Medical recommendations and informed consent

It is widely accepted that medical treatments require informed consent from the patient. This requires medical professionals to educate patients, to a reasonable degree, on the relevant scientific aspects of the treatment.

Interestingly, I have been told by a medical ethicist that it is not widely accepted that medical recommendations, whether from one’s individual physician or from a government body, are governed by similar informed consent standards. Thus, before giving you an injection, the physician is required to give you both the medical pros and cons of the injection, but if the physician recommends exercise to you, there is no such education requirement (e.g., the physician is not required to tell a clueless patient that exercise can result in joint pain).

This view seems wrong to me. The main reason for requiring informed consent is patient autonomy. But autonomy can be compromised just as much by recommendations omitting salient information as by actual treatment. Let’s say that Jeeves is annoyed by Wooster’s ugly mustache, and recommends to a Wooster the deliciousness of a particular brand of chocolate, having heard from the factory owner's valet that this brand has been contaminated with a chemical that makes one’s facial hair fall out. Jeeves has violated Wooster’s bodily autonomy through the recommendation almost as much as if Jeeves had shaved Wooster in the night.

Forcing and threatening

Suppose the state thought it had good reason to force me to undergo a medical procedure that I believed to be immoral. The state would have two kinds of options:

1. Threaten me with a variety of serious threats such as deprivation of employment and educational opportunities, fines or imprisonment if I refused to cooperate with the procedure.

2. Force me to undergo the procedure by physically holding me down and performing the procedure.

Intuitively, the threat option seems like the “nicer” option, at least if the threats fall short of imprisonment. And the force option clearly violates standard principles of consent in medical ethics.

But what has struck me was this interesting fact: depending on the details of the case, I might well prefer being forced to being threatened. For if I am threatened, there are two possibilities: either I resist the threat or I give in. If I resist, then I have to suffer the serious losses that were threatened. And if I give in, then I have to live with the knowledge that I have violated my conscience. But if I am forced, then my conscience is clear, I do not suffer any of the threatened losses, and if the procedure is one that is in fact medically beneficial, I get the benefits of the procedure. (And note that it is quite possible to believe a procedure to be immoral while knowing that it is medically beneficial. For instance, one might reasonably think that it is immoral to accept an organ transplant from a prisoner who was compelled by an evil state to yield the organ, even though one knows that the transplant would be beneficial.)

Of course, if asked, I couldn’t very well say: “Please force me.” For that would be consent to a procedure I believed to be immoral. But nonetheless I might prefer the force option. In such a case, it’s hard to say that the threat option is “nicer”. Indeed, it might impose much greater hardship than the force option.

So from the point of view of a state that thinks the procedure is intrinsically permissible and necessary for the public good, it seems that there is good reason to prefer the force option, in that it might impose much less hardship. But this seems paradoxical. It seems obvious that the threat option is better, especially for non-punitive threats that are “naturally” tied to the refusal (“We won’t employ anyone who medically could be vaccinated but refuses to be”), even though the force option seems the better one for both the person being forced and for the rest of society (since it’s more effective).

Perhaps the way out of the paradox is that it is so important for us as a society to maintain the requirement of consent for medical procedures that forcing people to undergo a medical procedure should be avoided except in the most extreme of cases (such as when the very existence of society is at stake), and hence even though the short-term consequences of forcing are better than those of threatening—including morally better for the person being forced who isn’t tempted to violate conscience—forcing should be avoided. But this isn’t a complete solution. For normally we think threats also vitiate consent. But perhaps they vitiate it less?