Abstract The clinical practices around informed consent in healthcare settings have undergone a revolution for the better over recent decades. However the way doctor obtains informed consent still remains problematic. A number of factors have contributed to the continued dominance of the traditional dentist-patient imbalance of power, but, demands for more patient autonomy are increasing. The reasons for this ambiguity are varied. The complexity of communication in clinical encounter, the role of autonomy and the changing nature of the doctor-patient relationship, have also contributed to this uncertainty which still remains in many clinical settings. The uncertainty is partly due to the conceptual dullness of important core concepts.

1. TRUE PROFESSIONAL’S AND DOCTRINE OF
INFORMED CONSENT IN SHARED DECISION
MAKING
Author: Dr. Shoeb Ahmed Ilyas BDS, MPH, EMSRHS, M.Phil (HHSM),
MHRM, MHA, MS (PSY), MS(BIOTECH), FHTA.
Health Care Quality Management Consultant
Ruby Med Plus, Telangana State, India
Abstract
The clinical practices around informed consent in healthcare settings have undergone a
revolution for the better over recent decades. However the way doctor obtains informed
consent still remains problematic. A number of factors have contributed to the continued
dominance of the traditional dentist-patient imbalance of power, but, demands for more
patient autonomy are increasing. The reasons for this ambiguity are varied. The complexity
of communication in clinical encounter, the role of autonomy and the changing nature of the
doctor-patient relationship, have also contributed to this uncertainty which still remains in
many clinical settings. The uncertainty is partly due to the conceptual dullness of important
core concepts.
Introduction
Many health care practices face difficulties of implementing the doctrine of informed consent
and fail to protect patients’ rights and dignity. This happens because of doctor’s cynicism
about the existence of the right to informed consent, patients' reluctance to make decisions,
the existing busy health care centres, and the absence of clear guidelines about implementing
informed consent. Shared decision-making is increasingly advocated in health care but, is not
widely adopted in clinical practice may be due to professional resistance, lack of skills, lack
of time, and barriers. The traditional concept of the doctor-patient relationship places the
patient in a passive, compliant role. The patient's only obligation is to seek competent help
and cooperate with the doctor. A number of factors have contributed to the continued
dominance of the traditional doctor-patient imbalance of power, but, demands for more
patient autonomy are increasing.

2. Doctors ought to make all things considered value judgments about what is best for their
patients. If doctors are properly to respect patient autonomy and to function as moral agents,
they must make evaluations of what their patients should do. Still it is not clear that why
doctors avoid making value judgments about what patients should do or what it is best for
them to do. Sometimes these value judgments are difficult to spot, because rarely peer group
evaluates professional work of doctors working in private settings, hence, difficult to controls
the manner in which professional work is accomplished in clinical settings. The major issue
for evaluating the autonomy of doctors is not whether they control diplomacy, but whether
they control the goals that the patient seeks.
Doctrine of Informed Consent
The doctrine of informed consent, defined as respect for autonomy, is the tool used to govern
the relationship between doctors and patients. Its framework relies on rights and duties that
mark these relationships. The main purpose of informed consent is to promote human rights
and dignity and it is the requirement, which favours patient to participate in clinical decision
making. In health care, esteem for autonomy obligates doctors to involve their patients "to
disclose information, to probe for and insure understanding and voluntariness, and to foster
adequate decision makingi
. The argument for the development of informed consent is based
on the assumption that the professional doctor exercises control over the professional-client
decision making process, and that normal rules of contracting are not sufficient to protect the
patient's rights.
Informed consent places obligations on doctor to supply information to patients so that they
can form their own views and make decisions concerning the nature of their health care.
Informed consent also gives power to patients to implement their decisions, a power or right
to reject medical treatment.
Informed consent is inappropriate for all "true" professionals, because professionals say they,
adhere to a set of internalized norms that include commitment to a patient best interests and
quality services, as the treating doctor has the major role in empowering patients. By
questioning there professional motives, informed consent may decrease the likelihood of
these internalized norms developing because they will no longer be part of the professional's
self- definition. To be autonomous, one must be informed. For example, a doctor, in
attempting to convince his patient that he is wrong in choosing the proposed alternate

3. treatment may threaten patient autonomy. To consider the choice of patient for given
treatment, patient must be informed of the facts, but also consider its valueii
.
Autonomy
The principle of respect for autonomy is a prima facie principle. Autonomy has been the
essential value of medical ethics and is "the single most important value for informed
consentiii
.” Professional autonomy is defined as control over how work is performed and
evaluated. This autonomy is thought necessary because the services delivered by the
professional involve the application of specialized knowledge. The patients lack specialized
clinical knowledge and therefore they cannot evaluate the services nor determine how they
should be performed. The professional is required to communicate some of his or her
specialized knowledge with the patient to facilitate in the decision making process and in
determining how the professional work is to be performed.
Philosophers sometimes, pigeonhole the principle of respect for autonomy as a positive or
negative obligation. As a negative obligation, this principle states that "Autonomous action
should not be subjected to controlling constraints by others.” Positive obligations, the
principle of respect for autonomy requires “respectful treatment in disclosing information and
fostering autonomous decision makingiv
”.
The distinctiveness of an autonomous person includes capacities of self-determination such
as understanding, deciding, reasoning, and independent choice. A self-directed action
requires only "a substantial degree of understanding and freedom from constraint, not a full
understanding or a complete absence of influence. The principle of beneficence requires that
moral agents take positive steps to help others, not merely to avoid harming others as the
principle of non-malfeasance requiresv
.
To insure that patients' autonomy and free choice are a part of every doctor-patient
interaction, doctors and patients need actively to promote them as values that are absolutely
indispensable in doctors' offices, clinics, and hospitals. The right to self-determination refers
to “the right of individuals to make their own decisions without interference from othersvi
.”
The Nurnberg code states four characteristics of an informed consent that are required for the
consent to be adequate: it has to be informed, competent, voluntary and comprehending. An
informed consent will only be regarded as morally acceptable if it is genuinely voluntary.

4. One of the main threats to autonomy, which makes informed consent in health care a
necessity, is people's illness, or “wounded humanity,” as some call itvii
. Brody transparent
model proposes following aspects: First, doctors are to arrange only “the typical patient-
management thought process” and convey it to patients in a language they can understand.
Second, what is involved and when the process is sufficiently completed. Third, doctors
avoid hyper-informing the patients about the proposed medical treatment or about their
medical condition. Instead they offer a specific communication of the essential components
and pertinent issuesviii
.
Decision Making
In decision making, competence (defined as "the ability to perform a task") and autonomous
decision making, as well as the validity of informed consent, are closely connected. This is
important because incompetent individuals cannot give valid informed consentix
.Like in any
clinical treatment disclosure is a duty of doctors because their expertise and commitment are
to the welfare of the patient. Consequently, the courts reckon only expert testimony from
members of the profession as evidence that someone has violated a patient's right to
informationx
. The purpose of disclosure is to make convinced that patients understand the
relevant information regarding their medical conditions and thus give valid consent. Another
squabble is that some patients have very limited knowledge bases, which makes
communication about new or unfamiliar procedures extremely difficult, particularly if new
information includes new concepts or cognitive constructsxi
.
Disclosure and Manipulation:
Disclosure generally include the following elements: an explanation of the purpose of the
clinical treatment; a description of the treatment; a description of the risks and potential
benefits to patient from proposed treatment; a description of alternatives available to patient
should they choose not to take treatment; a description of confidentiality protections; and,
information on whom they may contact with questions. Manipulation refers to several types
of influence that include all intentional and successful influence of others by non-coercively
modifying the actual available alternatives or by non-persuasively changing other people's’
perceptions of those alternativesxii
. Mostly doctors and patients who often do not share the
same values jeopardised the therapeutic nature of the patient-doctor relationship. On the other
hand, promoting patient autonomy does not mean that doctor expertise should be ignored or
disregarded.

5. Conclusion
Informed consent standard must encourage open communication, shares input and
responsibility between doctor and patient.

6. References
i
Beauchamp, Principles 64.
ii
Beauchamp, Principles 284.
iii
Faden, History 18.
iv
Beauchamp, Principles 64.
v
Beauchamp, Principles 165.
vi
Jay Katz, The Silent World of Doctor and Patient (New York: Free Press, 1984) 105.
vii
Wear, Consent 42; Edmund D. Pellegrino, "Toward a Reconstruction of Medical Morality: The Primacy of
the act of Profession and the Fact of Illness," Journal of Medicine and Philosophy 4 (1979): 35.
viii
Brody, "Transparency" 5-9.
ix
Beauchamp, Principles 69.
x
“Necessity and Sufficiency of Expert Evidence and Extent of Physician’s Duty to Inform Patient of Risks of
Proposed Treatment.” American Law Reports 3d, 52 (1977): 1084. “Physician’s duty to Inform of risks.”
xi
Beauchamp, Principles 89.
xii
Faden, History 261