Understanding plays a key role in discourse about informed consent. It makes sense to require a person to not only understand what it is they consent to, but to understand when they are giving consent. Although understanding is a basic requirement for consent and not only tied to Faden and Beauchamp's autonomous authorisation theory (since one must understand when they are giving effective consent1.8 as well), it is discussed here in line with their argument for autonomous authorisation.
Faden and Beauchamp discuss understanding in terms of justified beliefs about the consequences of actions. According to them, understanding requires not only knowledge of the nature of the action being performed, but knowledge of the foreseeable consequences of performing or not performing the action. Only then can it be considered sufficient for autonomy. When put into practice, however, this is difficult to adequately assess, as it is common for people to underestimate the outcomes of an action (for example, kicking a rock over a cliff causing an avalanche), or misunderstand (but really think they do understand) the nature of the action and its consequences, or have false beliefs about the results of the action, especially if there is risk involved. There are also problems with accurate interpretation, as without this there can be no understanding, since, according to Faden and Beauchamp, ``to understand what someone has said is often to establish a correspondence between one's interpretation or representation of the statement and what the person meant to say'' (p. 255). In information technology, particularly, a lot of context, body language, etc. is lost in text-only writing that is found in face-to-face interactions which allows for easier understanding and interpretation of the true meaning and intention behind words.
Understanding is Faden and Beauchamp's key enabler in making the autonomous authorisation model for informed consent a pragmatic goal, instead of leaving it as an ideal. They argue that if any consent decision fails a sufficiency test to be an autonomous authorisation, it is more than likely not solely because of a lack of intentionality or authorisation on behalf of the decision-maker, but because of a lack of understanding. However, they claim, ``the connection between understanding and [intention and authorisation] is neither logical nor causal'' (p. 299), but there is a ``special relationship'' between these conditions, such that without the fulfilment of the condition of understanding, there can be no informed consent. It is hard, for example, to imagine a situation where a patient consents unintentionally to a procedure if there was adequate understanding that what the patient was doing was consenting to the procedure. It is equally unlikely that a person would mistakenly perform an act of authorisation if they understood adequately that they were performing that act. Faden and Beauchamp then further elaborate on what must be understood: one must understand that one is authorising as well as what they are authorising, and only then can they take responsibility for the authorisation. This statement seems to defeat their earlier argument about the connection between understanding and authorisation being neither logical nor causal, but they qualify this particular example by establishing that the scenarios thought up that would make the connection logical or causal are not pragmatic, and would never happen outside of theoretical suppositions. ``One can produce far-fetched imaginative cases - accidental slips of the tongue in response to a request for consent, e.g. - where the understanding condition is satisfied and intentionality or authorisation is not; but such problems virtually never arise in actual informed consent contexts.'' (p. 299) From a theoretical perspective this is not a particularly sound argument, since any counter-example that is potentially plausible could become common and undermine the argument. Although these examples of understanding what one is doing but not doing it intentionally could theoretically occur, for example, slips of the tongue, mistakes, etc., these situations rarely happen during the consent-giving process, according to Faden and Beauchamp. Therefore, when dealing with standards and common expectations it seems reasonable to deal with what is likely to occur rather than concentrate on outlying anomalies, and in this case, problems such as the unintentional consenting of the understanding patient are unlikely to occur, and would point to problems in other areas, such as distraction or temporary incapacity, not just here.
The condition of understanding has firm links to the requirement for disclosure in effective consent (see section 1.2.2). In order for a person to attempt to give effective consent, the consent-requiring party must make the path to the user's understanding as easy as possible. This is an obligation on behalf of the consent-requiring party, as only through effective disclosure and communication between both parties leading to adequate understanding will they receive informed consent that fulfils these requirements. This will be discussed in the section on effective consent and disclosure later in this chapter.
This description and discussion of the concept of understanding is important for a theory of informed consent in information technology because it addresses some of the issues that are commonly found in IT situations, especially the issue of underestimation or misunderstanding. End User License Agreements (see section 2.1), in particular, commonly suffer from presenting information in a way that makes it difficult for computer users to understand, and the large number of problems that stem from this single issue, such as a failure of capacity, confusion about intention, and ultimately an uninformed consent decision, is testament to the importance of understanding. How these issues are to be addressed is context sensitive, and will be investigated in the theory for information technology developed in Chapter 3, where I will argue that understanding is of paramount importance to a successful communication transaction. The arguments presented by Faden and Beauchamp are equally valid in that theory as they are here, but, as I will argue later in this chapter and in Chapter 3, their overall framework does not translate as well to information technology as the theory presented in Chapter 3 does.