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Informed consent improves the experience for patients, families, and doctors while addressing the burdens of surgery
By: Amy Denney
A woman who was suffering from gallstones wanted to try a home remedy before considering surgery, but the surgeon “flat out told her that wasn’t going to work.”
The encounter happened many years ago as Dr. Jeff Hubbard, then a first-year medical student, observed a mentor whom he admired respond in a way that was a bit unnerving.
“He wasn’t pushy. He was just a little bit condescending,” Dr. Hubbard told The Epoch Times. “I really respect him, but just reflecting on the experience, I realize that—for lack of a better explanation—there’s indoctrination, a training that you go through as a physician that puts you in a mindset that you know everything.”
Gallbladders are among a handful of organs that doctors have been taught—and most people have come to agree—are “unessential,” meaning that we can live without them. There are about 300,000 cholecystectomies, or gallbladder removal surgeries, performed annually in the United States, at a cost of $3,167 to $5,881, based on Medicare estimates.
The example illustrates the complexities surrounding surgery—a rapidly growing medical field mingled with serious risks and complications. It’s hard to quantify how many patients avoid cholecystectomies or other surgeries by delaying them and attempting other remedies, but it’s an area that many agree deserves examination.
Critics say there’s too big a push for surgery in situations in which it isn’t warranted. But it’s unlikely that you’ll hear that—or the consequences of choosing surgery—from recommending physicians.
Despite warnings for years that the system of surgery is broken and wrought with questionable, rigid practices, little has changed. The problem invites a shared financial burden through taxes allocated to health care and insurance rates, whether we participate as patients or not. Unnecessary surgery is also a source of potential physical and emotional hardship for patients and their families. Many patients feel unprepared for surgery and can be left feeling confused, regretful, and worse off than before.
The Expense of Surgery
From a financial standpoint, surgery costs everyone. Tax-funded Medicare spent about half of its budget on surgical care in 2014, according to a 2020 Journal of Surgical Annals analysis. The actual costs exceeded $120 billion for that year.
The analysis pointed out that surgical care accounts for the greatest growth in Medicare payments, and that outpatient surgeries especially represent an area in which the government could recoup costs.
“Moving forward, future research should evaluate the extent to which spending on outpatient surgical care is driven by discretionary (versus non-discretionary) procedures. A better understanding of this will aid in the design of interventions to reduce surgery spending,” the authors wrote.
Michigan State University and Rutgers University collaborated on research to quantify how much money is wasted in hospital operating rooms. The findings, published in 2019 in the Journal of Operations Management, revealed that hospitals could save on average $1,800 per surgery—or nearly $28 million per hospital annually—by avoiding and reducing unplanned costs.
Some savings could potentially come by way of allowing only apt candidates to be considered. A 2022 JAMA investigation that followed nearly 1,000 community-living adults for a year after major surgeries reported a mortality rate of 13.4 percent. More than 1 in 4 community-living older U.S. adults who were frail and nearly 1 in 3 who had probable dementia died in the year after major surgery.
Such practices bring up the issue of informed consent and whether doctors are relaying information about true risks. Rarely does one die during surgery—a fact that appears to convey safety. Contextually, however, adverse events could take weeks or months to resolve—if at all—and 30-day postoperative mortality is a reality for as many as 4 percent of patients, according to a 2020 article in the Journal of International Surgery.
Major Cause of Death
In fact, the article makes the argument that the trauma surrounding major surgery should be counted alongside heart disease and cancer as a major cause of death.
“An annual global mortality of around 8 million patients places major surgery comparable with the leading causes of death from cardiovascular disease and stroke, cancer and injury,” author Geoffrey P. Dobson wrote.
The article highlights studies and statistics regarding surgical risk, including 30-day readmission rates in the United States that range from 5.7 percent to 12 percent. Mr. Dobson also cited research showing that 14.4 percent of patients experience adverse events—one-third of which were preventable—based on a 2013 study of more than 16,000 patients in eight developed countries.
“If surgical complications were classified as a pandemic, like HIV/AIDS or [COVID-19], developed countries would work together and devise an immediate action plan and allocate resources to address it,” he wrote. “Seeking to reduce preventable deaths and post-surgical complications would save billions of dollars in health care costs.”
Unraveling Informed Consent
If these facts about surgery are unfamiliar, it might be because the system doesn’t incentivize informed consent or the time required to explain the realities and complexities of surgery with every patient.
As a 2016 World Journal of Surgery editorial stated, “In practice, surgeons do not provide patients with all possible information and leave out perhaps critically relevant information.”
In a study of informed consent for high-risk surgery published in the Canadian Journal of Surgery, just 45 percent of discussions met all elements of adequate informed consent, and 23 percent didn’t meet even basic elements.
Informed consent is mutually beneficial for patients and surgeons, as the World Journal of Surgery editorial pointed out:
“By explicitly asking patients about their expectations for the procedure (for example, ‘to be rid of pain,’ or ‘to come home to my family’), we may better understand whether the patient’s expectations fall within the scope of possible post-operative outcomes. If we explicitly uncover such expectations, we may avoid a situation in which the patient expects the surgeon to achieve a perhaps unattainable goal, which may lead to patient dissatisfaction.”
Dr. Hubbard said surgeons who reject informed consent send a message that they don’t believe patients are intelligent enough to make decisions.
The physician-patient relationship can be very one-directional, Dr. Hubbard said.
“It’s one of the only relationships where … somebody who’s technically a stranger can tell you to do something, and you don’t question it,” he said. “You’re expected to just do it, and if you do ask a bunch of questions, they label you as noncompliant or a troublemaker because you want to make an informed decision.”
Caring for the Whole Person
Dr. Hubbard moved from conventional medicine into an integrative model after observing the shortfalls of modern medicine.
For example, when something unexpected happens during surgery, surgeons often have the option to pause the surgery and ask patients’ families what they should do, but this rarely happens.
Dr. Hubbard suspects that surgeons do what they want in more cases than not, especially if it interrupts their time.
Deeper, richer conversations beyond the operation are also valuable—something that Dr. Hubbard said was illuminated as he witnessed uncaring attitudes among health care workers.
In one situation, he was returning a black woman to her room and remarked to the surgical nurse that her hair was “jacked up”—unnecessarily and horribly shaved in surgical preparation. He was met with an arrogant response that she should be grateful to have her life and her hair is irrelevant.
