Rethinking informed consent in the age of behavioural sciences and relational autonomy

Abstract

• Many cognitive biases influence medical decision making in patients and clinicians. • Cognitive biases and relational autonomy challenge today's informed consent . • Informed consent must be adapted to strengthen patients’ autonomous decision making. Informed consent is one of the cornerstones of modern medicine, clinical ethics, and biomedical research. However, emerging evidence in behavioural sciences and relational accounts of autonomy in clinical ethics have highlighted biases and constructs that may challenge informed consent. In this paper, we examine these findings and explore ways forward to ensure the integrity of informed medical decision making. Cognitive biases affecting patients and clinicians were reviewed in relation to their influence on the cognitive abilities traditionally considered fundamental to informed decision making required for consent: understanding, appreciation and reasoning. The way these findings resonate with criticisms advanced by proponents of relational autonomy was explored. For patients and clinicians alike, perceiving risks, interpreting probabilities and projecting oneself into the future are influenced by many biases, including loss aversion, underweighting of small probabilities and optimistic bias. These biases directly impact informed decision making by affecting the cognitive processes of understanding, appreciation, and reasoning. In clinical ethics, growing interest in relational accounts of autonomy have highlighted how people are socially embedded, and how patients’ identities and preferences are forged through important social and relational influences. In all, evidence from the behavioural sciences offers support for relational accounts of autonomy and ways forward to improve current practices of informed consent. Integrating the empirical evidence from behavioural sciences and theoretical elements of relational autonomy compels us to adapt current practices of informed consent. To ensure the integrity of informed medical decision making, the process must further consider the inherent contextual and relational elements that shape how persons consider risks and make decisions.