocess of shared decision making.2,3,8–11Wide agreement on this label,however, masks deep uncertainties about its precise meaning. The term isoften used without definition or further explanation, and likely meansdifferent things to different authors. On one view, shared decision makinghas three features: (1)informationflowistwo-way,(2)boththepatientandthe physician (as well as perhaps others) participate in deliberations aboutthe decision, and (3)thepatientandphysiciansharethefinaldecision.12Onanother view, shared decision making involves a division of labor:Physicia ns present a nd contextualize the facts that are materia l to thedecision, whereas patients integrate those facts with their own values andpreferences to make a final decision.7,10,13,14This division of labor is toosharp. Especially in the Internet age, patients often contribute material factsto medical discussions. In addition, physicians have a duty, based on theirown values and status as moral agents, to respectfully challenge theirpatients when they perceive patients’ choices to be contrary to their owninterests.8,11,13Nevertheless, the concept of a division of l abor captures anessential, if partial, truth about the distinct roles of patients and clinicians, aswell as about the power differential and lack of symmetry between theseparties, in the decision-making process.2Emanuel and Emanuel provide further insight into the range of con-ceptual models that