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@NEJM Ask the Author & Experts: Too Much Information — Choosing Unshared Decision Making

Perspective

The Paternalism Preference — Choosing Unshared Decision Making

The day after 19-year-old Jerry Canterbury underwent surgical laminectomy, he fell out of bed and became paralyzed from the waist down. His neurosurgeon, William Spence, reoperated to relieve pressure on the spinal cord, restoring most motor function. But Canterbury had enduring bowel and bladder dysfunction, necessitating a penile clamp. It was 1959, and though “informed consent” had been mandated for decades, its meaning remained nebulous. Canterbury later sued, claiming Spence hadn’t adequately informed him of the risk of paralysis.

Spence argued that he’d followed the community standard for disclosure, and the district court agreed. Nevertheless, the court deciding Canterbury’s appeal ruled that “True consent . . . is the informed exercise of a choice, and that entails an opportunity to evaluate knowledgeably the options available and the risks attendant upon each” (Canterbury v. Spence, 464 F.2d 772, 1972).

That opinion established two principles applied to medical decisions today: consent is not merely the granting of permission but an exercise in choosing, and choice requires disclosure of a certain amount of information. How much information is adequate? Rather tautologically, as much as necessary to decide: “The scope of the physician’s communications to the patient must be measured by the patient’s need, and that need is whatever information is material to the decision.”