Risk-benefit ratio: the soft underbelly of patient autonomy.

On the face of it, nothing could be more reasonable than for a patient to weigh the risks attendant to a medical treatment against any benefits it might be expected to produce. Everyone supports the idea of informed consent, so appropriate to the autonomy of the individual. No one should have done to him anything he does not approve. In law, when someone touches another without his consent, it is assault and battery. (1) It is also assault and battery if the consent to touching has been obtained by misrepresentation. (2) The physician is given no special exemption by reason of his professional status. He must obtain consent from the patient before touching him. If the patient is not fully informed about the consequences of this encounter, he has the right to seek redress. The law and common sense dictate that the patient be made aware of the ramifications of his decision to allow treatment. Even when patients have been informed of the possible consequences of medical intervention, they may not adequately understand what is involved. Natural intelligence, level of education, and vocabulary all may limit the patient's comprehension. To meet this problem, physicians try to put informed consent into "plain" English. Medical terminology is replaced by lay expressions in the hope of truly informing the patient. The tendency is to simplify. The requirement for informed consent is not satisfied by merely recounting risks and benefits to a patient, but by doing so in a way that is intelligible to a particular patient in view of his individual capacities. But it is here that problems arise. In some cases medical information may be translated into a format that can be assimilated by the listener. This is probably what happens in most cases. It is almost impossible for a physician trained over a course of many years to convey his level of knowledge of a medical treatment and its untoward effects. While something may be lost in the translation, the expectation is that the patient will pick up enough to have some understanding of what is about to take place, what could go awry, and probable negative side effects. In some instances it is clear that adequate communication is not possible between physician and patient. A baby who requires an operation obviously cannot give informed consent, so we look to the parents to represent the baby's interests. But there are limitations here. Society looks over the parents' shoulders to make sure they make a decision truly in the child's interests. They can authorize a blood transfusion, but they cannot refuse one on religious grounds. If they do, then the courts are consulted. There seens to be almost universal approbation within the medical community for recourse to the courts when a parent refuses treatment for a child based on the parent's religious belief. Court rulings authorizing treatment under such circumstances are accepted as a proper exercise of judicial function. This is an interesting phenomenon, since in other circumstances many in the medical community believe that medical decision should be left to family or next friends and physicians. Here judicial intervention is not welcomed. The courts are not the place, according to the common view, to work out these "private" and intimate decisions. The standard seems to be that the courts should be involved when medical professionals agree with what they will decide, but not when they might reach an outcome we do not like. This attitude may be a spillover from the medical malpractice crisis. Here many physicians blame plaintiffs' lawyers for a problem that may be largely the result of physician negligence or incompetence. The contingency fee that gives the poor man access to the legal system is not regarded by physicians as an enlightened measure but as a cause of exposing their colleagues' ineptitude. Perhaps there is also fear that the contingency fee in law may set a precedent for the medical profession, and that patients may begin to refuse to pay fees when a case is botched. …