NO UNDERSTANDING, NO CONSENT: THE CASE AGAINST ALTERNATIVE MEDICINE ARIANNE SHAHVISI Keywords informed consent, alternative medicine, epistemology ABSTRACT The demand for informed consent in clinical medicine is usually justified on the basis that it promotes patient autonomy. In this article I argue that the most effective way to promote autonomy is to improve patient under- standing in order to reduce the epistemic disparity between patient and medical professional. Informed consent therefore derives its moral value from its capacity to reduce inequalities of power as they derive from epis- temic inequalities. So in order for a patient to have given informed con- sent, she must understand the treatment. I take this to mean that she has sufficient knowledge of its causal mechanisms and has accepted the explanations in which the treatment is implicated. If this interpreta- tion of informed consent is correct, it is unethical for medical professio- nals to offer or endorse ‘alternative medicine’ treatments, for which there is no known causal mechanism, for if they do, they may end up widening the epistemic disparity. In this way, informed consent may be understood as an effective way of ruling out particular treatments in order to improve patient autonomy and maintain trust in the medical profession. I. INTRODUCTION Medical ethics enshrines autonomy in one of its central tenets: that patients should have the opportunity to act autonomously in their choice of treatment by being asked to give informed consent (IC) prior to starting any treatment. Other rationales have been put forward to jus- tify the need for informed consent – protection, trust, preventing abuse, self-ownership, non-domination, and personal integrity 1 – but I take it that all of these may be reduced to the desire to encourage conditions under which patients have greater agency. In this article, I assume that the moral value of bodily autonomy is axiomatic, and consider only decisionally- capacitated adults giving informed consent to medical care, rather than medical research (though much of what I conclude also applies to the latter). The moral value of IC is then contingent on the extent to which it serves the patient as an autonomous agent. The requirement that medical professionals seek IC from their patients is a way of ensuring that patients qua peo- ple do not have their right to autonomy violated. If IC does not, in practice, or cannot, in principle, serve this aim, then (de facto, or de jure) IC cannot be claimed to be a moral good. I will show that (a) in practice, IC is less than optimal as a realizer of patient autonomy because being informed is often taken to mean knowing, rather than understanding, and (b) in principle, IC is less than opti- mal as a realizer of patient autonomy because of the overriding influence of external social factors on the decision-making of patients. Yet I will show that it is possible to fortify IC against these shortcomings, which is important since it remains the primary means for Address for correspondence: Arianne Shahvisi, University of Sussex, Medical School, Biology Road, Falmer, Brighton, East Sussex, BN1 9PX, United Kingdom. Email: arianneshahvisi@outlook.com 1 c.f. N. Eyal. Informed Consent. In: E.N. Zalta, editor. Stanford Ency- clopedia of Philosophy 2011. Available at: http://plato.stanford.edu/ entries/informed-consent/ [cited 2014 December 29] V C 2016 John Wiley & Sons Ltd Bioethics ISSN 0269-9702 (print); 1467-8519 (online) doi:10.1111/bioe.12228 Volume 30 Number 2 2016 pp 69–76