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I have a confession to make.

I don't believe in informed consent.

Or rather, I believe that informed consent is occasionally possible (and should always be the goal/intention), but also that achieving true informed consent is rare.

Even if I spend an HOUR talking to a patient about every possible common effect or complication of every drug and piece of equipment I use, maybe even if I get to the UNcommon things, I don't think I can adequately convey the amount of information that would enable anyone except another trained anesthesiologist to give me genuine, fully informed consent for an anesthetic. Fairly well informed consent I can get, probably, but not fully informed.

If an orthopedic surgeon spends a very long time explaining the ins and outs of, say, a radial head resection to me, I'll get a general idea, perhaps even a very good idea, of what I'm in for if I need the surgery, but I won't have his or her years of experience witnessing and doing the procedure and dealing with all the possible events it might generate. Even with medical school under my belt and some surgical experience, the intimate knowledge that comes from hard-earned expertise will never be mine.

That's why I don't want my orthopedist to just list statistics about possible complications for me. I want advice. I want medical guidance in light of the knowledge and education I lack. I want HELP making the decision that's the best fit for me and my problem.

For this reason, just as I believe a paternalistic approach to doctor-patient communication is wrong, I believe the "independent choice" model, in which patients are given information but not recommendations, is wrong: a disservice and a failure to provide the patient care we took an oath to provide when we all promised we'd try to be good doctors. I favor a more collaborative approach that allows me to put my expertise to the service of another and also preserves my patient's right to make decisions in as informed a way as possible.

I do not think of patients as customers. I think of patients as patients. Customers buy things they want for themselves. Patients seek help that they lack the knowledge, skill, and expertise to provide for themselves, and often that help comes in the form of experiences they really don't want but which might be necessary in order to recuperate or preserve their health and safety. That is, unless they are truly unwilling to experience those unwanted things and would literally rather die than undergo those experiences. If someone is competent to come to that decision, I am duty-bound to respect his or her wishes. But if patients are willing to let me offer the help I know how to offer, then sometimes I have to put patient safety ahead of patient comfort, though I always strive for both.

I studied basic principles of medical ethics in med school. There are four principles written about extensively by Beauchamp and Childress that have given medical practitioners a common language to use in discourse and practice, regardless of differences in cultural background, value systems, and religious or moral views. These principles or ethical goals are

• Patient autonomy
• Beneficence
• Nonmaleficence and
• Justice.

I never think much about the way I am confronted daily with small ethics issues, but lately I've been noticing that they're actually a pretty prominent part of my practice of medicine, especially the first principle: patient autonomy. My job actually entails taking away people's autonomy entirely, at least temporarily; once they are anesthetized, they have little control over the treatment decisions I make. But usually there's a chance to discuss the important points beforehand, and during those discussions I try to respect patient autonomy while also expressing my preferences and plans.

An example: a woman whose preop history I was recording asked me if she would be given the drug Versed (generic name: midazolam) without being told before her surgery. I told her that I personally never administer it without making sure a patient wants to receive it and knows of possible effects such as memory loss of events around the time of the drug's administration. Very rarely, patients report experiences with this drug that are so awful for them that there's even a website on which hundreds of vitriolic comments (including some exceedingly ignorant and bigoted ones) against anesthesiologists have been posted, one even comparing us all to people who commit date-rape. While I try to be as thorough as I can about explaining my anesthetic plan, I do think it's unrealistic, not always useful, and often downright impractical for us to give patients a full run-down on every single drug we administer as part of the anesthetic.

Another example: a morbidly obese pregnant woman needed to have a cesarean delivery for a fetus in breech position. She adamantly refused to have an IV inserted. My colleague informed her that he absolutely could not and would not provide anesthetic care without IV access and would have to have her sign a form stating she was refusing care and aware of the risks. She eventually agreed to an I.V. He also tried to explain the relative danger of a general anesthetic versus a spinal or epidural for the procedure, but she would have none of it - she wanted a general anesthetic, no regional anesthetic, but she wanted to be woken up as soon as the baby was pulled out of her body and she wanted her husband to cut the cord. He had to tell her that this plan just would not be possible. Sometimes full patient autonomy is not only impossible but also inadvisable.

Another: a mother at Children's once told me that under no circumstances did she want a breathing tube inserted in her child. I told her that we would have no choice but to cancel, or at least postpone, the surgery. An un-secured airway was just not an option for the procedure; proceeding without one would have constituted malpractice. She then relented a little and began to ask questions - why the tube was necessary, what it meant for her child, whether her child would experience discomfort from it. I answered all her questions as thoughtfully as I could, and in the end she gave us permission to take care of her child.

One more: a former nurse refused to give consent for a general anesthetic for a procedure we most commonly performed under general. She told me she would cancel and go home if she couldn't have a spinal. I told her I could safely provide a spinal anesthetic but was professionally and ethically obligated to inform her of the possible complications before we proceeded. When I started explaining these, she was irritated at first, saying, "The other anesthesiologist I talked to in the preop clinic didn't tell me any of this!" In the end, though, with some investment in a thorough conversation, she felt reassured, and happy that I respected her wishes despite the fact that it wasn't the usual m.o. at our institution for her surgery.

I'll listen intently to what's important to my patients, and I'll do everything in my power to provide the experience they want if I can do so safely. I won't force a patient to submit to something against his or her will. But I won't practice bad medicine against my will either. My patients' safety matters too much.