Re. Consent to external-beam radiotherapy.

procedures, but between procedures in which more, and procedures in which less, is at stake. In this regard, external-beam radiotherapy does not differ relevantly from technically more invasive procedures such as brachytherapy. The authors reject the argument that implicit consent has been obtained simply because a “patient attends for consultation and follows through on all of the multiple steps that lead up to the treatment itself.” Here, it might be helpful to distinguish between consent and informed consent. Arguably, by following through on the steps that lead up to the treatment, patients are giving implicit consent in some minimal sense. However, it does not follow that that consent is adequately informed, which is crucial. It is therefore clear that a heightened standard of informed consent is required for external-beam radiotherapy. The question, then, is whether written consent forms, tailored to the type and site of the tumour, constitute an improvement over the practice of documenting a discussion with the patient. Dr. Freeman and colleagues are correct that a consent form signed by a patient can be empowering to that patient in a way that a chart note, often not seen by the patient, cannot. It is also the case that written forms can avoid the problem of doctors forgetting to mention relevant information. In this way, consent forms can function like a version of a surgical checklist. However, a serious danger inherent in written consent forms must be avoided if the benefits are not to be outweighed by the costs—specifically, the tendency for written consent forms to become a substitute for obtaining informed consent. Instead of actually informing the patient, the doctor invites the patient to read and sign a form. Patients often do both perfunctorily. Thus, it is crucial that written consent be an aid to, rather than a substitute for, truly informed consent.