Recently, a medical student assigned to my service spent a day in the outpatient office seeing patients with me. After seeing two consecutive patients who needed thyroidectomies, this student commented on the differences in how I obtained informed consent for thyroidectomy from the two patients. Why, she asked, had I spent relatively little time emphasizing the risks of the operation with one patient and so much more time discussing risks with the second patient?
In order to understand why there appeared to be such a dramatic difference between the discussions with the two patients, it is helpful to understand the different indications for surgery. The first patient had recently been diagnosed with a 2.3-cm papillary thyroid cancer. I had explained that the first step in the treatment was to remove the thyroid, and I detailed the risks to the recurrent laryngeal nerves and the parathyroid glands.
The second patient had been treated for Graves’ disease for the last 3 years. She had many cycles of hyper- and hypothyroidism and had now decided that she needed definitive treatment. Although she had discussed the option of radioactive iodine with her endocrinologist, she had a significant fear of radiation and also was hoping to become pregnant in the next several months. I had discussed the risks of thyroidectomy with this patient. However, even though the risk I quoted of having a complication from the thyroidectomy was just the same as in the first case, I deliberately spent more time discussing the ramifications of the complications and the alternatives with the second patient.
My student was initially perplexed by this description. As she correctly stated, if the risks are the same for the same operation between the two patients, why emphasize the risks so much more for the second patient, compared with the first?
To most surgeons, the reason for this difference is clear. The first patient needed to know the risks, but there were few options to total thyroidectomy as the initial step in the treatment. The second patient had the clear option of getting radioactive iodine instead of surgery. Although the risks of the surgical procedure are the same with the two operations, I felt that the second patient needed to clearly understand the alternative to surgery and to fully consider the implications of the potential complications should one occur in her case.
As I think back over this interchange with my student, it is clear that the informed consent discussion for any operation cannot be fully standardized for every patient. Even if the risks remain the same, the indications for surgery are different and, of course, the patients are different.
More than 30 years ago, Dr. C. Rollins Hanlon, then executive director of the American College of Surgeons wrote, "Both ethics and surgery are inexact disciplines, in definition, practice, and in relation to one another." The more years I have been in practice, the more I am convinced of the truth of these words. Although my two patients both needed the same operation, it was important for me to emphasize the choices that the second patient had. In so doing, I felt it was essential to ensure that in evaluating the choices, the patient fully understood the implications of the risks. Although the patient with thyroid cancer had the same risks of the procedure, she did not have a good alternative choice to surgery. The difference between these two patients, and in how I altered my discussions of the proposed thyroidectomy, reveal the personal dimension of informed consent that goes beyond a simple statement of risks.
In obtaining informed consent from my patients, I should be providing them with much more than "just the facts." Patients can (and often do) obtain the data about the risks of surgical procedures from the Internet prior to seeing me. I believe that I should be giving them something more than they could obtain from reading about the risks of a procedure. I should provide them with a context in which to consider the risks, relative to their particular condition. Even small risks may be very significant if there are alternatives that have no risks. In contrast, patients often quickly agree to high-risk operations when there is no good nonoperative alternative. As surgeons, we must be cognizant of the critical personal dimension of the informed consent process and thereby be sure to put the discussion of risks in the appropriate context to help our patients make good decisions.
Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.