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The Linacre QuarterlyVolume 48 | Number 4 Article 1311-1-1981[Book Review of ] Informed Consent in MedicalTherapy and Research, by Bernard BarberCarson StrongFollow this and additional works at: http://epublications.marquette.edu/lnqPart of the Ethics and Political Philosophy Commons, and the Medicine and Health SciencesCommonsRecommended CitationStrong, Carson (1981) "[Book Review of] Informed Consent in Medical Therapy and Research, by Bernard Barber," The LinacreQuarterly: Vol. 48: No. 4, Article 13.Available at: http://epublications.marquette.edu/lnq/vol48/iss4/13Book Reviews Informed Consent in Medical Therapy and Research Bernard Barber Rutgers University Press, New Brunswick, N. J., 1980. 214 pp., $14.50 (hardcover). This recent treatise in the sociology of medicine combines social science data and a normative message. Of interest is the way that a sociologist sets up the prob-lem of informed consent. Barber views the issue of informed consent as a soc ial problem - that is, as a social condition which a sizable group recognizes as bad, unnecessary, and remediable. Social problems typically involve value conflicts and associated power conflicts between two or more groups. The specific social prob-lem in question is the use of research subjects without their voluntary and informed consent. Barber identifies the conflicting values as those which physi-cians place on their own autonomy and authority and the value which the public attaches to equality in the physician-patient relationship. Barber has in mind moral equality, which he says is the same as the value we place on human dignity. "When we speak of the moral claims of human dignity , we say that each indi-vidual in and of himself deserves to be treated in a certain way , with respect and protectiveness ... The task which Barber sets for himself is to provide a "social systems analysis" of informed consent. According to Barber, in order to understand the nature of this social problem we have to examine the entire social system in which doctors and patients interact. The system of health care delivery produces roles, attitudes, and expectations which affect the values and behavior of physicians and patients. Barber's systems analysis consists of examining the literature on each of the fol-lowing factors which influence the relations among the various participants in the medical research system: relevant moral values and norms, legal principles and rules concerning informed consent, the communication structures and patterns of understanding and misunderstanding, the authority relations, and the mechanisms of informal and formal social control. Informal control refers to interactions which influence one's moral attitudes and which occur in everyday working rela-tionships among physicians or between physicians and patients. Formal control refers to official structures which influence ethical behavior, such as state licensing boards or IRB's. . After examining the above factors , Barber reaches the normative conclusion that physicians are too au thoritarian and do not adequately inform their patients. In the process he argues that there is little informal control with respect to ethics in medical education and among practicing physicians. He also argues that there are serious defects in present mechanisms of formal control. With respect to hos-pita l review committees, for example, he cites a study which claims that most moral lapses by physicians which are reviewed are swept under the carpet. He con-cludes that formal controls need to be improved, "though probably the primary improvement must occur in the informal mechanisms." All in all, there is relatively li ttle in this book which has not been said before. Barber's original contribution is to attempt to marshal all the social science data November, 1981 375 which bears on his thesis that doct~rs a~e too authoritarian. What he accom-plishes, in a backhanded way, is the demonstration that there is not really much hard data to support his thesis. The reader who is hoping for new data will be dis-appointed. In addition, Barber's claim that informal controls are not present in a significant way in medical education has been contradicted by some recent work by Charles L. Bosk , a sociologist who spent 18 months as an observer of surgeons and residents in a clinical setting. Perhaps the major shortcoming of the book is the lack of adequate ethical analysis. To carry Barber's insistence on a systems approach one step further, the ethical assumptions which are part of one's sytems analysis must be carefully examined. To expand on this point, let us consider several instances in which questionable assumptions are made without argument. One occurs, for example, in Barber 's argument that patien ts are not adequately informed. Barber overlooks the fact that informed consent situations often involve a conflict between the principle of beneficence, which may support nondisclosure, and the principle of patient autonomy, which favors disclosure. Before concluding that disclosures are inadequate , one must address the prior question of when the withholding of information is morally justified on grounds of beneficence. Although Barber does not consider this issue of justifiable paternalism, he tries to support his thesis by citing various studies in which information was withheld. The inadequacy of this approach can be illustrated by one of the studies he cites. Harmon Smith observed the consent interviews of 23 patients for cardiac catheterization following myocardial infarction, and found that in 10 of the consent situations no mention was made of the risks of the procedure. Although Barber cites this data in support of his thesis, a strong case can be made, as Smith himself argues, that the with-holding of information is morally justified in such cases on beneficent grounds because of the extreme anxiety typical of post-M.L patients. Since none of the data Barber cites is analyzed by him in light of the general issue of paternalism , it is unclear to what extent the data actually supports his conclusions. Inadequate ethical analysis also occurs in Barber 's examination of authority relations, in which models of doctor-patient interaction are discussed. The two models which are presented are the collegiality model, which represents an ideal of high patient autonomy, and the dominance model , in which the patient is passive and the physician is authoritarian. The question is raised as to which model is more in accord with the empirical realities, and Barber's conclusion is that the evidence, though sparse, leans more toward the dominance model. How-ever, one suspects there are other models between these extremes. For example, a physician could recommend a course of treatment and at the same time mention alternatives, allowing the patient to accept or reject his recommendation. One suspects that Barber has biased his conclusions at the outset by failing to consider and develop other models which are plausible alternatives to the dominance modeL In addition, a subtle bias may be introduced by Barber's account of the moral values which are in conflict. Rather than a conflict between physician authority and the human dignity of patients , the issue appears to be more thoroughly and precisely characterized as a conflict of physician authority and beneficence against patient autonomy. The idea that there may be limits to the dignity owed to patients by their physicians appears less palatable than the idea that there are limits to a patient's right to autonomy . The latter way of setting up the conflict seems, therefore, more open to the possibility that there are c ircumstances in which information can justifiably be withheld from patients. Barber's disregard of the issue of paternalism is thus reflected in the way he sets up the conflict. The above comments should no t be taken as an indication that I am unsympa-thetic to Barber's conclusions. In fact , my impression from teaching at a m edical school is that patients tend to be inadequately informed. The point is , rather, that 376 Linacre Quarterly this book does not provide solid confirmation of such anecdotal impressions, due to lack of the necessary ethical analysis. I do not wish to be entirely negative, however. The book contains a valuable and seemingly thorough review of the social science literature on informed con-sent. The data contained in numerous articles is summarized with unfailing clarity. The bibliography provides a helpful tool to those who wish to explore this litera-ture further. The book is highly readable and is well-organized. In short, it provides a good point of entry into the literature on informed consent. - Carson Strong University of Tennessee Center for the Health Sciences Sex and the nlusion 0/ Freedom Dr. Donald DeMarco Mission Press, 53 Dundas Street East, Toronto, Ontario, Canada, 118 pp. One of the unfortunate misconceptions growing out of the recent "sexual revolution" is the notion that chastity is an unattainable ideal not to be taken seriously as an "alternate lifestyle." Chastity has become identified as the opposite polar extreme to promiscuity, symptomatic of a similar neurotic aberra-tion of sexual adjustment. Very few voices have been raised on behalf of chastity as the virtue resulting from the application of reason to the sexual appetite. Young people at the high school level have few resources at their disposal to reinforce their basic propensity toward continence. Even religious spokesmen, functioning as opinion-makers, seem to be influenced more in their public state-ments by Planned Parenthood and the social hygiene movement than by their own solemn vow of chastity. Dr. DeMarco, an influential and prolific writer, has made an important effort to fill the current void with this small and highly readable book with a style that is alternately whimsical and professional. He brings a phil-osopher's insights into the cliches and conventional wisdom of the social engineers. The book consists of 30 brief essays, half devoted to sex and the other half to the illusion of freedom. With brevity and a willingness to restrict each chapter to a single nugget of argumentation, DeMarco has developed an effective critique of present attempts to reduce sex to a limited, appetitive function rather than an integrative aspect of the whole person. With a sense of the tyranny of language, he points out how words have been used by the propagandizers of the contraceptive society to politicize value-free sexual activity. The importance of this kind of expose can best be appreciated when we recognize that the whole abortion movement really arose from a need to address the reproductive consequences of societally-sanctioned adolescent sexual activity. The book can be commended equally to parents and college-age offspring. Proceeds from the sale of the book are being donated to the support of Birthright of Toronto. - Eugene F. Diamond, M.D. Loyola University Stritch School of Medicine November, 1981 377 

[Book Review of] \u3cem\u3eInformed Consent in Medical Therapy and Research\u3c/em\u3e, by Bernard Barber

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[Book Review of] \u3cem\u3eInformed Consent in Medical Therapy and Research\u3c/em\u3e, by Bernard Barber

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