During the coronavirus disease 2019 (COVID-19) pandemic, various practices ranging from preoperative workups to urgent care consultations moved to virtual formats, including the preoperative informed consent practice. This shift was not accidental nor due to any unique improvement in communication technology. Rather, this shift was made out of necessity to limit the spread of the novel coronavirus in an unprecedented time. The pandemic is now largely considered resolved; however, the practice of using virtual means for an informed consent discussion continues despite the absence of the chief motivating force—public safety. With this context in mind, we worry that the continued and increasing practice of “virtual means” for informed consent threatens the moral ends of informed consent. This concern is driven by a preference for the model of informed consent as trust-building, rather than the widely accepted yet problematic “information transfer” model of informed consent. The former is a fuller conceptualization of the moral ends of the practice of obtaining informed consent, capturing what transpires as more than simply the fulfillment of a legal obligation. By exploring the unexamined consequences introduced by making this abstract shift, we suggest that virtual means of consent fail to accomplish its moral ends on both an interpersonal and systemic level. Subsequently, we offer an ethical structure for physicians to navigate this novel virtual space.

The process of informed consent has presented an ethical conundrum since its incorporation into mainstream medical practice. In practice, the existing paradigm presumes the purpose of informed consent to be transactional in nature, with the physician providing information and the patient demonstrating understanding and providing permission for the proposed procedure. Yet, despite fulfilling legal obligations, this process has been shown to be a poor method of information transfer; in other words, we continue to engage in a practice that we know consistently fails to accomplish its supposed purpose.1,2 For example, the literature estimates that patients are only able to correctly recall 50% of the critical information just provided to them after leaving physicians’ offices.2 As such, explanations have emerged to justify the practice of informed consent on an ethical level. Some have proposed an “event model,” justifying informed consent as a one-time procedure that must be done as part of the care process, or a “dialog model,” which views informed consent as an ongoing dialog that exists as part of the therapeutic process of diagnosis and treatment, while still others view informed consent as nothing more than a legal document.3

One recent model conceptualizes the process of informed consent as a “trust-building” practice that relies on authentic interpersonal interactions to thrive.4,5 In this light, the information and content of informed consent matter less than the “physical practice” of consenting, which typically entails taking time to check in on the patient, explaining the procedure in accessible terms, and allaying anxieties that the patient might be harboring. In other words, the real “moral weight” of informed consent shifts from content (as understood in the “information transfer” paradigm) to practice (as understood in the “trust-building” paradigm). Even a cursory glance at this alternative model reveals its strengths. It has been demonstrated that patients do not always comprehend the details of their proposed operation, and yet trust that their surgeon will take good care of them.4 To quote the surgeon-ethicist Peter Angelos, “Because surgical care requires patients to place such great trust in their surgeons, surgical informed consent must emphasize the importance of that trust.”5 If one accepts this latter paradigm, however, “how” one goes about obtaining informed consent takes on considerable ethical weight. Accepting this paradigm, then, demands that we turn a critical eye to how informed consent is obtained.

If we accept the “trust-building” conception of informed consent to be true to some degree, the recent proliferation of virtual means for informed consent brought on by the COVID-19 pandemic should be concerning when it comes to developing one-on-one trust between patients and physicians. Virtual formats present a double-layered threat. Interpersonally, the trust-building function of informed consent may be undermined by the lack of authentic interpersonal interactions inherent in virtual formats. Crucial details found in person-to-person interaction, such as body language, touch, vocal inflection, and presence, are lost.4,6 While it still may be possible to develop a therapeutic and flourishing relationship, the virtual format makes this much harder to accomplish. On a systemic level, virtual means for informed consent could create further unnecessary rifts between the patient and the physician. While, on the one hand, virtual formats may decrease the perceived barrier between the surgeon and marginalized patients through the flexibility of scheduling, the ability to have loved ones in attendance, and the ability to conduct a clinic visit in a comfortable space, there are other elements at play that may exacerbate injustices through virtual formats. Factors such as non-native English use, technological literacy, and access to reliable equipment are not necessarily givens for all patients and become magnified in importance through virtual formats.6,7 In addition, patients from rural settings, low-income status, or with psychiatric conditions may be further marginalized.6,8,9 Therefore, despite the use of virtual formats to increase accessibility to care, these formats also introduce barriers that may exacerbate existing mistrust in marginalized patient populations given historical injustices, and in turn, worsen existing health disparities.8,9 Similarly, while this has not been fully investigated, the logical space for socioeconomic variables to play an outsized role in the patient-physician relationship increases as well.

A review of the literature reveals that this is a novel issue. The use of technology to augment informed consent has been well studied, but the use of solely virtual means in the surgical consent process has little to no literature dedicated to it. This necessitates a reflection on its use and implications now that the fog of the war against COVID has lifted. We worry that the use of virtual means for this process fails to be morally satisfactory, even if it fulfills legalistic and pragmatic goals. The ethical reasoning behind this statement lies in the concept of what a “morally satisfactory” circumstance entails. Because the “good” of a given action is inextricably tied to the circumstances in which that action is taking place, these circumstances thus hold moral weight. With this in mind, if the moral end of informed consent is trust-building, then circumstances that allow for the most robust trust formation are morally preferable to circumstances that do not allow for the most robust trust formation. If we accept that “richness in communicating with body language and touch” allows for more robust trust formation than the absence of such communication, then such circumstances that allow for this richness in communication must be morally preferable to circumstances that do not allow for this kind of communication. In turn, in-person informed consent must then be morally preferable, in many circumstances, to virtual informed consent (this is not to say that this practice is objectionable in toto but rather that this practice is lacking and can be improved upon). Therefore, while this is far from a novel solution, the practice of informed consent in-person and face-to-face grows in importance, as this will best fulfill the moral obligations ushered in with this trust-building action and minimize potential unintended harms caused by virtual consent practices.

Our recommendation is not to reinvent the wheel, but instead, to reimagine it. In this technological era where informed consent can be done using virtual formats, an intentional focus on practicing informed consent interpersonally perhaps holds even more moral weight. As perception of physician empathy is directly related to trust in the physician,4 deliberately prioritizing in-person consent over a phone or video call to answer questions, provide reassurance, and perform a physical examination becomes a more significant space to practice this empathy. In this way, the intentionality of physical presence imbues the old wheel with new meaning—or perhaps a meaning that has always been there but is often opaque to us who practice it.

There is another unexamined aspect of “obtaining informed consent”; that is, its function as a “rite of passage.” A rite of passage, as first described by the anthropologist van Gennep,10 is a ritual that changes a person’s status within society (e.g., bar mitzvah, wedding). A person is not a surgical patient ready for the operating room unless that informed consent process has occurred and culminated in a signed document. We tend to understand this activity in legal terms, but consent also includes existential trust-building, as well as signifies to all members of the surgical team that cutting this person is now a morally licit act. If we grant that obtaining informed consent may resemble other rites of passage within society, then we recognize that aspects of the performance of the activity—such as the physical presence of the surgeon—may have meaning that should not be changed without due consideration.

Why advocate for in-person informed consent conversations? After all, requiring in-person informed consent can exacerbate the busy surgeon’s workflow. However, virtual consent is not simply a neutral action; virtual consent is a simulacrum. While there is not yet data quantifying the precise diminution of communication between being physically present and virtually apparent, it is evident that there is less than a 1:1 correlation. In a virtuous medical practice, there are numerous examples where an action performed may not be convenient (i.e., avoiding breaking bad news over the phone, responding to urgent patient concerns while on vacation, etc.), but are demanded of physicians to provide robust care. In-person virtual consent is no exception. If we accept that what we owe our patients may require us to go beyond what satisfies mere legal requirements, then taking these potential unintended consequences of virtual informed consent seriously requires us to consider that the convenience may not be worth it.

Second, one could argue that this conservative view stems from Luddite sensibilities. To be clear, we are not advocating for the rejection of the use of technology in the informed consent process outright nor discouraging adapting to new technology. There are many ways in which technology can help augment workflow, even the informed consent process, which is well documented. However, the specific practice of virtual informed consent was born out of necessity at the height of the COVID-19 pandemic, not as a result of innovation or improvement in the consent process over time. As such, reconsidering the wholesale use of virtual consent cannot be fairly characterized as a rejection of technological advances in medicine.

Practicing informed consent through virtual means may appear innocuous at first glance. However, if one accepts that trust-building is the intended purpose of informed consent rather than simply information transfer, then one must also attend to the specific actions that build this trust, and that virtual formats provide a diminished version of the interpersonal details that are critical to trust-building, and introduce practical considerations that may further alienate some patients. In this context and within this paradigm, in-person informed consent takes on a greater ethical role in the patient-physician relationship and should be practiced whenever possible.

1. Mulsow JJW, Feeley TM, Tierney S. Beyond consent—improving understanding in surgical patients. Am J Surg. 2012;203:112–120. 2. Beckman H. The medical interview: the three function approach: by Steven A. Cohen-Cole. St. Louis, MO, Mosby Year Book, 1991 ($19.95, paperback), 197 pp. Gen Hosp Psychiatry. 1993;15:60–61. 3. Lidz CW, Appelbaum PS, Meisel A. Two models of implementing informed consent. Arch Intern Med. 1988;148:1385–1389. 4. Hogikyan ND, Kana LA, Shuman AG, et al. Patient perceptions of trust formation in the surgeon-patient relationship: a thematic analysis. Patient Educ Couns. 2021;104:2338–2343. 5. Skowron KB, Angelos P. Surgical informed consent revisited: time to revise the routine? World J Surg. 2017;41:1–4. 6. Nemetz ETA, Urbach DR, Devon KM. The art of surgery: balancing compassionate with virtual care. J Med Internet Res. 2020;22:e22417. 7. Davis TC, Williams MV, Marin E, et al. Health literacy and cancer communication. CA Cancer J Clin. 2002;52:134–149. 8. Wesson DE, Lucey CR, Cooper LA. Building trust in health systems to eliminate health disparities. JAMA. 2019;322:111–112. 9. Arlia C, Saperstein AM, Meyler S, et al. Disparities in technology literacy and access negatively impact cognitive remediation scalability. Schizophr Res. 2022;243:456–457. 10. Van Gennep A. The Rites of Passage. Chicago, IL: University of Chicago Press. 2001.