Autonomy and Informed Consent

The process of obtaining informed consent is designed to operationalize respect forautonomy. Informed consent requires that the agent have capacity for decision-making, that the agent be informed, and that the agent’s decision be voluntary. Under most circumstances, patients are presumed competent, and the onus is upon the practitioner to prove otherwise. I argue that informed consent, in its current practice, fails to ensure respect for autonomy. Complacency on the part of both patients and practitioners leads to four flaws that have the potential either to undermine patient autonomy or to presume competence where it is absent. Practitioners must do their due diligence in assessing patients for competence, above and beyond the minimum required in the consent document. I call this process Rigorous Informed Consent. I propose two solutions for improving the informed consent process. The first utilizes informed consent specialists” to ensure that patients are properly informed. The second implements “informed consent coding” to define the level of capacity required for a given clinical situation, on a numerical scale. Next, I analyze four domains of influence upon authenticity and describe potential “red flags” for authenticity issues. I present my own formulation of what elements are required for autonomous agency and introduce the concepts of Substantial Autonomy and Threshold Competence. “Full autonomy” or “ideal autonomy” is not always possible, nor is it always necessary to attain. The “exceptional cases,” are when agents are assumed to be incompetent, simply because they are refusing the treatment that is recommended by their practitioners. I cite studies that show that that suicide is no more prevalent in the terminally ill than in the general population, that depressed patients maintain both capacity and appreciation of their situation, that preferences for the end of life amongst depressed patients are similar to those without depression, and that patient’s preferences are stable over time, even after treatment for depression. I explain how Threshold Competence can be applied to depressed patients and argue that mild to moderate depression does not significantly alter patients’ preferences, so the wishes they express should be taken as reliable and authentic