From Medical Guardianship to Informed Consent

Medicine is the field where paternalism was not a contested exception but the norm. The doctor was traditionally construed as the one who knows better than the patient what is good for them. The history of the twentieth century is the history of abandoning this model.

"The doctor knows best"

The model of medical paternalism rested on a natural inequality of knowledge: the doctor has competence, the patient has illness and trust. Decisions were made for the patient, often without explanation. The shift to informed consent became one of the central intellectual turning points of the century.

The right to determine what is done with one's own body

The legal source of the doctrine is Judge Benjamin Cardozo's ruling in Schloendorff v. Society of New York Hospital (1914): an operation performed without the patient's consent was qualified as a wrongful trespass (LSU Law). Bodily autonomy received its first clear legal formulation.

The Nuremberg Code

The Nuremberg Code (1947), formulated by American judges at the trial of Nazi doctors, was the first to codify the requirement of a research participant's voluntary consent as absolutely essential (USHMM). The term "informed consent" itself appeared in case law later — in Salgo (1957) — and the "reasonable patient" standard was established by Canterbury v. Spence (1972).

The Belmont Report

The Belmont Report (1979) reduced research ethics to three principles: respect for persons, beneficence, and justice (HHS). From "respect for persons" follows directly the patient's autonomy as an autonomous agent. That same year, Beauchamp and Childress placed respect for autonomy among the four basic principles of bioethics.

From guardianship to partnership

Angela Coulter's programmatic editorial "Paternalism or partnership?" (BMJ, 1999) recorded the shift: paternalism was called endemic to the health-care system and productive of an unhealthy dependence in the patient (PMC). "The doctor knows best," according to Coulter, should have no place in modern medicine.

Shared decision-making

The resulting model is shared decision-making, whose canonical definition was given by Charles, Gafni, and Whelan (1997) (PubMed). Medicine has traveled a road that other spheres have yet to take: from care that decides for a person to care that decides together with them. This is the best known answer to the dilemma of paternalism.