Consenting to Surgery: Assessing the Patient’s Capacity to Make Decisions About Own Medical Care

  • Maya PrabhuEmail author


Informed consent is the cornerstone of the therapeutic relationship between physician and patient. However, the peri-surgical setting poses several challenges to implementing an effective informed consent process. This clinically oriented chapter provides an overview of the informed consent process in surgical care including making recommendations for enhancing patient comprehension, identifying issues while assessing capacity, and enumerating next steps to take if patients are found to be incapacitated. The chapter will also identify several special issues relating to mental and physical illness that surgical teams may encounter.


Informed consent Capacity Substituted decision-making Ethics Disclosure 


  1. 1.
    Jacoby LH, Maloy B, Cirenza E, Shelton W, Goggins T, Balint J. The basis of informed consent for BMT patients. Bone Marrow Transplant. 1999;23(7):711–7.PubMedGoogle Scholar
  2. 2.
    Schloendorff v. Society of New York Hospital, 105 N.E. 92(1914).Google Scholar
  3. 3.
    Natanson v. Kline, 350 P. 2d 1093(1960).Google Scholar
  4. 4.
    Canterbury v. Spence, 464 F.2d 772(1972).Google Scholar
  5. 5.
    DeGeorge BR Jr, Archual AJ, Gehle BD, Morgan RF. Enhanced informed consent in hand surgery: techniques to improve the informed consent process. Ann Plast Surg. 2017;79(6):521–4.PubMedGoogle Scholar
  6. 6.
    Studdert DM, Mello MM, Levy MK, Gruen RL, Dunn EJ, Orav EJ, et al. Geographic variation in informed consent law: two standards for disclosure of treatment risks. J Empir Leg Stud. 2007;4(1):103–24.Google Scholar
  7. 7.
    The Joint Commission. Informed consent: more than getting a signature. Quick safety. 2016:(21). Available at: Accessed 2 Oct 2018.
  8. 8.
    Appelbaum PS. Clinical practice. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357(18):1834–40.PubMedGoogle Scholar
  9. 9.
    Beauchamp TL. Informed consent: its history, meaning, and present challenges. Camb Q Healthc Ethics. 2011;20(4):515–23.PubMedGoogle Scholar
  10. 10.
    Fedson SE, MacKenzie KK, Delgado ED, Abraham MN, Estep JD, Blumenthal-Barby JS, et al. Mapping the informed consent process for left ventricular assist devices. ASAIO J. 2018;64(5):630–5.PubMedGoogle Scholar
  11. 11.
    Medicaid. CfMa. Revisions to the hospital interpretive guidelines for informed consent. 2013.
  12. 12.
    Association AM. Chapter 2: opinions on consent, communication & decision making. 2016.
  13. 13.
    Ophthalmology. AAo. Practice guidelines for informed consent. 2010.
  14. 14.
    Surgeons. BotACo. Procedure-specific consents available online. 2013.
  15. 15.
    Chrimes N, Marshall SD. The illusion of informed consent. Anaesthesia. 2018;73(1):9–14.PubMedGoogle Scholar
  16. 16.
    Kriwanek S, Armbruster C, Beckerhinn P, Blauensteier W, Gschwantler M. Patients’ assessment and recall of surgical information after laparoscopic cholecystectomy. Dig Surg. 1998;15(6):669–73.PubMedGoogle Scholar
  17. 17.
    Stanley BM, Walters DJ, Maddern GJ. Informed consent: how much information is enough? Aust N Z J Surg. 1998;68(11):788–91.PubMedGoogle Scholar
  18. 18.
    Donovan EE, Crook C, Brown LE, Pastorek AE, Hall CA, Mackert MS, et al. An experimental test of medical disclosure and consent documentation: assessing patient comprehension, self-efficacy, and uncertainty. Commun Monogr. 2014;81:239.Google Scholar
  19. 19.
    Little M, Jordens CF, McGrath C, Montgomery K, Lipworth W, Kerridge I. Informed consent and medical ordeal: a qualitative study. Intern Med J. 2008;38(8):624–8.PubMedGoogle Scholar
  20. 20.
    Patenaude AF, Rappeport JM, Smith BR. The physician’s influence on informed consent for bone marrow transplantation. Theor Med. 1986;7(2):165–79.PubMedGoogle Scholar
  21. 21.
    Tait AR, Teig MK, Voepel-Lewis T. Informed consent for anesthesia: a review of practice and strategies for optimizing the consent process. Can J Anaesth. 2014;61(9):832–42.PubMedGoogle Scholar
  22. 22.
    Michalski A, Stopa M, Miskowiak B. Use of multimedia technology in the doctor-patient relationship for obtaining patient informed consent. Med Sci Monit. 2016;22:3994–9.PubMedPubMedCentralGoogle Scholar
  23. 23.
    Grady C, Cummings SR, Rowbotham MC, McConnell MV, Ashley EA, Kang G. Informed consent. N Engl J Med. 2017;376(9):856–67.PubMedGoogle Scholar
  24. 24.
    Wollinger C, Hirnschall N, Findl O. Computer-based tutorial to enhance the quality and efficiency of the informed-consent process for cataract surgery. J Cataract Refract Surg. 2012;38(4):655–9.PubMedGoogle Scholar
  25. 25.
    Palmer BW, Harmell AL. Assessment of healthcare decision-making capacity. Arch Clin Neuropsychol. 2016;31(6):530–40.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Pescosolido BA, Monahan J, Link BG, Stueve A, Kikuzawa S. The public’s view of the competence, dangerousness, and need for legal coercion of persons with mental health problems. Am J Public Health. 1999;89(9):1339–45.PubMedPubMedCentralGoogle Scholar
  27. 27.
    Resnick PJ, Sorrentino R. Forensic issues in consultation-liaison psychiatry. Psychiatric Times. 2005;13(14):1.Google Scholar
  28. 28.
    Moye J, Marson DC. Assessment of decision-making capacity in older adults: an emerging area of practice and research. J Gerontol B Psychol Sci Soc Sci. 2007;62(1):P3–P11.PubMedGoogle Scholar
  29. 29.
    Main BG, McNair AGK, Huxtable R, Donovan JL, Thomas SJ, Kinnersley P, et al. Core information sets for informed consent to surgical interventions: baseline information of importance to patients and clinicians. BMC Med Ethics. 2017;18(1):29.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Grisso T, Appelbaum PS. Using the MacArthur competence assessment tool – treatment. Assessing competence to consent to treatment: a guide for physicians and other health professionals. New York: Oxford University Press; 1998.Google Scholar
  31. 31.
    Lai JM, Gill TM, Cooney LM, Bradley EH, Hawkins KA, Karlawish JH. Everyday decision-making ability in older persons with cognitive impairment. Am J Geriatr Psychiatry. 2008;16(8):693–6.PubMedPubMedCentralGoogle Scholar
  32. 32.
    Candia PC, Barba AC. Mental capacity and consent to treatment in psychiatric patients: the state of the research. Curr Opin Psychiatry. 2011;24(5):442–6.PubMedGoogle Scholar
  33. 33.
    Bester J, Cole CM, Kodish E. The limits of informed consent for an overwhelmed patient: clinicians’ role in protecting patients and preventing overwhelm. AMA J Ethics. 2016;18(9):869–86.PubMedGoogle Scholar
  34. 34.
    Ivashkov Y, Van Norman GA. Informed consent and the ethical management of the older patient. Anesthesiol Clin. 2009;27(3):569–80, table of contents.PubMedGoogle Scholar
  35. 35.
    Surman OS, Cosimi AB, DiMartini A. Psychiatric care of patients undergoing organ transplantation. Transplantation. 2009;87(12):1753–61.PubMedGoogle Scholar
  36. 36.
    Hindmarch T, Hotopf M, Owen GS. Depression and decision-making capacity for treatment or research: a systematic review. BMC Med Ethics. 2013;14:54.PubMedPubMedCentralGoogle Scholar
  37. 37.
    Appelbaum PS, Roth LH. Competency to consent to research: a psychiatric overview. Arch Gen Psychiatry. 1982;39(8):951–8.PubMedGoogle Scholar
  38. 38.
    Gergel T, Owen GS. Fluctuating capacity and advance decision-making in bipolar affective disorder – self-binding directives and self-determination. Int J Law Psychiatry. 2015;40:92–101.PubMedPubMedCentralGoogle Scholar
  39. 39.
    Kirkendall A, Linton K, Farris S. Intellectual disabilities and decision making at end of life: a literature review. J Appl Res Intellect Disabil. 2017;30(6):982–94.PubMedGoogle Scholar
  40. 40.
    Goede M, Wheeler M. Advance directives, living wills, and futility in perioperative care. Surg Clin North Am. 2015;95(2):443–51.PubMedGoogle Scholar
  41. 41.
    Rinkus K. The pregnancy exclusion in advance directives: are women’s constitutional rights being violated? Pub Int Law Rep. 2014;19(2):94–100.Google Scholar
  42. 42.
    Kim SY, Karlawish JH, Kim HM, Wall IF, Bozoki AC, Appelbaum PS. Preservation of the capacity to appoint a proxy decision maker: implications for dementia research. Arch Gen Psychiatry. 2011;68(2):214–20.PubMedPubMedCentralGoogle Scholar
  43. 43.
    Pope TM. Legal fundamentals of surrogate decision making. Chest. 2012;141(4):1074–81.PubMedGoogle Scholar
  44. 44.
    DeMartino ES, Dudzinski DM, Doyle CK, Sperry BP, Gregory SE, Siegler M, et al. Who decides when a patient can’t? Statutes on alternate decision makers. N Engl J Med. 2017;376(15):1478–82.PubMedPubMedCentralGoogle Scholar
  45. 45.
    ABA. ABA commission on law and aging : health care decision making. 2017.
  46. 46.
    Lo B. Resolving ethical dilemmas: a guide for clinicians. Philadelphia, PA: Wolters Kluwer Health; 2012.Google Scholar
  47. 47.
    Scarrow AM, Scarrow MR. Informed consent for the neurosurgeon. Surg Neurol. 2002;57(1):63–8; discussion 8-9.PubMedGoogle Scholar
  48. 48.
    Etchells E, Sharpe G, Burgess MM, Singer PA. Bioethics for clinicians: 2. Disclosure. CMAJ. 1996;155(4):387–91.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Klove CA, DiBoise SJ, Pang B, Yarbrough WC. Informed consent: ethical and legal aspects. Thorac Surg Clin. 2005;15(2):213–9.PubMedGoogle Scholar
  50. 50.
    Bostick NA, Sade R, McMahon JW, Benjamin R. Report of the American Medical Association Council on Ethical and Judicial Affairs: withholding information from patients: rethinking the propriety of “therapeutic privilege”. J Clin Ethics. 2006;17(4):302–6.PubMedGoogle Scholar
  51. 51.
    Grauberger J, Kerezoudis P, Choudhry AJ, Alvi MA, Nassr A, Currier B, et al. Allegations of failure to obtain informed consent in spinal surgery medical malpractice claims. JAMA Surg. 2017;152(6):e170544.PubMedPubMedCentralGoogle Scholar
  52. 52.
    Agarwal N, Gupta R, Agarwal P, Matthew P, Wolferz R Jr, Shah A, et al. Descriptive analysis of state and federal spine surgery malpractice litigation in the United States. Spine (Phila Pa 1976). 2017;43(14):984–90.Google Scholar
  53. 53.
    Svider PF, Blake DM, Husain Q, Mauro AC, Turbin RE, Eloy JA, et al. In the eyes of the law: malpractice litigation in oculoplastic surgery. Ophthal Plast Reconstr Surg. 2014;30(2):119–23.PubMedGoogle Scholar
  54. 54.
    Abbott RL. Informed consent in cataract surgery. Curr Opin Ophthalmol. 2009;20(1):52–5.PubMedGoogle Scholar
  55. 55.
    Raymond MR, Mee J, King A, Haist SA, Winward ML. What new residents do during their initial months of training. Acad Med. 2011;86(10 Suppl):S59–62.PubMedGoogle Scholar
  56. 56.
    Schenker Y, Wang F, Selig SJ, Ng R, Fernandez A. The impact of language barriers on documentation of informed consent at a hospital with on-site interpreter services. J Gen Intern Med. 2007;22(Suppl 2):294–9.PubMedPubMedCentralGoogle Scholar
  57. 57.
    Bezuidenhout L, Borry P. Examining the role of informal interpretation in medical interviews. J Med Ethics. 2009;35(3):159–62.PubMedGoogle Scholar
  58. 58.
    Scharman CD, Burger D, Shatzel JJ, Kim E, DeLoughery TG. Treatment of individuals who cannot receive blood products for religious or other reasons. Am J Hematol. 2017;92(12):1370–81.PubMedGoogle Scholar
  59. 59.
    Stamford Hospital vs. Nelly E. Vega, 674 A. 2d 821(1996).Google Scholar
  60. 60.
    Belaouchi M, Romero E, Mazzinari G, Esparza M, Garcia-Cebrian C, Gil F, et al. Management of massive bleeding in a Jehovah’s Witness obstetric patient: the overwhelming importance of a pre-established multidisciplinary protocol. Blood Transfus. 2016;14(6):541–4.PubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Law and Psychiatry DivisionYale University School of MedicineNew HavenUSA

Personalised recommendations