Informed consent in the electronic age.

INTRODUCTION A. INFORMING THE PATIENT. . . MILLENNIUM STYLE Dr. X, a urologist, has just told his patient, Mr. Y, a fifty-eight-year-old businessman, that he has prostate cancer. The revelation was difficult for both parties, but it did not come as a complete surprise because it had been preceded by a multistep diagnostic process. Although hoping for better, Mr. Y and his wife were expecting this bad news when they went into the doctor's office. After offering some words of hope and encouragement, Dr. X tells the patient and his wife that, before they discuss any further the important choices that lie ahead in the treatment of Mr. Y's condition, he would like them to take time to review carefully the information contained in the CD-ROM program he has just handed them. The program, entitled "Living with a Diagnosis of Prostate Cancer," is one of a library of such programs developed and marketed by a company specializing in computer-based patient education products. Dr. X explains to Mr. and Mrs. Y that the computer program can convey the complex facts that bear on this decision process more fully and effectively than he has the ability or time to do, and it uses sophisticated multimedia effects to aid viewers' understanding. Moreover, Dr. X continues, the couple can consider each aspect of the explanation fully, spending as long on each part as they feel is necessary. They can do this in the comfort and privacy of their own home, where they can discuss the information and the choices more freely than they may feel comfortable doing in the doctor's presence. Dr. X has already ascertained that his patient has a computer to play the CD-ROM, and Mr. Y is confident that he can use the program properly. It is, after all, no more difficult than working through Myst or Riven, two computer games that Y and his wife enjoy playing together. The doctor explains that while Mr. Y works through the program, it will ask him, at various points, to answer questions about what he has seen and read. If his comprehension is lacking on any point, he will be instructed to go back and review the relevant material, after which he will be queried again. An electronic record will later reveal to the doctor the points on which the patient may be uncertain, helping to focus further conversation between them. Ultimately, the program will document the patient's successful completion of the instructional exercise and provide proof that the patient understands the material essential to his informed consent for whatever treatment the parties jointly choose. Dr. X and his patient agree to meet again in a week, with Mrs. Y present if her husband wishes, after the two of them have navigated through the educational program and digested its contents. Dr. X assures them that, in this follow-up meeting, they can take as much time as they need to discuss questions, options and other aspects of the choices Mr. Y has to make. The CD-ROM, the doctor explains, is not meant as a substitute for his professional input or for their personal interaction, but only as a basis for their further discussions. Their entire meeting, including the presentation of the lab results confirming the existence of the cancer, has taken less than fifteen minutes. The above scenario is one of many that might be used to illustrate how doctorpatient relations are changing as we enter the twenty-first century. The medical world of the future, here now in many respects, or at least right around the corner, is a wondrous place, with much that is attractive and hopeful; but it has its dark aspects too. On the plus side, the prepackaged patient education program described above allows an effective, low-transaction-cost transmission of information from a physician to a patient desiring, and presumably about to receive, his services. For the doctor's part, he is able to convey to the patient all of the relevant and necessary information with significantly less time and effort than was formally required. …