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Should Informed Consent Be Based on Rational Beliefs?

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Should Informed Consent Be Based on Rational Beliefs? J Med Ethics: first published as 10.1136/jme.23.5.282 on 1 October 1997. Downloaded from Journal ofMedical Ethics 1997; 23: 282-288 Should informed consent be based on rational beliefs? Julian Savulescu and Richard W Momeyer Green College, Oxford and Miami University, Oxford, Ohio, USA Abstract upon a competent patient unless that patient has Our aim is to expand the regulative ideal governing consented to have that procedure, after having been consent. We argue that consent should not only be provided with the relevant facts. informed but also based on rational beliefs. We argue We have no quarrel with these principles. We do, that holding true beliefs promotes autonomy. however, question their interpretation and applica- Information is important insofar as it helps a person to tion. Our contention is that being autonomous hold the relevant true beliefs. But in order to hold the requires that a person hold rational beliefs. We relevant true beliefs, competent people must also think distinguish between rational choice and rational rationally. Insofar as information is important, rational belief. Being autonomous may not require that one's deliberation is important. Just as physicians should aim choices and actions are rational. But it does require to provide relevant information regarding the medical that one's beliefs which ground those choices are procedures prior to patients consenting to have those rational. If this is right, what passes for respectingcopyright. procedures, they should also assist patients to think more autonomy sometimes consists of little more than rationally. We distinguish between rational providing information, and stops short of assessing choice/action and rational belief. While autonomous whether this information is rationally processed. choice need not necessarily be rational, it should be Some of what purports to be medical deference to based on rational belief. The implication for the doctrine a patient's values is not this at all: rather, it is of informed consent and the practice ofmedicine is that, acquiescence to irrationality. Some of what passes ifphysicians are to respect patient autonomy and help for respecting patient autonomy may turn out to behttp://jme.bmj.com/ patients to choose and act more rationally, not only less respect than abandonment. Abandonment of must they provide information, but they should care patients has never been regarded as a morally more about the theoretical rationality of their patients. admirable practice. They should not abandon their patients to irrationality. We will outline three ways in which patients hold They should help their patients to deliberate more irrational beliefs: (1) ignorance, (2) not caring effectively and to care more about thinking rationally. enough about rational deliberation, and (3) making We illustrate these arguments in the context of mistakes in deliberation. We argue that it is the on September 26, 2021 by guest. Protected JYehovah's Witnesses refusing life-saving blood responsibility of physicians not only to provide transfusions. Insofar as Jehovah's Witnesses should be relevant information (which addresses 1), but to informed of the consequences of their actions, they should improve the rationality of belief that grounds also deliberate rationally about these consequences. consent (2 and 3). I Introduction II Rationality and autonomy Medical ethics places great emphasis on physicians II.I TRUE BELIEF AND AUTONOMY respecting patient autonomy. It encourages toler- The word, "autonomy", comes from the Greek: ance even towards harmful choices patients make on autos (self) and nomos (rule or law).' Autonomy is the basis of their own values. This ethic has been self-government or self-determination. Being defended by consequentialists and deontologists. autonomous involves freely and actively making Respect for autonomy finds expression in the one's own evaluative choices about how one's life doctrine of informed consent. According to that should go. doctrine, no medical procedure may be performed It is a familiar idea that it is necessary to hold true beliefs if we are to get what we want. For example, John loves Northern Indian dishes and loathes Key words Southern Indian dishes. Yet he is very confused Informed consent; autonomy; rationality; doctor-patient about which dishes belong to which area. He con- relationship; religion; belief. sistently orders Southern Indian dishes thinking he is J Med Ethics: first published as 10.1136/jme.23.5.282 on 1 October 1997. Downloaded from J7ulian Savulescu and Richard WMomeyer 283 ordering Northern Indian dishes. His false beliefs Theoretical rationality is concerned with what it is cause him to fail to get what he wants. rational to believe. However, true beliefs are important for evaluative choice in a more fundamental way: we cannot form It is rational for a person to believe some proposition if an idea of what we want without knowing what the he/she ought to believe that proposition if he/she were options on offer are like. Consider a person with deliberating rationally about the evidence available and gangrene of the foot. She is offered an amputation. his/herpresent beliefs, and those beliefs are not themselves In evaluating "having an amputation" she is irrational. attempting to evaluate a complete state of affairs: how much pain she will experience, whether she will Let's say that a person is "deliberating rationally" if: be able to live by herself, visit her grandchildren, and so on. (Importantly, knowing the name of one's 1. She holds a degree of belief in a proposition disease and the nature of the operation are less which is responsive to the evidence supporting that important facts.) proposition. For example, the firmer the evidence, the greater the degree of belief ought to be. II.1I TRUE BELIEF AND PRACTICAL RATIONALITY 2. She examines her beliefs for consistency. If she Practical rationality is concerned with what we have detects inconsistency, she ought appropriately to reason to care about and do. Let's distinguish contract her set of beliefs or adjust her degree of between what there is good reason to do and what it belief in the relevantly inconsistent beliefs. is rational to do. Paul sits down after work to have a 3. She exposes her reasoning to the norms of induc- relaxing evening with his wife. She gives him a glass tive and deductive logic. Valid logic is important of what he believes is wine, but is in fact poison. because it helps us to have the broadest range of true There is a good reason for Paul not to drink it, even beliefs. if this is not known to Paul. However, if he believes that it is wine, it is rational for him to drink it.2 Thus: Consider the following example. Peter is trying to decide whether to have an operation. Suppose that copyright. It is rational for a person to perform some act if there he is provided with certain information and reasons would be a good reason to perform that act if the facts in the following way. were as he/she believes them to be. (1) There is a risk of dying from anaesthesia. (true) Thus holding true beliefs is important in two ways: (2) I will require an anaesthetic if I am to have this (1) it promotes our autonomy and (2) allows us to operation. (true) see what there is good reason to do. This does not Therefore, if I have this operation, I will probably http://jme.bmj.com/ collapse autonomous choice with rational choice. die. Even holding all the relevant true beliefs, a person may autonomously choose some course which he or The conclusion does not follow from the premises. she has no good reason to choose. For example, Peter comes to hold an irrational belief because he assume that the harms of smoking outweigh the commits a logical error. Irrational beliefs are less benefits. Jim has good reason to give up smoking. likely to be true than rational beliefs. Since knowl- like However, he may choose to smoke knowing all the edge of truth is elusive for subjective beings us, on September 26, 2021 by guest. Protected good and bad effects of smoking. His choice is then the best we can hope for is informed, rational belief. irrational but his beliefs may be rational and he may If we are right that information is important be autonomous. His choice is not an expression of to evaluative choice because of its contribution his autonomy if he believes that smoking is not only to a person holding the relevant true beliefs neces- pleasurable, but good for your health. sary for evaluation, then deliberating rationally is as important as being informed, since this also II.III COMING TO HOLD TRUE BELIEFS affects the likelihood that one's beliefs are true. One important way to hold true beliefs is via access Being fully autonomous requires not only that we to relevant information. For example, one way to get are informed, but that we exercise our theoretical Paul to believe that the wine is poisoned is to provide rationality. him with evidence that it is poisoned. We can never know for certain that our beliefs are true. We can only be confident of their III An example of irrational belief: truth. Confidence is the likelihood that a belief Jehovah's Witnesses and blood is true. Beliefs which are based on evidence Jehovah's Witnesses (JWs) who refuse life-saving (rational beliefs) are more likely to be true than blood transfusions for themselves are often taken to unfounded (irrational) beliefs. The likelihood that be paradigm cases of autonomous, informed choice our beliefs are true is a function both of how based on different (non-medically shared) values informed they are and of how we think about that that require respect and deference.
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