Consent in different cultures

Consent is fascinating. It seems to different things to different people. Some patients want to make choices. Some want me to make the choice. Many never seems to have even considered it. Colleagues often find it threatening, a challenge to their self perceived clinical autonomy. Personally I find it a challenge to my personal knowledge and time, but when it is done well it seems to aid patient compliance with medication, testing etc.

But more interesting is taking a wider, universal look at informed consent and the issue of different cultural attitudes on informed consent as an individual's decision. A recent article reviewed on Global Family Doctor (http://www.globalfamilydoctor.com/search/GFDSearch.asp?itemNum=10115) found a distinctive North/South and East/West gradient (northern hemisphere that is) on whether prenatal testing (screening) was a matter of individual right.
If you have access to the full text of the article, the researchers felt that the burden of disease and attitudes towards disability are major drivers of the difference between cultures. Certainly the attitude towards disability varies from culture to culture and fits nicely with this research finding. One only has to look at the way different societies aid disabled persons to understand why this should be so..

But wait, there's more. What about the place of a pregnant woman in the society hierarchy? In many cultures women in such positions often subjugated their views to those of others, something that was hinted at in the study but not discussed.  Wider family, especially in matriarchial societies will take responsibility for such decision. In patriarchial societies obvious men will hold sway and in paternalistic societies it sometimes will be the medical profession. Which example is right and which is wrong?

Such matters really get to the philosophical basis of medicine. Who should make the decisions about such matters? The persons most affected by any such decision,  those who will suffer the most? Antenatal testing is a real problem in detremining this. A disabled person requires significantly more societal resources and parenting. But why then is the decision passed to others rather than a mathers in those socieities where disability support is less?

I suspect that whoever makes the decision will do so with the best interests of their position in their society in mind, be it nuclear family, matriachial, patriaichial or whatever. And if medicine makes the decision, especially a very hierarchially orientated medicine, then it will be to medicine's advantage. Just look at things like breast cancer screening. Think about whether such screening would actually have occurred if women were given proper information on the harms and benefits of screening. Jorgensen/Gotzsche's article in BMJ 2006;332;538-541 identifies the significant deficits of breast screening program “informed consent”. 

So what exactly is informed consent? (watch this spot)