A structurational analysis of the doctrine of informed consent to treatment: Societal evolution, contradiction, and appropriations in medical practice
The doctrine of informed consent to treatment (IC) mandates physician disclosures (e.g., risks, alternatives) and patient choice and consent. IC is designed to protect patients' bodily integrity and autonomy and facilitates coping and negotiations. Past research into IC relied on surveys or coding schemes to investigate the surgeon's or general practitioner's levels of disclosure. These efforts lacked theoretical framing and relied on methods that inhibit the emergence of factors shaping how IC is practiced. Further, they ignored the trend toward specialization and operated independently of the literature on IC law. This study uses Structuration theory (ST) to examine IC and bridge the literatures on IC law and practice. ST is used to demonstrate that IC's societal laws are articulated by changing and contradictory systems of meaning. These meaning systems---traditionalism, liability, and decision making---differ, respectively, on whether physicians, states and administrative entities, or patients control the decision making and disclosure process. Questions are posed on the role physicians occupy---through their everyday practice and experience---in reproducing and transforming the doctrine's contradictory societal meanings. Further, an additional question is posed on physician's IC learning. ^ These questions are pursued in the Radiology program of a medical school. Preceded by a course practicum and observations at the school, three semi-structured focus group interviews are conducted with 15 Radiology residents. Supplemental data include a formal interview with a program leader and local and national documents. Verbatim transcripts of the interviews are analyzed with the line-by-line constant comparative method of Grounded Theory. Residents' reports indicate their discourse appropriations are contingent upon several health system (e.g., roles, policies) and micro (e.g., knowledge, style) factors. Additional findings indicate: they chronically reproduce and challenge the discourse of liability, their system (rules, culture, identity) constrains the discourse of decision making but enables the discourses of traditionalism and liability, and although they seek change towards a system and practices that are primarily constituted by the discourse of decision making, they resist some of its tenets for themselves but expect it of other providers. Additionally, they learn IC through informal interactions with the work group, on their own, and in formal settings. ^
Steven R. Wilson, Purdue University.