Actual Consent Research Articles

Historical Lessons and Discourse on Defence in France and Germany, 1945-90

Two things, which strictly speaking are just one, constitute [a nation]…. One is the past, the other is the present. One is the common possession of a rich legacy of memories; the other is the actual consent … to live together, the will to continue to value the heritage that has been received in common. … The nation, like the individual, is the outcome of a long and strenuous past of sacrifice and devotion…. An heroic past of great men, of glory…: this is the social capital on which a national idea is established. (Renan 1996: 57f.)

Allocating health care: cost-utility analysis, informed democratic decision making, or the veil of ignorance?

Assuming that rationing health care is unavoidable, and that it requires moral reasoning, how should we allocate limited health care resources? This question is difficult because our pluralistic, liberal society has no consensus on a conception of distributive justice. In this article I focus on an alternative: Who shall decide how to ration health care, and how shall this be done to respect autonomy, pluralism, liberalism, and fairness? I explore three processes for making rationing decisions: cost-utility analysis, informed democratic decision making, and applications of the veil of ignorance. I evaluate these processes as examples of procedural justice, assuming that there is no outcome considered the most just. I use consent as a criterion to judge competing processes so that rationing decisions are, to some extent, self-imposed. I also examine the processes' feasibility in our current health care system. Cost-utility analysis does not meet criteria for actual or presumed consent, even if costs and health-related utility could be measured perfectly. Existing structures of government cannot creditably assimilate the information required for sound rationing decisions, and grassroots efforts are not representative. Applications of the veil of ignorance are more useful for identifying principles relevant to health care rationing than for making concrete rationing decisions. I outline a process of decision making, specifically for health care, that relies on substantive, selected representation, respects pluralism, liberalism, and deliberative democracy, and could be implemented at the community or organizational level.

Abandoning Informed Consent

Consent has emerged as a concept central to modern medical ethics. Often the term is used with a modifier, such as informed or voluntary or full, as in loosely used phrases like fully informed and voluntary In some form or another, modern ethics in health care could hardly function without the notion of consent. While we might occasionally encounter an old-guard retrograde longing for the day when physicians did not have to go through the process of getting consent, by and large consent is now taken as a given, at least at the level of theory. To be sure, we know that actual consent is not obtained in all cases and even when consent is obtained, it may not be adequately informed or autonomous. For purposes of this discussion, we shall not worry about the deviations from the ideal; rather the focus will be on whether consent ought to be the goal. This consensus in favor of consent may turn out to be all too facile. Consent may be what can be called a transition concept, one that appears on the scene as an apparently progressive innovation, but after a period of experience turns out to be only useful as a transition to a more thoroughly revisionary conceptual framework. This paper will defend the thesis that consent is merely a transitional concept. While it emerged in the field as a liberal, innovative idea, its time may have passed and newer, more enlightened formulations may be needed. Consent means approval or agreement with the actions or opinions of another; terms such as acquiescence and condoning appear in the dictionary definitions. In medicine, the physician or other health care provider will, after reviewing the facts of the case and attempting to determine what is in the best interest of the patient, propose a course of action for the patient's concurrence. While a few decades ago it might have been considered both radical and innovative to seek the patient's acquiescence in the professional's clinical judgment, by now that may not be nearly enough. It is increasingly clear if one studies the theory of clinical decisionmaking that there is no longer any basis for presuming that the clinician can even guess at what is in the overall best interest of the patient. If that is true, then a model in which the clinician guesses at what he or she believes is best for the patient, pausing only to elicit the patient's concurrence, will no longer be sufficient. Increasingly we will have to go beyond patient consent to a model in which plausible options are presented (perhaps with the professional's recommendation regarding a personal preference among them, based on the professional's personally held beliefs and values), but with no rational or professional basis for even guessing at which one might truly be in the patient's best interest. To demonstrate that the concept of consent will no longer be adequate for the era of contemporary medicine, some work will be in order. After briefly summarizing the emergence of the consent doctrine, we will look at what we learn from axiology--the philosophical study of the theory of the good--that calls into question the adequacy of consent as a way of legitimating clinical decisions. This, I suggest, will provide a basis for demonstrating why experts in an area such as medicine ought not to be expected to be able to guess correctly what course is in the patient's interest, and therefore should not be able to propose a course to which the patient's response is mere consent or refusal. The History of Consent The history of consent reveals that it is a relatively recent phenomenon.[1] None of the classical documents in the ethics of medicine had anything resembling a notion of consent, informed or no. Autonomy of decisionmaking, especially lay decisionmaking, was not in the operating framework. For example, neither the Hippocratic oath nor any of the other Hippocratic writings says anything about consent or any other form of patient participation in decision-making[2]. …

Health Care Reform: A Study in Moral Malfeasance

Instead of benefitting from open meetings and public discussions, the Clintons drafted their health care plan in private and asked that it be accepted in haste. They advance an ideology that claims we can receive the best care for all without any increase in cost or rationing, and then they use "ethicists" to justify this ideology through a supposedly common morality. However, there is no such common morality. In the context of American pluralism, one must look to the actual consent of the governed and recognize the limits on state authority. The result will be a two tiered system of health care, with a basic tier focusing on cost-effective care for the poor that eliminates suffering rather than equalizing inputs, and a space for collateral private insurance.

A randomized controlled trial comparing quantitative informed consent formats

Informed consent has been indirectly studied only in settings that do not replicate the actual consent process. We designed a sham study and randomly allocated adult ambulatory patients to receive one of two consent forms: Consent A ( n = 52) described a randomized trial of usual treatment vs a new medication that “may work twice as fast as the usual treatment”; or Consent B ( n = 48) that described a randomized trial of a new medication that “may work half as fast as the usual treatment”. Patients randomized to Consent A were more likely to consent than those randomized to Consent B (consent rate A = 67%, consent rate B = 42%, p < 0.01). Among patients who cited quantitative information, the difference in consent rate was even more marked (95% vs 36%, p < 0.001); patients who did not cite quantitative information had equivalent consent rates. Patients who perceived minimal or severe symptoms had lower consent rates than those with mid-range symptom scores ( χ 2 2 = 8.35, p = 0.015). Patients who recognize quantitative information will use it to make informed consent decisions.

Consent: Informed, Implied, and Deferred

To the Editor.— Abramson et al 1 are to be congratulated for merging the legal doctrines of informed consent with the medical realities of research in the critically ill patient. They have thereby formulated a practical solution to a difficult problem. The institutional review boards (IRBs) of the various hospitals in the study should also be commended for their acceptance of this sorely needed concept. The authors have noted federal regulations that foster research and at the same time protect individuals. Unfortunately, despite these guidelines many IRBs and attorneys are reluctant to allow research to occur without the actual consent of the patient himself. Some people view research as a risk rather than as a benefit for subjects, especially if the subject has a 50% chance of receiving a placebo. Often forgotten is the Hawthorne effect-the fact that one may benefit solely by being part of a research project. 2

The Utility of Consent in John Locke's Political Philosophy

This paper argues that the interpretation of Locke's doctrine of political consent is best built on ground between and above the extremes of voluntarism (deriving legitimacy from the form of actual consent) and utilitarianism (basing legitimacy on the proper end of hypothetical consent). Locke's characteristic combination of voluntarism and utilitarian considerations is illustrated by looking at his thoughts on religious toleration and property. Finally, some of the outstanding difficulties in Locke's account of consent are reviewed in the light of these reflections on the intention of his doctrine.

The Handling and Disposal of Coal Ash in the Cegb in Relation to the Aqueous Environment

Pulverised fuel ash (pfa) and furnace bottom ash (fba) are the principal solid wastes from modern coal fired plant. These residues are often handled and disposed of as slurries and pfa is frequently used for the reclamation of derelict land. The disposal of excess water from the handling operation after the ash has been allowed to settle in a pond or lagoon is the first interaction with the aqueous environment that needs to be considered. In CEGB, the discharge of such effluents to rivers is governed by consents laid down by Water Authorities. The state of the art is such that the required conditions can be met in once-through handling systems without undue difficulty but one factor which requires careful management is the level of suspended solids in the outfall when a lagoon is nearly full. Whether ash is disposed of wet, or merely conditioned with water to facilitate handling. there may be a further need to consider the percolation of water through the ash and its possible interaction with groundwater. This calls for knowledge or study of the ash itself, the size of the area to be reclaimed, the rainfall pattern and the local hydrogeology, including the size and rate of recharge of the aquifer. Each case needs to be considered on its merits. The basic CEGB approach to this aspect of ash disposal is discussed; it requires the combination of laboratory studies of percolate quality with hydrogeological assessment to evaluate the potential risk, if any. The actual consent to dispose of ash, taking such factors into account, is made by the Local Authority in consultation with the Water Authority. The present view of ash disposal relative to the aqueous environment could be disturbed if legislation and the associated Codes of Practice were to become more stringent. Recent control measures which are pertinent to these activities are, therefore, considered and comment made on their content and application.

Risk and Consent: Philosophical Issues for Centralized Decisions

Centralized decisions that impose risks demand a justification. The most promising way to justify these decisions is in terms of consent of those people who will be affected by them. Attempts to determine how safe is safe enough in terms of justice, rights, or efficiency are unlikely to get us very far. The problem with consent, however, is that actual consent is impossible to obtain for decisions that affect large numbers of persons. For this reason, we need to explore other kinds of consent and the idea of what a reasonable person would agree to. Three models of consent are described, each one more powerful (but more controversial) in terms of its potential for justifying centralized decisions.

Early Liberal Roots of Feminism: John Locke and the Attack on Patriarchy

The seventeenth-century conflict between patriarchal and liberal political thought grew out of a shift in views on the nature of man and society. Sir Robert Filmer insisted that the king ruled absolutely, the divinely ordained father of his people. Sidney, Tyrrell, and Locke grounded political power in an act of consent on the part of free-born individuals.To what extent did these changing beliefs about human nature also bring about new perspectives on the nature, role and status of women? While this aspect of political theory has usually remained unexplored, it was an important critical weapon in the battle between patriarchal and liberal thought. Patriarchal theorists, relying on the Book of Genesis, could assign women to an appropriately subordinate place in family and society. Consent theories, though, as Filmer noted, depended for consistency on the inclusion of women (as well as children) in the formation of civil society. Early liberal writers including Tyrrell and Sidney were unwilling, then, to abandon patriarchal theory in all its forms and insisted that the consent of the “promiscuous multitude” of women and children was unnecessary. John Locke never specifically dealt with the role of women in the formation of society. Thus, he seemed to have escaped some of the difficulties of finding a place for women consistent with both traditional views of female status and newer views of human nature. Where Locke did speak directly about women, he often departed from traditional views in favor of an individualist approach. Examples of this may be found in his comments on marriage, education and in his discussion of female preaching.

Social Contract: Interpretation and Misinterpretation

L'interprétation habituelle du contractualisme social se fonde sur un syllogisme dont l'acte volontaire et arbitraire de consentement constitue la pierre d'achoppement. Pour interpréter le contrat social, l'auteur présente un nouveau syllogisme, le « contrat imputé », lequel repose en grande partie sur un raisonnement propre aux adeptes de la loi naturelle et dont la logique échappe aux critiques et objections formulées à l'encontre du contractualisme classique. En laissant de côté le faux concept de « contrat original », cette nouvelle approche restitue à la pensée contractualiste son fondement authentique et permet de comprendre pourquoi le mythe du contrat social, maintenant cavalièrement écarté, a été longtemps tenu pour un concept sérieux de la philosophie politique.

Justifying Paternalism

1. IntroductionA paternalistic act is one in which the protection or promotion of a subject's welfare is the primary reason for attempted or successful coercive interference with an action or state of that person. My aim in this paper is to determine the conditions under which such acts are Justified. The route I take is through the concept of consent, with actual consent providing the foundation for a rather complex condition which I claim is necessary and sufficient for the Justification of paternalism.Because a paternalistic act apparently violates a subject's right to non-interference, it constitutes a problem in the general area of rights. Ideally, then, one should have a developed and convincing theory of rights — that is, a theory which contains an analysis of the concept of a right, and offers solutions to the central problems, e.g. who has rights and why, what considerations overrideprima facierights, and how the relative importance ofprima facierights is determined — from which the solutions to various problems about paternalism can be derived.