Editors' Column: Of Consent and Free Will

As it stands today, in our practice of radiology or interventional radiology, obtaining and documenting a patient's informed consent is not only a legal prerequisite but also a moral duty. This moral duty involves respecting the patient's autonomy, free will, and right to self-determination.

Free will, the basis of personal right to self-determination, is the ability to make independent choices without external coercion. Free will, and its implication, namely, a patient's right to choose a mode of treatment or a medical procedure, is a fundamental concept in bioethics and moral philosophy. Free will grants patients the right to decide what happens to their bodies.

In medical ethics, autonomy is enshrined in the principle of informed consent, ensuring that patients voluntarily decide on their treatment based on complete and accurate information. However, the validity of this consent becomes complicated when a patient is experiencing bodily agony or mental anxiety, raising critical concerns about whether true autonomy can be exercised under such conditions. Onora O'Neill's argument in Autonomy and Trust in Bioethics (2002) helps navigate these complexities, suggesting that consent is not merely about information disclosure but also about fostering an environment of trust that supports patient decision-making.[1] Despite efforts to respect patient autonomy and improve regulation, public trust in medicine appears to be weakening. Is our increased focus on respecting the patient's autonomy contributing to this decline?[1]

Autonomy, as a patient's right, is recognized both legally and ethically. It is deeply embedded in the modern art of medicine, ensuring that individuals are not subjected to treatments without their explicit agreement. Much has been debated and discussed in professional forums and meetings about the procedure of obtaining consent for procedures. We need to understand that the process of informed consent rests on the following three basic preconditions:

• The patient must have the capacity to understand and decide.

• The patient should have knowledge or information about the risks and alternatives.

• The patient must give their consent voluntarily, free from coercion.

This very framework dictates that patients are in a position to grasp, process, and act upon the critical scientific information rationally. As we insist that respect for autonomy dictates our duty to get informed consent, it follows that informed consent presupposes the patient's decision-making capacity. Therefore, the decision-making capacity is seen as the key element for informed consent in medicine.[2] In real-life scenarios, a patient is very often in severe pain, bodily distress, or mental turmoil. The fact that the whole process of consent is happening in a hospital room does not help the patient to calm his or her mind either. Therefore, the patient's capacity for rational decision-making is possibly compromised. If this line of argument is accepted, the next logical question is: Does a sick person or a person in pain truly possess the ability to exercise free will ? If there is constrained free will, is rationality from the neutral viewpoint compromised? One needs to question whether legally we should consider bodily suffering or mental agony to be a constraint for exercising free will.

A patient's ability to make choices and decisions can fluctuate with symptom changes, as well as over time and across different situations.[3] It may be stated that a person may be deemed to have the ability to make decisions for matters of everyday life (e.g., what to eat) but may not be sufficiently capable of making decisions regarding medical treatment referred to as decisional relativity by Buchanan and Brock.[4]

O'Neill critiques the dominant model of autonomy that assumes that an individual always makes rational and independent choices. Trust is an important component of the doctor–patient relationship. In a hospital setting, patient autonomy does not exist in isolation but is interwoven with trust and external support. Patients rely on doctors not only for medical expertise but also for guidance in choosing treatment options.

This challenge is particularly pronounced in the Indian health care system, where cultural factors often shape medical consent. In many cases, families play a central role in decision-making, sometimes overriding the patient's preferences. This is truer in India than perhaps the western world. While collective decision-making may provide emotional support, it can also diminish personal autonomy if the patient is pressured into a choice they would not have made independently. Paternalistic attitude in collective decision-making may not support the autonomy of the patient. Additionally, disparities in education and health care literacy can result in patients agreeing to procedures they do not fully understand, further weakening the notion of true informed consent. We also need to include the typical scenario of language barrier in an Indian context. It is not unfair to cite the case of large numbers of northeastern Indian origin patients seeking advanced therapeutic options in larger Indian cities. It is quite demanding for the doctors or staff in these hospitals or centers of excellence to explain procedures, risks, and alternatives in an appropriate manner to patients whose native language is neither Hindi nor English.

Trust placed in health care providers imposes a moral obligation to act in the patient's best interest. Breaches of this trust, such as performing procedures without valid consent or withholding pertinent information, can lead to legal repercussions and erosion of public confidence in the medical profession. Therefore, maintaining transparency, respecting patient autonomy, and upholding ethical standards are essential to preserving the sanctity of the doctor–patient relationship.

It is a common concern in diagnostic or interventional radiology to decide on the degree of disclosure of the risks of a procedure. While patients must be informed of potential complications, the way in which this information is communicated significantly impacts their decision. A patient in pain may be more susceptible to suggestion, agreeing to whatever course of action the doctor recommends out of desperation. Conversely, a patient suffering from anxiety may become paralyzed by fear, refusing necessary treatment even when it is in their best interest. In such cases, the ethical responsibility of the physician extends beyond merely informing the patient. It needs to be ensured that the patient is in a state in which decisions can be made with as much autonomy as possible.

It is appropriate that radiologists develop a nuanced understanding of the issues of consent and debate and discuss a simpler effective way to design documentation of such processes that will withstand legal scrutiny. We take this opportunity to extend an invitation to all members of the fraternity to engage in debates and discourses on ethical medical practices, issues of consent, and to suggest best practice guidelines to improve the standard of care in this region.

In conclusion, remember that informed consent is always valid as long as information is provided. True consent requires trust, an enabling environment, and careful consideration of the patient's condition at the time of decision-making. Ethical medical practice must move beyond rigid consent forms to a model that ensures decisions are made with genuine free will, even in the face of suffering.

Conflict of Interest

None declared.

• References

• 1 O'Neill O. Autonomy and Trust in Bioethics. Cambridge: Cambridge University Press; 2002
• 2 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 (01) 3-P11
• 3 Appelbaum PS, Grisso T, Frank E, O'Donnell S, Kupfer DJ. Competence of depressed patients for consent to research. Am J Psychiatry 1999; 156 (09) 1380-1384
• 4 Buchanan AE, Brock DW. Deciding for Others: The Ethics of Surrogate Decision Making. Cambridge: Cambridge University Press; 1989

Publication History

Article published online:
29 April 2025