AMA Journal of Ethics^®

Language is a very powerful element of the patient-physician relationship. At the most basic level, patients and physicians need to understand the information they are exchanging with one another simply to establish mutual understandings of an illness or injury and treatment recommendations. Many exchanges, however, are not this simple. Patients come from a range of backgrounds: their literacy and health literacy—and, in particular, their socioeconomic status, health beliefs, and past health and health care experiences—all contribute to patients’ narratives. A physician’s background can influence the patient’s narrative as well, but the physician will always be in a position of knowledge and power relative to a patient because of her or his education, skills, and knowledge. When a physician speaks with a patient, most often, it is as an expert in the language of medicine speaking with a nonexpert. Patients can’t generally be expected to speak this language, and so a physician must translate appropriately.

The AMA Code of Medical Ethics speaks to this notion of facilitating patients’ understanding of medical language in several places. Opinion 1.1.3, “Patient Rights” [1], states that patients have a right to “receive information from their physicians and to have opportunity to discuss the benefits, risks, and costs of appropriate treatment alternatives, including the risks, benefits and costs of forgoing treatment” and “to ask questions about their health status or recommended treatment when they do not fully understand what has been described and to have their questions answered.” For patients to fully understand could mean that a barrier to understanding should be addressed, whether it’s language—in which case, in keeping with Title VI [2] and Office for Civil Rights guidance [3], calling a certified interpreter would be appropriate—or health literacy, in which case a clinical situation should be explained in simpler terms. Opinion 2.1.1, “Informed Consent,” goes deeper into the nuances of what is meant by full understanding.

Informed consent to medical treatment is fundamental in both ethics and law. Patients have the right to receive information and ask questions about recommended treatments so that they can make well-considered decisions about care. Successful communication in the patient-physician relationship fosters trust and supports shared decision making.

The process of informed consent occurs when communication between a patient and physician results in the patient’s authorization or agreement to undergo a specific medical intervention. In seeking a patient’s informed consent (or the consent of the patient’s surrogate if the patient lacks decision-making capacity or declines to participate in making decisions), physicians should … assess the patient’s ability to understand relevant medical information and the implications of treatment alternatives and to make an independent, voluntary decision [4].

This opinion clarifies that valid informed consent hinges on the patient’s ability to understand the information presented about a diagnosis or treatment—including risks and benefits of undergoing or foregoing treatment—and that it is the physician’s responsibility to make sure that this is so. Opinion 2.1.5, “Reporting Clinical Test Results,” also addresses a physician’s obligation to facilitate a patient’s understanding.

To ensure that test results are communicated appropriately to patients, physicians should adopt, or advocate for, policies and procedures to ensure that … test results are conveyed sensitively, in a way that is understandable to the patient/surrogate, and the patient/surrogate receives information needed to make well-considered decisions about medical treatment and give informed consent to future treatment (emphasis added) [5].

Finally, sensitivity to these issues of language and understanding is essential to eliminating disparities in health care. Opinion 8.5, “Disparities in Health Care” [6], states that, as part of fulfilling this professional obligation, physicians should “cultivate effective communication and trust by seeking to better understand factors that can influence patients’ health care decisions, such as cultural traditions, health beliefs and health literacy, language or other barriers to communication and fears or misperceptions about the health care system.”