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  • The Varieties of Consent
  • Rebecca Dresser (bio)
The Ethics of Consent: Theory and Practice. Edited by Franklin G. Miller and Alan Wertheimer. Oxford University Press, 2009. 432 pages. Hardcover. $39.99.

Do we really need another book on informed consent? Frank Miller and Alan Wertheimer, who edited The Ethics of Consent, have two good answers to this question. First, they write, “despite a considerable literature on consent in different contexts, there is surprisingly little systematic analysis of the concept of consent and the moral and legal work that it performs” (p. x). Second, they point out (correctly, I believe) that “bioethicists sometimes write as if the concept and principle of (informed) consent was first developed for their purposes and [as if] there was no need to reflect on the way in which consent operates in other contexts in order to provide an adequate account of consent in medicine and clinical research” (pp. x–xi).

Miller and Wertheimer set out to rectify this situation by commissioning authors with a range of expertise to write about consent theories and applications in a variety of contexts. The Ethics of Consent has chapters on the history of consent, political obligation and consent, and consent in sexual relations, criminal law, and contract law. It also has chapters on several medical ethics topics, such as consent in medicine, consent in biomedical research, and consent to organ donation. Chapter authors include professors of philosophy, law, political science, and medicine.

The Ethics of Consent has several potential audiences. Its fifteen chapters cover much ground and a diversity of topics. The volume could be useful to people working in philosophy, law, and political science, as well as in medicine and bioethics. I read the book as someone in the bioethics field, so I will review it from that perspective.

Many chapters in The Ethics of Consent are quite relevant to bioethics. For example, in “Autonomy and Consent,” Tom Beauchamp analyzes informed and voluntary consent in medicine and research. He notes that social rules determine which sorts of consent “count” in various settings, and that sometimes those rules fail to require the autonomous authorization that constitutes a morally valid choice. Although this can be defensible in certain situations, he believes that consent rules should conform as much as possible to a standard that truly protects the individual’s autonomy. At the same time, Beauchamp thinks that some philosophers define autonomous action in ways that are too demanding. He criticizes “split-level” theories that define autonomous persons as those capable of acting according to their higher-order preferences, as opposed to the lower-level desires that drive most ordinary conduct. “Requiring reflective identification and stable volitional patterns unduly narrows the scope of actions protected by a principle of respect for autonomy” (p. 65), Beauchamp contends. He points out that such an approach classifies many ordinary life activities as nonautonomous and thus unworthy of the respect we give to autonomous actions. Beauchamp proposes instead that an autonomous authorization exists when a competent individual intentionally agrees to something with adequate understanding while free of the internal and external pressures that “rob the person of self-directedness” (p. 69). He explains how each of these conditions may be satisfied and applies his account to specific bioethics problems, such as the therapeutic misconception and the exploitation of subjects in biomedical research.

In a jointly written chapter, Miller and Wertheimer offer an analysis that expands the conventional view that valid consent is the element that makes an action morally permissible. In their view, valid consent transactions must be “morally transformative” (p. 79). To meet this standard, consent transactions must incorporate more than a valid individual consent. The background conditions for a transaction determine whether the consent is morally transformative. Although the chapter examines consent in many different settings, Miller and Wertheimer specifically address consent to medical treatment and research participation. In the research context, they suggest, a fair consent transaction will include “affirmative steps to counteract therapeutic misconceptions,” such as discussion of the differences between research participation and clinical care and evaluation of whether prospective subjects understand “key features of the research” (pp. 102–3).

Steve Joffe and Bob Truog extend this “fair transaction” concept of...

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