Informed Consent Practices in Anesthesia Field Raise Ethical Concerns

By Stacey Kusterbeck

Surgeons often spend entire consultation appointments with patients, allowing ample time for discussion regarding risks, benefits, and alternatives. In contrast, anesthesia providers are under pressure to shorten turnover times and bring the next patient to the operating or procedure room.

“Our interactions with the patient are often limited to a short interview in a small holding area. The process of informed consent is often inadequate and rushed,” says Jennifer Greenwood, CRNA, PhD, an associate program director in the department of nurse anesthesia at Rosalind Franklin University of Medicine and Science.

Greenwood and colleagues analyzed 24 malpractice claims against anesthesia providers from 1990-2022 and found that informed consent often was inadequate.¹ Risks of the anesthetic not being fully disclosed or informed consent not being obtained before delivery of care (or both of these issues) were the most frequent omissions in the informed consent process.

“Failure to adequately inform a patient of the risks of anesthesia sets the provider up for a very difficult conversation — and possible litigation, if the patient goes on to have a negative outcome,” warns Greenwood. The researchers performed a subgroup analysis of the cases related to ethical principles. Autonomy was the most commonly violated ethical principle, followed by violations of nonmaleficence, beneficence, and justice.

In one case, a patient experienced ongoing back pain because of the use of lidocaine in the spine for a short procedure. The patient alleged that they should have been warned about the potential for long-term back pain and the possibility of transient neurologic syndrome. “Had they known this, the patient may have made a different decision about their anesthetic of choice. A more comprehensive informed consent process may have prevented litigation in the first place, and the patient would have perceived more control over their care,” says Greenwood.

Anesthesia providers first must determine that the patient is competent to consent, then they have a duty to disclose the nature and purpose of the proposed anesthesia technique; the risks, benefits, and side effects of the anesthesia technique; alternatives and their risks and benefits; and the risks of not receiving anesthesia care. “This is a lot to cover in a relatively short amount of time. But failing to provide these details potentially robs the patient of their autonomy in decision-making,” says Greenwood.

Ideally, at the time surgery is scheduled, patients are given printed information regarding the likely type of anesthesia they will receive. This gives patients some idea of what to expect regarding anesthesia before they arrive for the surgery. “That would allow the anesthesia consent process to be more of a conversation, rather than a rehearsed monologue from the anesthesia provider that may be confusing to the patient,” says Greenwood.

As a general surgery resident, Charlotte Harrington, MD, felt uneasy having patients sign surgical consent forms that also included anesthesia. Harrington felt ill-equipped to fully explain anesthesia-specific risks to the patient, despite knowing the anesthesia team would have their own conversation with the patient. “If consent for anesthesia is rushed or bundled into surgery, patients may not have the chance to meaningfully weigh their options,” explains Harrington, now a senior fellow at the University of Chicago’s MacLean Center for Clinical Medical Ethics.

Some hospitals use embedded consent forms, which cover both surgical and anesthesia consent — a potentially problematic practice from an ethical perspective.² “Patients are consenting to anesthesia before ever meeting their anesthesia provider. That can blur the line between surgical and anesthesia risks. But anesthesia is its own process, and there are often meaningful options for patients to consider,” says Harrington. Based on the guidance of the anesthesiologist, patients may need to decide among clinically appropriate options (such as spinal vs. general anesthesia, or whether to use a regional block for pain control). Patients also should understand the specific risks of anesthesia, such as nausea, sore throat, airway complications, or nerve injury. “The main principle at stake is respect for autonomy, but there’s also a transparency concern. Patients may not realize who is responsible for different aspects of their care. Those gaps don’t come from bad intentions, but from systems designed around efficiency rather than patient-centered communication,” says Harrington.

Another ethical concern is the timing of the anesthesia consent. Since anesthesiologists often first meet patients on the day of surgery, patients may feel the decision already has been made to consent to anesthesia. For patients who are at higher risk, earlier visits in an anesthesia clinic can provide an opportunity to ask questions and have a fuller discussion. For other patients, printed information about anesthesia could be helpful, says Harrington.

Inconsistency of anesthesia informed consent practices also raise some ethical concerns. A subcommittee of the American Society of Anesthesiologists Committee on Ethics surveyed 2,128 practicing anesthesiologists and found that informed consent practices varied by region, practice setting, and even within the same institution.³

“There definitely is room for improvement to standardize the procedure of informed consent,” says Garret Weber, MD, one of the study authors and an associate professor of anesthesiology at New York Medical College. Some key findings:

• Most anesthesiologists use a separate form specifically to obtain informed consent for anesthesia care. This was more common in the Northeast and Southern regions, and in non-academic practice settings.
• About 45% of anesthesia providers reported using both oral and written consent and 31% reported using written consent only.
• The timing of the informed consent process varied. One-third of providers stated that consent must be obtained on the day of anesthesia care and one-third stated that it could be obtained beforehand.
• Most providers thought it was important to have an individualized risk discussion instead of a generalized risk discussion.
• There were concerning knowledge gaps regarding state regulations among practitioners. Most (about 70%) were not certain if there were state regulations related to informed consent for anesthesia care. Just 17% of respondents stated that they were familiar with their state’s regulations for anesthesia-specific informed consent.
• Most providers saw the need for flexibility regarding who is able to obtain informed consent, and whether it can be delegated.

Ethics consultants can help institutions step back and examine whether their consent processes are aligned with core values, such as autonomy, transparency, and trust, says Harrington. Ethicists can use data from consults to highlight recurring themes, such as people being confused about anesthesia consent. That can prompt hospitals to review informed consent processes. “Ethics committees can also raise these issues in policy or quality improvement discussions, framing them less as criticism and more as aligning processes with values like autonomy and transparency,” offers Harrington.

Ethicists also can be useful in individual cases if patients or family complain they were not told about anesthesia risks or options or claim they signed a form without really understanding what it meant. “Those concerns can snowball into mistrust about the entire care plan. Having ethics involved can clarify responsibilities and ensure communication is patient-centered,” says Harrington.

Another group of researchers examined how frequently informed consent issues came up during ethics consults. “We wanted to understand the ethical challenges clinicians face during the informed consent process, especially in complex situations that escalate to hospital ethics consults — a topic less explored than consent forms or information delivery,” says Daniel Habib, the study’s lead author.

Habib and colleagues analyzed de-identified ethics consult notes and patient data from 2014-2024 at Vanderbilt University Medical Center.⁴

If the consult involved a consent-related issue, whether it was the primary reason or not, the researchers included it as a consent-related consult. Of 4,127 ethics consults, 137 were consent-related. In many cases, ethicists acted as mediators and guides. They helped clarify medical information, facilitated family meetings, and provided frameworks for decision-making. Sometimes, they offered practical recommendations, such as involving social work or legal counsel to appoint a guardian. Ethicists also supported the clinical team in documenting consent discussions, and protecting patient autonomy while enabling appropriate care. These were the most common reasons for informed consent ethics consults:

Concerns about decision-making capacity. One patient lacked decision-making capacity because of developmental delays but had turned 18 years of age without a court-appointed conservator in place. In another case, clinicians found a laceration that could be causing an infection, but the patient could not consent for the exam as the result of worsening mental status. “This raised the need for discussion of what the procedure entails, why it’s necessary, and how privacy and dignity will be protected,” says Habib.

Issues involving surrogate decision-making. Sometimes, the problem is that no surrogate can be reached, and the situation poses significant medical risk. “Clinicians, supported by the ethics team, could ethically justify proceeding under the emergency exception while carefully documenting the necessity and efforts made to respect the patient’s dignity,” says Habib.

One patient’s mother was identified as the surrogate decision-maker, but clinicians realized she did not understand the patient’s diagnosis or prognosis. In another case, the clinical team knew that family members were in touch with a patient but had no contact information for any of them. Some patients have no one available to consent to medical decisions on their behalf. “Ethicists can educate teams about the legal hierarchy for surrogate decision-making in that state, help identify previously unknown relatives or friends, or guide clinicians in initiating emergency guardianship processes,” says Habib.

Concerns about the timing of treatment. In one case, the clinical team contacted ethics out of concern that a patient who was unable to consent could lose her limb without emergent treatment. Ethicists can help in such urgent situations, where patients do not have capacity to consent because of temporary or permanent conditions affecting their decision-making abilities. “Ethicists help teams to balance the principles of autonomy and beneficence,” says Habib. Often, ethicists recommend proceeding with treatment based on the “emergency exception” rationale and engaging the patient or surrogate as soon as possible.

“Integrating these topics within continuing education may help ethicists guide surrogates effectively, adapt communication to patients’ needs and contexts, and balance urgency with respect for autonomy in time-pressured decisions,” says Habib.

Stacey Kusterbeck is an award-winning contributing author for Relias. She has more than 20 years of medical journalism experience and greatly enjoys keeping on top of constant changes in the healthcare field.

References

1. Larsen S, Cova M, Chambers P, et al. Deficiencies of informed consent among anesthesia providers: An integrative review. AANA J. 2025;93(4):251-258.

2. Harrington CL, Gerlach RM, Shakhsheer BA. Ethical considerations in anesthesia consent. Int Anesthesiol Clin. 2025;63(4):13-17.

3. Nelson N, Reno A, Gray S, et al. Informed consent practices in anesthesiology: A national survey of informed consent preferences and perceptions among practicing anesthesiologists. Int Anesthesiol Clin. 2025;63(4):18-25.

4. Habib DRS, Naranjo C, Langerman AJ. Informed consent challenges: A mixed-methods study of hospital ethics consultations. J Clin Ethics. 2025;36(3):215-223.