“Ethical dimensions of informed consent”: A psychiatric perspective

Abstract

I n Ethical Dimensions of Informed Consent, the ACOG Committee on Ethics addresses the tensions between the extremes of traditional paternalistic coercion and modern psychological abandonment, between the lures of oversimplification and the paralyzing dangers of complexity. Questions of consent in obstetrics and gynecology are made especially poignant by the psychologically loaded implications of the procedures consented to or refused, and their closeness to powerful, universal, and mysterious human drives and values. Consent is also complicated by the inadequacy of information about the outcome of many of the interventions proposed. Nevertheless, as the Committee on Ethics explains so well, informed consent represents a legal, ethical, and clinical imperative. This commentary by a psychiatrist will deal with some of the psychosocial realities impinging on informed consent, and offer clinical suggestions. Under the guise of informed consent, emotional processes and decisions may masquerade as or be reduced to cognitive ones. Consulting psychiatrists frequently discover that a clear, but unexplored, psychological dilemma is at the root of what seems to be an ethical impasse. For example, the patient who is refusing a lifesaving procedure on grounds of autonomy is not aware of, or cannot acknowledge, an overwhelming terror arising from an unresolved past experience. The clinicians cannot grasp the psychological meaning of a religious proscription against a particular intervention (blood transfusion). Resolution of the psychological conflict solves the ethical conflict. Questions of informed consent in obstetrics and gynecology involve medical/surgical interventions performed on the reproductive organs of women. Discussion of informed consent in this context must take into account women's psychology, as it pertains both to their reproductive organs and capacities and to their management of medical information, women's traditional and evolving role in society, and the history of women's treatment in the medical setting. Women's reproductive organs tend to be experienced by them and by medical professionals as messy, dirty, troublesome--with the trouble ranging from inconvenient (menstruation) to life-threatening (ovarian malignancies). There has been a corresponding tendency in Western medicine to look © 1993 by The Jacobs Institute of Women's Health 1049-3867/93/$6.00