“We know there are things we know we know. We also know there are known unknowns; that is to say that we know there are some things we do not know. But there are also unknown unknowns—the ones we don’t know we don’t know.”
– Donald Rumsfeld, February 12, 2002

The history of informed consent is one of continuous evolution in search of a best practice, from the mid-20th century, physician-oriented “paternalistic” approach to the “reasonable patient” standard established by Canterbury v Spence in 1972 [1]. The process of surgical informed consent still eludes a single, universal template. It is an inherently idiosyncratic interaction during which the experience, clinical judgment, and biases of the surgeon are distilled into a focused conversation between caregiver and patient, with the goal of reaching agreement and, ultimately, permission to proceed with a recommended intervention. Ideally, the surgeon weaves data and evidence (“facts and figures”) extracted from textbooks, published scientific literature, and other sources into a narrative tailored to fit the needs of the patient including the perceived appetite of that patient for information [2]. An open- ended opportunity to ask questions and to express fears and concerns is essential, and surgeons should balance expressions of reassurance and empathy with appropriate expectation-setting around the more likely outcomes including the possibility of significant complications. The informed consent discussion is particularly challenging for riskier procedures with less certain outcomes. The advantages of a patient- oriented, shared decision-making model have been articulated by Schwarze and colleagues, who propose using best-case, worst-case scenarios as an anchoring framework [3].

The assumption underlying all informed consent discussions is that we as surgeons know the risks and know the benefits with a reasonable (but far from absolute) degree of certainty, and that we can accurately weigh those in comparison to the known alternatives, including the option of no intervention. How might the process of informed consent be adapted during a time of great medical uncertainty: the current COVID-19 pandemic?

Beginning in mid-March, once the scope and severity of COVID-19 on hospitals in the United States became clear, our institution instituted several response measures, among them (1) cancellation of all non-time sensitive elective procedures, (2) bi-weekly department-wide virtual conference discussions regarding ethical implications and challenges we were likely to face as an institution, and (3) bi-weekly virtual town halls with the surgical housestaff and leadership to establish open communication as a group. The department also acted quickly to develop a quantitative, rational system for scoring medically necessary, time-sensitive procedures (MeNTS), based on current resource availability, patient risk factors, degree of resource utilization presented by a proposed procedure, and the medical and surgical feasibility of postponing an intervention [4].