Little J M, Leeder S
Department of Surgery, University of Sydney, Westmead Hospital, NSW, Australia.
Eur J Surg. 1996 Jan;162(1):3-10.
A belief in the validity of informed consent is one of the most important consequences of the doctrine of autonomy in medical ethics. Truly informed consent requires full disclosure of all relevant information by the doctor, competence of the patient to appreciate what the information signifies, understanding of the facts and issues by the patient, a voluntary choice by the patient and an autonomous authorisation for treatment or entry into a trial. Each of these conditions is hard to fulfil. In particular, full autonomy cannot exist in illness, and this is acknowledged by the act of consultation. The issue is further complicated by the stochastic nature of biological systems and the responses to illness and treatment. Disclosure of likely outcomes is, of necessity, unsatisfactory when a patient seeks surety when entering the clinical process with a serious and life threatening disease. Neither strict logic nor the law provide answers to this problem. The legal and moral issues have become confused. This is unfortunate, because the legal concern often centres on avoidance of actions in law rather than on the more fundamental issue of benefit to the patient. There is a need to teach doctors that discussion is a necessary part of the doctor-patient relationship, that fully informed consent is seldom-if ever-possible, and that skill in understanding what the patient is seeking is more important than the development of rigid and legally "complete" consent forms.
对知情同意有效性的信念是医学伦理中自主原则最重要的后果之一。真正的知情同意要求医生充分披露所有相关信息，患者有能力理解这些信息的意义，患者理解事实和问题，患者做出自愿选择，并对治疗或参与试验给予自主授权。这些条件中的每一个都很难满足。特别是，在患病状态下不可能存在完全的自主性，而这一点在诊疗行为中是得到承认的。生物系统的随机性以及对疾病和治疗的反应使这个问题更加复杂。当患者带着严重的危及生命的疾病进入临床过程并寻求确定性时，对可能结果的披露必然是不令人满意的。无论是严格的逻辑还是法律都无法解决这个问题。法律和道德问题已经变得混乱。这是不幸的，因为法律关注往往集中在避免法律诉讼上，而不是更根本的对患者有益的问题。有必要教导医生，讨论是医患关系的必要组成部分，完全知情同意很少（如果有的话）是可能的，理解患者需求的技巧比制定严格的、法律上“完整”的同意书更重要。
