:ETHICS Nuances of Informed Consent: The Paradigm of Regional Anesthesia

Informed Consent is the primary method employed in clinical practice by which patients and their physicians incorporate a patient_s values, preferences, expectations, and fears in treatment decision-making [1]. Grounded in the philosophical concept of autonomy, it reflects a departure from the paternalistic tradition of western medicine, revealed first in the writings of Hippocrates and remaining dominant until recent times [2]. The practice of Informed Consent in the clinical arena evolved primarily through the medical profession_s responses to various decisions by the courts. In this paper we review the concept of Informed Consent from a historical and ethical perspective and, in so doing, provide a context for a discussion of these considerations to a specific clinical domain, that of regional anesthesia. Historical considerations That a medical procedure could be performed without including the patient in the decision-making process will seem inconceivable to the physician of today. Nonetheless, the modern practice of Informed Consent is just that— modern—with a history not yet a century old. Indeed. the American Medical Association_s position paper on this practice was published in 1981 [3]. When viewed from a historical perspective, a reluctance to promote full disclo-sure from patients has been the dominant posture of the medical profession. Such non-disclosure is probably as ancient as the practice of medicine and for most of recorded medical history what is now considered a primary obligation was seen as antithetical to one of the dominant ideas of practice. Even the venerable Hippocrates advo-cated concealing most information from patients [4]. This reticence likely arose as a consequence of the limited therapeutic options available to physicians in earlier times and the widespread use of placebos. However, the extraordinary advances made in medical practice over the last 50 years have produced a fundamental change in this long-enduring belief and established an attitude of disclosure. What has now become the doctrine of Informed Consent has arisen in response to a number of decisive legal judgments beginning in 1914 with Schloendorff v