7 Ethics and Informed Consent
Vijaya M. Vemulakonda, MD, JD
A
s clinical urologic practice continues to become more complex,
the ethical and legal implications of practice become more
profound. The purpose of this chapter is to provide a brief
history of the origins of medical ethics and legal principles of informed
consent, to define key ethical principles and their application to
clinical decision making, and to consider the ethical and legal
requirements for informed consent in both the clinical and surgical
settings.
MEDICAL ETHICS
History of Medical Ethics
The origins of medical ethics are thought to be rooted in the writings
of Hippocrates, considered to be the “father of medicine.” Fore-
most among his contributions to medicine is the Hippocratic oath
(Box 7.1), considered the cornerstone of ancient Greek medical ethics,
which postulated that the primary goal of medicine is to protect
the patient’s interests. The oath establishes the moral framework
governing the physician-patient relationship and introduces the
ethical principles of beneficence, nonmaleficence, confidentiality,
and accountability to the medical profession (Antoniou et al., 2010).
However, in the 20th century, the traditional values embodied
by the oath were challenged by prominent ethicists such as Robert
Veatch. In this view, the oath relies on the physician to make judg-
ments about diagnosis and treatment because of the patient’s inability
to understand the information needed for decision making. As a
result, the oath undermines the growing respect for patient autonomy
that emerged during the late 20th century (Veatch, 1991; Veatch,
2009). Additionally, the oath has been criticized for not addressing
issues surrounding justice in the allocation of medical resources,
instead focusing on the individual outside of the social context of
his care (Veatch, 1991).
As criticism of the Hippocratic oath grew, the interdisciplinary
field of bioethics emerged. During the 1960s, physicians first began
to discuss the impact of technology, such as antibiotics and genetic
testing, on medical care (Jonsen, 2001). In 1970 Van Rensselaer
Potter first coined the term bioethics to describe “the study of the
moral relationship between humans and their social and physical
world (Jonsen, 2001; Potter, 1970).” Concerns over the eugenic
experiments of the Nazis during World War II strengthened the focus
on patient autonomy and patient rights to protect their medical and
genetic information (Jonsen, 2001). This focus on respect for patient
autonomy and informed consent was reinforced in the research
realm as information about the Tuskegee syphilis studies became
public in the early 1970s (Jonsen, 2001). In 1979 the “Four Principles”
framework for addressing ethical issues in medicine was first described
by Beauchamp and Childress. This approach remains the cornerstone
of modern medical ethics (Beauchamp and Childress, 1979).
The Four-Principles Framework
The four principles delineated by Beauchamp and Childress were
developed to help provide a common set of moral commitments
and language with which to address ethical issues (Gillon, 1994).
The principles include autonomy, beneficence, nonmaleficence,
and justice. These principles are considered equal in weight and
should be considered prima facie binding unless in conflict, leading
to ethical dilemmas in circumstances in which the physician and
patient must prioritize among conflicting principles (Gillon, 1994).
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Autonomy, described as respect for the “deliberated self-rule”
of individuals, includes an obligation to respect that patients are
able to make their own choices even if the outcomes of those
choices do not coincide with the physician’s calculation of maximal
benefit and minimal harm (Gillon, 1994). This principle is grounded
in the Kantian “categorical imperative” that people be considered
ends in themselves rather than a means to an end. Although some
have postulated that autonomy should be prioritized when in conflict
with other principles, it is also considered bound by justice or the
consideration of autonomy of others in addition to the individual
patient (Gillon, 1994). Respect for autonomy provides the foundation
for several physician obligations, including informed consent,
confidentiality, and avoidance of deceit. Importantly, communication
is essential to providing the physician with the information about
patient preferences and attitudes needed to guide discussions of
options and to frame medical decision making in a way that is
respectful of the patient (Gillon, 1994).
Beneficence and nonmaleficence are grounded in the Hippocratic
oath’s dictum to protect the patient’s best interests (Antoniou et al.,
2010). Beneficence refers to the physician’s obligation to optimize
benefit to the patient and should be considered through the prism
of the patient’s values and preferences (autonomy). Nonmaleficence
is grounded in the Hippocratic dictum primum non nocere (first
do no harm) and refers to the obligation to avoid or minimize
harm to the patient. These principles mean that (1) we must be
able to provide the benefits we promise, through adequate training,
education, and professional standards and (2) we must be clear
about the probability and magnitude of risk and benefit associated
with treatment to ensure that we are able to optimize the patient’s
understanding (Gillon, 1994). As a result, the complementary
principles of beneficence and nonmaleficence can be seen as an
obligation not only to provide training to the individual clinician
but also to conduct research to ensure that the information we offer
is as accurate as possible. Finally, the weighing of risks and benefits
should be considered both at the individual and at the population
level (justice) to ensure that risks and benefits are equally shared
among patients.
Justice refers to the obligation to seek and achieve fairness in
the distribution of resources, benefits, and risks across patients.
Although equality and justice share many traits, they are not equiva-
lent; “people may be treated unjustly even if they are treated equally”
(Gillon, 1994). At the individual patient level, justice means that
the physician should try to minimize the effect of self-interest or
personal preferences on patient decisions and should respect the
patient’s right to self-determination. Additionally, the physician
should try to minimize waste of resources when possible. At the
societal level, determination of justice may be more difficult. Compet-
ing values in justice may lead to different outcomes: does just distribu-
tion require equal access to care, provision to those who need it
most, advocacy by physicians to maximize the benefit for their
patients, limitation of societal costs (via taxes or insurance deduct-
ibles), or respect for patient choice? Although all of these values
have merit, how do we as physicians and as a society determine
which should have priority (Gillon, 1994)?
Medical Ethics in Clinical Practice
Despite the focus on these four principles in medical society codes
of ethics and in training, the translation of these principles to specific
medical care may not always be clear (Page, 2012). To address this
115
116 PART I Clinical Decision Making
BOX 7.1 Translation of the Original Hippocratic Oath
I swear by Apollo the physician, and Aesculapius, and Health, and
All-heal, and all the gods and goddesses, that, according to my
ability and judgment, I will keep this Oath and this stipulation: to
reckon him who taught me this Art equally dear to me as my
parents, to share my substance with him, and relieve his necessities
if required; to look upon his offspring in the same footing as my
own brothers, and to teach them this Art, if they shall wish to learn
it, without fee or stipulation; and that by precept, lecture, and
every other mode of instruction, I will impart a knowledge of the
Art to my own sons, and those of my teachers, and to disciples
bound by a stipulation and oath according to the law of medicine,
but to none others.
I will follow that system of regimen which, according to my
ability and judgment, I consider for the benefit of my patients, and
abstain from whatever is deleterious and mischievous. I will give
no deadly medicine to anyone if asked, nor suggest any such
counsel; and in like manner I will not give to a woman a pessary
to produce abortion. With purity and with holiness will I pass my
life and practice my Art.
I will not cut persons labouring under the stone, but will leave
this to be done by men who are practitioners of this work. Into
whatever houses I enter, I will go into them for the benefit of the
sick, and will abstain from any voluntary act of mischief and cor-
ruption; and, further, from the seduction of females or males, of
freemen and slaves.
Whatever, in connection with my professional practice, or not
in connection with it, I see or hear, in the life of men, which ought
not to be spoken of abroad, I will not divulge, as reckoning that
all such should be kept secret. While I continue to keep this Oath
unviolated, may it be granted to me to enjoy life and the practice
of the Art, respected by all men, in all times! But should I trespass
and violate this Oath, may the reverse be my lot!
From The Genuine Works of Hippocrates, translated from the Greek by
Francis Adams, Surgeon, volume 2, London, 1849.
issue, Jonsen et al. recommend use of the “Four-Box” technique to
provide a more systematic method to consider and apply ethical
principles to medical cases (Table 7.1) (Jonsen et al., 1998). The
four topics to be considered include the following:
Medical Indications include the general goals of medical treat-
ment (prevention and care of illness) and are grounded in the
principles of beneficence and nonmaleficence (Jonsen et al., 1998).
In addition to discussion of clinical issues and potential treatment
options, this discussion should extend to the goals of intervention.
To act ethically, the physician must use his or her clinical judgment
to evaluate the potential risks and benefits of treatment, to make a
recommendation based on this assessment, and to identify the
patient’s preferences regarding treatment choice. The physician should
consider and discuss with the patient potential clinical uncertainty
both in terms of suspected diagnosis and outcomes. Additionally,
when the risks and benefits of treatment appear to be equivocal,
the physician should defer to the patient’s stated preferences
(Schumann and Alfandre, 2008).
Patient Preferences refer to the patient’s values and assessment
of relative benefits of treatment alternatives and are grounded in
the ethical principle of autonomy (Schumann and Alfandre, 2008).
To ensure adequate consideration of patient preferences, the provider
must ensure the patient has sufficient information and comprehension
to weigh treatment options. Additionally, the provider should ensure
that the patient has a clear understanding of the uncertainty in
outcome and the potential range of treatment choices and outcomes.
Finally, it is essential to ensure the patient’s choice is voluntary. In
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the setting of lack of adequate capacity, the physician should ensure
that the appropriate person has been identified to act as the patient’s
surrogate and is acting in accordance with the patient’s beliefs and
wishes when possible (Schumann and Alfandre, 2008).
Quality of Life is the most ephemeral of the factors to be
considered in practice and stems from the principles of autonomy,
beneficence, and nonmaleficence (Schumann and Alfandre, 2008).
As a result of the variable understanding of this term, it may be
difficult for the provider to intuit the impact of treatment on the
patient’s perceived quality of life. As a result, the substitution of the
provider’s views for the patient’s raises concerns about potential bias
that should be considered in the decision-making process, and the
provider should try to elicit from the patient his or her values and
preferences to guide assessment of quality of life (Jonsen et al., 1998).
Contextual Features allow for consideration of a patient-physician
partnership within the greater framework of personal, institutional,
legal, and social relationships and is grounded in the ethical
principle of justice. This may include family dynamics, patient
socioeconomic circumstances, as well as religious beliefs (Schumann
and Alfandre, 2008). Additionally, this topic includes the dynamics
of the treatment team, the need for coordination of care among
multiple providers, as well as potential physician biases or interests
that may affect treatment decisions (Jonsen et al., 1998).
Although the Four-Box framework allows for a systematic approach
to assessing clinical conundrums by providing an easy-to use-technique
for organizing conflicting priorities in patient care and for discussing
areas of conflict with the patient and family, it may also lead to
oversimplification of ethical issues and may not always clearly guide
clinical decision making within the context of identified ethical
concerns. As a result, this framework (or any ethical model) should
be used in conjunction with the surgeon’s assessment of reasonable
alternatives for treatment as a vehicle to guide discussion of the
relative benefits of each alternative through the prism of the
patient’s preferences.
INFORMED CONSENT
History of Informed Consent
Although now considered within the scope of negligence, the legal
concept of informed consent originated in early 20th century battery
law. From 1905 to 1914, state courts identified a right to bodily
integrity that required physicians to obtain informed consent before
performing a procedure. They found that patients have the right to
decide their course of treatment, and as part of that right, they are
entitled to be informed about the risks associated with the procedure
and to evaluate those risks before coming to a decision (Faden and
Beauchamp, 1986). Patients also may limit the consent provided.
For example, consent for an examination under anesthesia does not
extend to a consent to surgery (Schloendorff, 1914). Furthermore,
consultation for medical advice from a physician does not imply
consent (Mohr vs. Williams, 1905). Although the courts did acknowl-
edge the potential for implied consent, this was limited to emergency
situations or to cases in which a life-threatening condition was
identified and the patient was not capable of consent (Faden and
Beauchamp, 1986; Luka vs. Lowrie, 1912).
In 1957 the term informed consent was coined and included that
physicians provide “any facts which are necessary to form the basis
of an intelligent consent by the patient to the proposed treatment”
(Salgo vs. Leland, 1957). Under this new standard, physicians faced
a heightened responsibility to provide information about the risks,
benefits, and alternatives to a procedure to facilitate an informed
decision by the patient. The Kansas Supreme Court in 1960 found
that physician liability for failure to adequately inform a patient
about the risks associated with treatment fell within the scope of
negligence. As a result, the legal standard for violating informed
consent required both establishing that a physician’s actions fell
outside of the scope of what a “reasonable and prudent” physician
would do and that these actions were the “proximate cause” of
the subsequent harm (Katz, 1977). This standard was expanded in
1972 by the DC Court of Appeals, which found that the disclosure

TABLE 7.1 The Four-Box Method to Application of Ethics in Clinical Practice
Medical Indications
1. What is the patient’s medical problem? History?
Diagnosis? Prognosis?
2. Is the problem acute? Chronic? Critical?
Emergent? Reversible?
3. What are the goals of treatment?
4. What are the probabilities of success?
5. What are plans in cases of therapeutic failure?
6. In sum, how can this patient be benefited by
medical and nursing care and how can harm be
avoided?
Quality of Life
1. What are the prospects, with or without treatment,
for a return to the patient’s normal life?
2. Are there biases that might prejudice the
provider’s evaluation of the patient’s quality of life?
3. What physical, mental, and social deficits is the
patient likely to experience if treatment succeeds?
4. Is the patient’s present or future condition such
that continued life might be judged undesirable by
him or her?
5. Is there a plan and rationale to forego treatment?
6. What are plans for comfort/palliative care?
Modified from Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: a practical approach to ethical decisions in clinical medicine. 4th ed.
McGraw-Hill; 1998.
should fit within what a “reasonable person” would want to know
rather than deferring to what a “reasonable physician” would disclose
(Canterbury vs Spence, 1972).
Elements of Informed Consent
Informed consent refers to the process by which a patient and medical
provider discuss a proposed medical treatment, its anticipated con-
sequences, potential risks and benefits, and alternatives. This process
allows for open discussion between the provider and the patient
and may theoretically help reduce medical errors, improve patient
outcomes, and increase patient empowerment (Cordasco, 2013).
A comprehensive informed consent consists of four basic
elements: (1) description of the clinical problem, the proposed
treatment, and alternatives including no treatment; (2) discussion
of the risks and benefits of the proposed treatment with com-
parisons to the risks and benefits of alternatives, and discussion
of medical/clinical uncertainties regarding the proposed treatment;
(3) assessment of the patient’s understanding of the information
provided by the medical provider; and (4) solicitation of the
patient’s preference and consent for treatment (Cordasco, 2013).
The extent of information to be provided is generally based on
the physician’s assessment of what information may impact diagnosis
and treatment planning. Extraneous information that is unlikely to
impact the patient’s decision may be withheld. Additionally, to the
extent possible, information should be provided in a way that is
understandable to the average layperson and facilitates his or her
meaningful participation in treatment planning. By discussing options
before making a recommendation, the surgeon may reduce undue
influence on the patient’s decision (McCullough et al., 1986).
To ensure adequate information for consent, patients must
understand the “material risks” and expected benefits of treatment.
However, there is no clear consensus on what constitutes a material
risk. Some have proposed a 1% risk cutoff, with lower risk considered
based on the severity of harm (Adams and Smith, 2001). Additionally,
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Chapter 7 Ethics and Informed Consent 117
Patient Preferences
1. What has the patient expressed about treatment preferences?
2. Has the patient been informed of benefits and risks, demonstrated
understanding, and given consent?
3. Is the patient mentally capable and legally competent? What evidence
is there of incapacity?
4. Has the patient expressed prior preferences (e.g., advance directives)?
5. If incapacitated, who is the appropriate surrogate? Is the surrogate
using appropriate standards?
6. Is the patient unwilling or unable to cooperate with medical treatment?
If so, why?
7. In sum, is the patient’s right to choose being respected to the extent
possible in ethics and law?
Contextual Features
1. Are there family issues that might influence treatment decisions?
2. Are there provider issues that might influence treatment decisions?
3. Are there financial and economic factors?
4. Are there religious or cultural factors?
5. Is there any justification to breach confidentiality?
6. Are there problems of resource allocation?
7. What are the legal implications of treatment decisions?
8. Is clinical research or teaching involved?
9. Are there any provider or institutional conflicts of interest?
there are several limitations to patient understanding of risks. First,
patients often use shortcuts to simplify the decision-making process,
often leading to misunderstanding of the risks posed by a treatment
(Lloyd, 2001). Second, patients may underestimate their own risks
compared with other people’s (Weinstein, 1989). Third, patients are
influenced by the way in which risks are presented (e.g., likelihood
of survival versus likelihood of death) (Lloyd, 2001). Counterintui-
tively, information about clinical uncertainty in the probability of
risk improves understanding of risk and also elicits more trust in
the information provided (Johnson and Slovic, 1995).
Patients often idealize surgeons and accept surgical recommenda-
tions without meaningful participation in the decision-making process
(McNeally and Martin, 2000). As a result, the surgeon has a heightened
responsibility to solicit patient feedback during the consent process.
By empowering the patient to both ask questions and to authorize
surgical intervention, the surgeon also strengthens their relationship
with the patient, opening the door to an ongoing process of com-
munication before, during, and after treatment (Jones et al., 2007).
Substantively, the physician should ensure that the patient understands
the goals of treatment, the general nature of the procedure to be
performed, as well as expected outcomes including what to expect
in the immediate postoperative period.
The last element of the informed consent process is explicit consent
or refusal of treatment based on the information and recommenda-
tions provided by the surgeon. The surgeon should help the patient
understand the potential future implications of his or her decisions.
The extent to which the surgeon directs the conversation regarding
treatment alternatives may depend on how active the patient chooses
to be in the decision-making process (Fig. 7.1). Regardless of the
patient’s role in the process, the surgeon should at least ensure
patient understanding of the potential outcomes, risks, and benefits
associated with the procedure before obtaining consent. To facilitate
the patient’s judgments about the relative risks and benefits of
treatment, the surgeon may ask the patient about what elements of
treatment are most important to him or her, such as impact on job
118 PART I Clinical Decision Making
PATERNALISTIC:
Information and recommendations
INFORMED MEDICAL DECISION MAKING:
Information
Clinician
SHARED DECISION MAKING:
Information and recommendations
Values and preferences
Fig. 7.1. Models of patient decision making. (From Schrager S, Phillips G,
Burnside E. A simple approach to shared decision making in cancer screening.
Fam Pract Manag 2017;24(3):5–10.)
performance, sexual function, continence, or ability to pursue leisure
activities.
Exceptions to the Informed Consent Requirement
Emergency situations: One of the well-established exceptions to
informed consent is in the emergency setting. In this setting,
where there is a significant threat to patient’s well-being or life,
consent is presumed (Hartman and Liang, 1999). In unconscious
patients in need of emergent medical care, the responsibility of
disclosure is waived because of the potential irreparable harm that
may result (Barnett vs. Bachrach, 1943). Similarly, in the pediatric
setting, informed consent from the parents may be waived if the
patient is at risk for “immediate injury or death (Hartman and
Liang, 1999).” However, this waiver does not extend to the conscious
patient, who may refuse treatment even if to do so would be life-
threatening (In re Quackenbush, 1978) or to children where obtaining
parental consent does not constitute an immediate threat of harm
(Rogers vs Sells, 1936).
Patients without decision-making capacity: In patients who are
unable to participate in the decision-making process, often family
members are empowered by law to make decisions for them (Areen,
1987). The goal is for the family to assess what the patient would
consider most important (“substituted judgment”) rather than for
the family to make decisions based on their own values. In cases
in which the family is unable to achieve substituted judgment, they
should instead act in the best interest of their loved one. When
the surgeon does not believe that the surrogate decision maker is
adequately pursuing the patient’s wishes, he or she should then
consult with the institutional ethics board or hospital administra-
tion to determine whether petitioning the court for a conservator
is warranted (McCullough et al., 1986).
Pediatric patients: Although by law parents are considered sur-
rogate decision makers for minor children (younger than 18 years
of age), children should participate in the decision-making process
to the extent that they are able (Committee on Bioethics, American
Academy of Pediatrics, 1995). When parents and their children
disagree about the best treatment decision, the surgeon should offer
to facilitate discussion to help them reach a common decision.
Additionally, providing information about the process, including
providing families with the opportunity to visit perioperative spaces
before surgery, may help improve understanding and alleviate anxiety
about the process (Ziegler and Prior, 1994).
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Quality of Informed Consent
In assessing the quality of consent, two questions must be answered:
(1) Did the physician provide the patient with enough information
about the diagnosis and treatment and (2) Did the patient consent to
treatment based on this information (Jones et al., 2007)? The standard
Patient by which to judge the adequacy of information should be based
on what a reasonable person (patient) needs for a meaningful
decision (Canterbury vs. Spence, 1972) and includes a responsibility
for the physician to respect the patient’s perspective of his or her
interests whether or not the physician agrees (Jones et al., 2007).
Despite the need for effective consent, most informed consent
processes are incomplete, with the most common missed element
being assessment of patient understanding of the information
provided by the physician (Cordasco, 2013). The information
provided in consent forms often is above the 12th-grade level,
although the majority of patients have reading levels well below
that (Hopper et al., 1998). Whether because of the difficulty of
understanding or recalling the information in informed consent
documents, patients who report reading consent forms do not
demonstrate better understanding of the procedure and its risks
than those who do not (Cassileth et al., 1980). This lack of under-
standing is even more pronounced in patients with limited English
proficiency (Cordasco, 2013).
To address these limitations, several techniques have been tried
to improve the informed consent process. Simplifying consent forms
alone has had mixed results in improving patient understanding
(Cordasco, 2013). Supplemental written materials providing informa-
tion about the procedure in more simplified language than the
consent form has had a more significant impact on patient recall
of information (Cordasco, 2013). Similarly, decision aids with more
detailed information about options and potential outcomes have
improved knowledge about procedures, reduced decisional conflict,
improved patient participation in the decision, and improved risk
assessment (O’Connor et al., 2009). Finally, use of “repeat-back”
methods in which the patient is asked to explain what he or she
has been told and the provider then clarifies the information provided
with subsequent repeat assessments of patient knowledge has been
found to be effective in improving comprehension but also adds
significant time to the patient-provider encounter, limiting its potential
feasibility (Fink et al., 2010).
KEY POINTS
• Although the scope of medical ethics continues to evolve,
the basic ethical principles of autonomy, beneficence,
nonmaleficence, and justice remain the foundation of
ethical medical practice.
• Informed consent is essential to the practice of surgery
with limited exceptions.
• Despite the goal of ensuring adequate understanding of
the nature, risks, benefits, and alternatives of surgery to
facilitate a meaningful decision, the informed consent
process is often incomplete. It is therefore the
responsibility of the surgeon to make every effort to
facilitate patient understanding and participation in the
decision-making process.
REFERENCES
The complete reference list is available online at ExpertConsult.com.

REFERENCES
Adams AM, Smith AF: Risk perception and communication, Anaesthesia
56:745–755, 2001.
Antoniou SA, Antoniou GA, Granderath FA, et al: Reflections of the hippocratic
oath in modern medicine, World J Surg 34(12):3075–3079, 2010.
Areen J: The legal status of consent obtained from families of adult patients
to withhold or withdraw treatment, JAMA 258:229–235, 1987.
Barnett vs. Bachrach. 34 A.2d 626, 1943.
Beauchamp TL, Childress JF: Principles of biomedical ethics, 1979, Oxford
University Press.
Canterbury vs Spence, 464 F 2d 772, 778, 1972.
Cassileth BR, Upkis RV, Sutton-Smith K, et al: Informed consent-why are its
goals imperfectly realized?, N Engl J Med 302(16):896–900, 1980.
Committee on Bioethics, American Academy of Pediatrics: Informed consent,
parental permission, and assent in pediatric practice, Pediatrics 95:314–317,
1995.
Cordasco KM: Obtaining informed consent from patients: brief update review.
In Making health care safer II: an updated critical analysis of the evidence for
patient safety practices, 2013, Agency for Healthcare Research and Quality
(US).
Faden RR, Beauchamp TR: A history and theory of informed consent, 1986,
Oxford University Press.
Fink AS, Prochazka AV, Henderson WG, et al: Enhancement of surgical
informed consent by addition of repeat back: a multicenter, randomized
controlled clinical trial, Ann Surg 252(1):27–36, 2010.
Gillon R: Medical ethics: four principles plus attention to scope, BMJ
309(6948):184–188, 1994.
Hartman KM, Liang BA: Exceptions to informed consent in emergency
medicine. Hosp Physician, 53-59, March 1999.
Hopper KD, TenHave TR, Tully DA, et al: The readability of currently used
surgical/procedure consent forms in the United States, Surgery 123(5):496–
503, 1998.
In re Quackenbush, 156 NJ Super 282, 383 A 2d 785, 1978.
Johnson BB, Slovic P: Presenting uncertainty in health risk assessment: initial
studies of its effects on risk perception and trust, Risk Anal 15:485–494,
1995.
Jones JW, McCullough LB, Richman BW: A comprehensive primer of surgical
consent, Surg Clin North Am 87:903–918, 2007.
Downloaded for Dulce Maria del Pilar Nazar Diaz Miron (dulcenazar@hotmail.com) at Cristobal Colon University from ClinicalKey.com by Elsevier on July 14, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
Chapter 7 Ethics and Informed Consent 118.e1
Jonsen AR: Social responsibilities of bioethics, J Urban Health 78(1):21–28,
2001.
Jonsen AR, Siegler M, Winslade WJ: Clinical ethics: a practical approach to
ethical decisions in clinical medicine, 4th ed, 1998, McGraw-Hill.
Katz J: Informed consent—a fairy tale? Law’s vision, University Pittsburg Law
Rev 137:1977.
Lloyd AJ: The extent of patients’ understanding of the risk of treatments,
Qual Health Care 10(Suppl 1):i14–i18, 2001.
Luka vs Lowrie, 136 NW 1106, 1912.
McCullough L, Jones JW, Brody BA: Informed consent: autonomous decision
making of the surgical patient. In McCullough LB, Jones JW, Brody BA,
editors: Surgical ethics, New York, 1986, Oxford University Press.
McNeally MF, Martin DK: An entrustment model of consent for surgical
treatment of life-threatening illness: perspective of patients requiring
esophagectomy, J Thorac Cardiovasc Surg 120:264–269, 2000.
Mohr vs Williams, 96 Minn 261, 104 NW 12, 1905.
O’Connor AM, Bennet CL, Stacey D, et al: Decision aids for people facing
health treatment or screening decisions, Cochrane Database Syst Rev
(3):CD001431, 2009.
Page K: The four principles: can they be measured and do they predict ethical
decision making?, BMC Med Ethics 13:10, 2012.
Potter VR: Bioethics, the science of survival, Perspect Biol Med 14(1):127–153,
1970.
Rogers vs Sells, 178 Okla 103, 1936.
Salgo vs Leland Stanford Jr University Board of Trustees, 317 P 2d 170, 173,
1957.
Schloendorff vs Society of New York Hospital, 211 NY 125, 105 NE 92, 93,
1914.
Schumann JH, Alfandre D: Clinical ethical decision making: the four topics
approach, Semin Med Pract 11:36–42, 2008.
Veatch RM: Patient, heal thyself: how new medicine puts the patient in charge,
2009, Oxford University Press.
Veatch RM: The patient-physician relation: the patient as partner, 1991, Indiana
University Press.
Weinstein ND: Optimism biases about personal risks, Science 246:1232–1233,
1989.
Ziegler DB, Prior MM: Preparation for surgery and adjustment to hospitaliza-
tion, Nurs Clin North Am 29(4):655–659, 1994.