Informed consent in developing countries: dilemmas and deliberations.

clinical practice as well as biomedical research have often evoked fervent debates. The doctrine of informed consent is one such case in point. Its existence primarily serves to protect individuals from exploitation or harm from healthcare professionals. However, despite the development of various recommendations and guidelines, the execution of individual voluntary informed consent in developing countries remains controversial and nebulous.1 The traditional paternalistic model of medical practice propagates that the physician knows what is best for the patient. Although incongruous with the fundamental rights of the patient, this model resonates the patient's trust in his physician. However, we are now gradually inching towards a model based more on patient autonomy. This development should be hailed; though one must be wary of the negative facets of a strong patient-autonomy-based model, whereby the trusting relationship is likely to be eroded.2 For a developing country like Pakistan, the procurement of informed consent is impeded by many obstacles such as sub-optimal functioning healthcare systems, low literacy rate with masses having little clue about the existence or concepts of individual rights and the superior societal status of physicians3 deterring the patients from accosting the judgment of their "messiahs". In addition, physicians may not be aware of the importance or the procedural details of informed consent or may simply be dismissing it as a superfluous or futile exercise without any contemplation of the future repercussions or potential litigations. A Pakistani study revealed that while some participants felt that informed consent was an important step in recruiting research participants, others felt that it was a trust-based process not requiring proper documentation. For recruiting women, both men and women believed it was important to approach women through their husbands and fathers.4 Voluntary informed consent is certainly important to protect patients from malpractice and medical negligence. However, the Western-recipe of informed consent should not be applied blindly to the developing countries where the complexity of demographics, entrenchment of culture and traditional relationships may not readily assimilate this concept. It is important to incorporate bioethics education at all levels of medical education to improve awareness of this issue. Patients should be empowered in the process of decision making. Additionally, while physicians should encourage the involvement of families in decision making, this involvement must be carefully tailored so as not to morph into a domineering intrusion. Beneficence and patient autonomy must go hand in hand if an enduring and secure patient-doctor relationship is to be engineered.3