Informed Consent in the OR: The Ethics of Patient Disclosure Regarding Medical Student Involvement in Surgical Procedures
Rabya Hasnain, BS, MBE
Acknowledgement: Dr. Shahla Siddiqui, HMS MBE Capstone Mentor
Published July 3, 2025 | Clinics in Medical Education
Issue 7 | Volume 1 | June 2025
The Current Preoperative Informed Consent Process
The informed consent process is one of the most crucial components of conducting surgical procedures, as it carries implications for the patient-doctor relationship and risks undermining ethical tenets of patient-centered care, such as developing mutual trust and encouraging voluntary decision-making. Surgical providers must relay the risks and benefits of an operation, its overall nature, possible alternatives to the operation, risks and benefits of the alternatives, and assess the patient’s understanding of each component.(1) Federal legislation provides more guidance on what information to deliver to patients preoperatively, such as generating and sharing a “roster of practitioners specifying the surgical privileges of each practitioner.”(2) However, in practice, the specific actions that medical students will take remain at the discretion of the surgical staff and are difficult to precisely disclose. This produces several ethical concerns, as surgeons must estimate the extent of information to deliver regarding medical students’ participation. This ongoing issue warrants a rigorous moral analysis using relevant ethical paradigms and applicable solutions that maintain medical education standards and high-quality care provision.
Stakeholder Perspectives
Many patients have expressed their approval of students’ intraoperative participation, as they acknowledge the potential academic benefits to the students’ future careers.(3,4) Patients also vocalized their right to give consent to surgeries, especially when medical students are present and wish to participate intraoperatively. In one study, only 42% of patients were actually asked to consent to students participating in their surgery.(5) The informed consent process when a medical student aims to participate demands moral attention in order to address the current gap in transparency and increase patient awareness and understanding.
A core experience of many students at accrediting medical schools across the U.S. is the ability to have a hands-on role in their third or fourth-year surgery rotations. Most medical schools and partnering teaching hospitals adopt a general surgery clerkship curriculum that supports students to acquire competencies, such as mastering surgical techniques, understanding principles of perioperative care, and acknowledging the roles of each provider, that are necessary for being a skilled clinician.(6) Despite the desired educational outcome for students in their general surgery rotation, most third and fourth-year students engage in their surgery clerkships for an average of 4-8 weeks and are left with novice skills to conduct the elements of pre, intra, and postoperative care.(7) Studies have illustrated that medical students largely feel unprepared to lead informed consent discussions, with 75% reporting that they have received little to no formal training.(8) While patients expect medical students to be more involved with the informed consent process, current curricula leave little space for students to observe and practice facilitating informed consent discussions and building patient trust preoperatively.
Surgeons express their desire to share information on medical students’ intraoperative participation to patients, but they routinely claim that time constraints make it challenging for them to achieve this goal.(9) Surgeons are also conflicted with their attempts to avoid overwhelming patients with too much detail while making sure that patients are fully aware of what students might be assisting with. Some surgeons even worry that patients might be less willing to agree to student participation if they knew that a medical student would be intubating them; students’ academic opportunities would be limited as a result.(10) Practical barriers and moral conflicts appear to greatly impede surgeons’ abilities to uphold complete disclosure of students’ intraoperative participation to patients.
Relevant Ethical Frameworks
Virtue ethics can be used to unpack this ethical issue. This moral theory is grounded in Greek philosophy and encourages moral actors to cultivate virtues, or morally praiseworthy qualities, to overcome ethical obstacles. Under this theory, most ethical courses of action are ones that virtuous agents would perform.(11) By being equipped with virtues like integrity, honesty, and compassion, agents can discern ethical problems and perform behaviors that reach favorable resolutions.
Kantian deontology, a duty-based ethical paradigm promulgated by Immanuel Kant, states that right conduct is classified as categorical imperatives that are unconditionally assigned to each moral agent.(12) One important formulation of the categorical imperative is that actions must be universalizable to be considered permissible; rational individuals ought to act in ways that would not be contradicted if every agent began performing those behaviors.(13) For instance, if surgeons were to continue withholding information regarding medical students’ roles during surgery, then patients would learn that surgeons were not being completely truthful about medical students’ involvements, potentially leading to mistrust in the medical team and restricted academic opportunities for students. Using Kantian deontology, continuous nondisclosure of medical students’ intraoperative roles would not be sustainable long-term and would be morally impermissible.
Clinical ethics principles, such as autonomy, voluntary decision-making, and truth telling, are central to delivering high-quality, ethical care. Patient autonomy in particular carries a lot of weight in the U.S. healthcare system and is entrenched within the practice of informed consent. Nondisclosure of necessary information can undermine patients’ ability to make self-governed decisions of their own healthcare. In order to elevate patients’ agency to make self-regulated health decisions, surgeons should disclose information about how medical students might be participating in a procedure. Prioritizing truth telling can increase patient awareness and allow them to make fully informed and autonomous choices that carry implications for medical students’ educational opportunities.
Recommendation
One recommendation would be to provide patients with a preoperative consent form or pamphlet that lists all possible steps that students might be involved in intraoperatively. Mentioning potential intraoperative actions can serve to promote patient autonomy, as they will be more aware of potential actions taken by the medical student.(14) Patients can consider whether they want medical students to take part in some steps of their surgical procedure. Not only would a preoperative pamphlet be informative for patients, it could also spark a more comprehensive and transparent conversation between surgeon and patient. Surgeons can more openly work with patients to fully comprehend medical students’ potential roles, and they can avoid the hardship of over-disclosing and causing unnecessary discomfort to patients who would now be empowered to inquire about the roles specifically listed in the pamphlet.
It could also be beneficial to broaden medical students’ surgical training by exposing and incorporating them into the informed consent discussions. Medical students can grow their confidence to lead informed consent conversations with patients.(15) As surgeons primarily answer patients’ questions and lead the preoperative dialogue, medical students should be encouraged to take a more present and active role in the conversation by maximizing clear communication and working with patients to establish mutual trust and respect – humanistic competencies that future clinicians should acquire. Establishing a triadic relationship between surgeon-student-patient could bolster patients’ trust in students and their comfort in consenting to students’ participation in the surgical procedure.(16) A broader recommendation to resolving this issue could be to conduct pedagogical reform of the current surgery clerkship curriculum. Implementing a more structured curriculum with a focus on advancing medical students’ surgical skills and practicing ethically grounded behaviors could optimize the surgical clerkship for students’ academic needs while maintaining key ethical principles of high-quality patient care.(17) While this suggestion might seem overwhelming, incremental reform of the surgical environment can also be impactful. Surgeons may find it helpful to reasonably allocate more attention to the preoperative informed consent discussion, providing space to exemplify virtuous qualities and uphold universalizable moral duties to patients. Medical students may benefit from a surgical rotation curriculum that has a greater focus on maximizing their current and future educational opportunities while leaning on moral frameworks that uphold patients’ ethical rights.
Conclusion
Patients, medical students, and surgeons are important stakeholders in this pressing ethical dilemma. Pertinent moral frameworks, such as virtue ethics, Kantian deontology, and clinical ethics principles, suggest that patients deserve full transparency from their surgeons, especially about the tasks medical students could be assisting with during the procedure. To balance medical education standards with patient awareness and overcoming structural obstacles, stakeholders should rely on apt ethical paradigms to inform reasonable recommendations that reduce patients’ perceived lack of consent and promote ethically grounded behaviors.
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2. 482.51 Condition of Participation: Surgical Services, Title 42 42 CFR 482.51 § 482.51. Retrieved June 14, 2025, from https://www.ecfr.gov/current/title-42/part-482/section-482.51
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13. Ibid, p. 221
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