Even though obtaining informed consent is an important procedure before spinal surgery, almost 40% of the patients in a recent study—published in the European Spine Journal—underwent surgery without reading the informed consent document or being aware of the risks posed by the procedure. Here, lead author Jorge H Núñez (Barcelona, Spain) explains the significance of these findings.
I hope this topic sounds familiar to you, as it is something that I believe can happen frequently. Patients who are in consultation have received a detailed explanation about their surgery and have signed an informed consent but, after the surgery, they ask, “Doctor, what did you do to me?”.
This is the topic addressed in the article published in July 2023 in the European Spine Journal, “Autonomy with responsibility: Is informed consent just a signature on a paper? An evaluation in patients undergoing spinal surgery”. The article evaluates patients’ understanding of the information when signing their informed consent.
In current medical practice, informed consent is an ethical requirement established by law. Therefore, no elective surgical procedure can be performed without patients signing their informed consent beforehand. However, the main finding of this study was that approximately 40% of patients undergo surgery without having read the informed consent they sign. This finding is relevant because the opportunity to read contracts preserves individual autonomy. However, it has also been observed that people rarely read the contracts they sign.
It is important not to confuse the patient’s informed consent as protection for the doctor or as a contract to exempt the doctor from liability for complications occurring after obtaining the patient’s signature. The process of informed consent should be considered an opportunity to establish a therapeutic alliance between patients and doctors. However, if nearly 40% of patients do not even read their informed consent, it is unlikely that they can make an informed, autonomous decision.
Another important finding of this study was that 39.1% of patients were not aware of the surgical risks inherent to their procedure. While some patients prefer to trust their surgeon rather than being informed about all possible complications of their operation, trust in the doctor cannot override the patient’s right to decide which health risks they are willing to assume. Based on the decision of the Montgomery versus Lanarkshire Health Board, patients should be considered as consumers exercising their choices and having the ability to decide on their own treatment, rather than passive recipients of medical care. Therefore, it is important to ensure that patients understand the inherent risks of surgical procedures.
Only younger patients and those with a higher level of education sought additional information about their surgery. It is important to note that, in the 21st century, patients can obtain a wide range of information about their illness and treatment through the internet. In 1957, when the concept of informed consent was introduced, it was unthinkable for patients to seek information about treatment options, as medical information was very limited and only available in medical libraries. However, nowadays, healthcare is approached completely differently. Thanks to technological advancements, patients have access to a vast amount of diverse medical information. Additionally, they are more involved in the decision-making process compared to previous decades when they relied mainly on their doctor’s opinion.
Current medicine is no longer paternalistic, and shared decision-making between doctor and patient is sought. Therefore, it is valid to question what the doctor’s responsibility is when operating on someone who does not understand their surgery, as well as the patient’s responsibility to want to understand their surgery and what they are signing in the informed consent. For good communication to exist, there needs to be a good transmitter and a good receiver.
Based on this European Spine Journal article, it is concluded that:
- The doctor has a duty to inform the patient, and the patient has the right to be informed and the responsibility to ask questions and understand their treatment
- The patient has the duty and right to be more involved in the decision-making process, especially in surgical cases
- The patient has the right to have a printed copy of the informed consent before and after signing it, to be able to review it at any time. However, the patient also has the responsibility to read it
In summary, it is important for both doctors and patients to make an effort to improve the process of informed consent, which should specify not only the rights but also the responsibilities of each party.
Jorge H Núñez is a spine surgeon in the Department of Traumatology and Orthopedic Surgery at the University Hospital of Mutua Terrassa in Barcelona, Spain.