Shared decision-making and the management of surgical ignorance: A short proposal for classification

Abstract

Surgery is an irreversible, invasive intervention associated with immediate and long-term risks, which make surgical decision-making particularly complex. In recent decades, Shared Decision-Making (SDM) has emerged as the ethical and practical standard, replacing traditional paternalism and addressing the limitations of informed consent. However, the actual implementation of SDM in surgery faces a fundamental challenge: the inevitable presence of surgical ignorance. This article aims to analyze the role of ignorance in SDM and propose a brief conceptual classification to facilitate its identification, communication, and ethical management. Four types of surgical ignorance are described: ignorance based on known evidence (Type I), unpredictable ignorance (Type II), strategic ignorance (Type III), and ignorance due to unknown evidence (Type IV). We argue that an authentic SDM process should not be limited to the communication of probabilistic risks but should explicitly incorporate different forms of ignorance, tailoring decision-making to the patient’s values, preferences, and goals.

Introduction

Surgery has distinctive characteristics, associating the decision to proceed with unique attributes: it is irreversible, invasive, and entails immediate and long-term risks.¹ Traditionally, the decision to operate has been grounded in a paternalistic model, in which the surgeon recommends the “optimal” course of action, primarily because they are the holder of expert knowledge.¹ In the 1970s, as a critical response to paternalism, patient-centered bioethics emphasizing autonomy began to emerge. In the 1980s and 1990s, this movement promoted the informed consent model as an ethical and legal requirement, whereby the patient attests to having received information about the procedure to be performed.² However, informed consent is understood differently depending on the context. It is also applied inconsistently and seldom fulfills its theoretical ideal.³

In response, the 21st century has seen an evolution toward less individualistic models, such as Shared Decision-Making (SDM).⁴ SDM is a collaborative process in which the patient and surgeon exchange information, deliberate options and reach consensus on the course of action. In surgery, SDM is considered the gold standard of ethical and practical care.^5,6

Within this context, the genuine implementation of SDM may encounter a fundamental obstacle: incomplete knowledge of the intervention to be performed. In other words, ignorance or uncertainty regarding variable aspects of the surgical act.⁷ Throughout this text, ignorance is understood as a lack of knowledge, completely different from incompetence.

It is likely that most of us have, at some point, invoked the commonplace assertion that “surgery is not an exact science.” Surgery is inherently a probabilistic endeavor, and therefore one characterized by uncertainty, applied to an extremely complex biological entity: the human being. Surgical decision-making may reveal what could be termed the “paradox of surgical decision-making,” insofar as such decisions are often perceived as acts carried out without any doubts. In reality, however, this is far from the case, as surgical decisions must be made in the context of uncertainty regarding clinical knowledge, the inherent variability of the surgical act itself, and the challenges of communicating complex evidence. The aim of this article is to analyze what we believe should constitute an “authentic” SDM process, meaning one that does not merely consist of the transmission of factual information, but one that also enables the explicit management of ignorance. Both surgeon and patient are required to navigate multiple surgical decisions within an uncertain terrain.

Shared Decision-Making (SDM)

SDM is an interactive clinical decision-making model. Four essential steps can be identified⁸: 1) the involvement of at least 2 participants (ie, patient and surgeon), with the possible inclusion of family members or legal guardians; 2) the joint use of information, whereby the patient contributes values, preferences, goals, fears and expectations, while the surgeon contributes knowledge of the disease, available treatment options (both non-surgical and surgical, including different techniques), as well as risks, benefits, and uncertainty (i.e., ignorance); 3) deliberation on the available options based on this bidirectional exchange of information; and 4) reaching a final decision and mutual agreement on the chosen course of action.

In the surgical setting, SDM encompasses not only the decision of whether to operate but also technical details (e.g., surgical approach, type of anastomosis, use of mesh), procedural staging (one-stage vs two-stage surgery) and the management of unpredictability, including authorization to act upon unexpected intraoperative findings.

However, several barriers limit the implementation of SDM in surgery: asymmetry of knowledge between patient and surgeon; the persistence of a ‘surgical culture’ combining paternalism with assertiveness (ie, surgeons accustomed to making decisions and acting on them); time constraints in overloaded outpatient clinics; the complexity of surgical information; the illusion of certainty, whereby both patients and surgeons may feel uncomfortable with ambiguity, leading to overconfident presentations of outcomes⁹ and patient mistrust when responsibility for decision-making is shifted away from the surgeon. Many of these barriers are directly or indirectly related to poor management of uncertainty, lack of knowledge and, ultimately, ignorance.⁷

Ignorance in the surgical context: a brief proposed classification

Ignorance (ie, uncertainty) in healthcare is not a single entity. It encompasses multiple meanings and forms that are often neither distinguished nor explicitly acknowledged, despite the fact that each may have distinct effects or justify different courses of action.¹⁰ To our knowledge, no specific taxonomy of ignorance exists in surgery. Based on research studies,^10–,11,12 we propose the following classification:

Ignorance due to known evidence (Type I): This form of ignorance is recognized and accepted as part of routine surgical practice. It represents probabilistic uncertainty derived from available data (eg, anastomotic leak rates, hernia recurrence rates, 5-year oncological survival, expressed as percentages). This quantified and communicable uncertainty is the foundation of the risk–benefit analysis in SDM. However, data derived from studies or registries may not be directly applicable to the individual patient involved in the SDM process.

Unpredictable ignorance (Type II): This refers to the domain of the unexpected or unforeseeable in surgery (eg, an extremely rare anatomical variant not detected on preoperative imaging, or a previously undescribed postoperative complication). SDM should explicitly acknowledge the existence of rare or unpredictable risks that cannot be fully anticipated.

Deliberate ignorance (Type III): This involves a conscious decision not to seek additional information, even when technically feasible. Such ignorance may be justified (individual or collective) or unjustified (usually individual). Justified deliberate ignorance includes avoiding extensive low-yield preoperative testing in otherwise healthy patients, or refraining from investigating incidental findings unrelated to the planned procedure (i.e., complying with organizational protocols or policies). Unjustified deliberate ignorance may, in some cases, amount to medical malpractice, particularly when it involves failure to review recent literature while neglecting expert consultation, ignoring unfavorable personal outcomes, disregarding social determinants affecting recovery (e.g., lack of home support) or uncritical reliance on opinion leaders. SDM requires surgeons to critically reflect on their own ignorance and to justify the limits placed on preoperative investigation and planning.

Ignorance due to unknown evidence (Type IV): This form of ignorance arises from the absence of potentially clarifying data in the literature. Examples include the lack of randomized trials in specific surgical subpopulations (e.g., elderly or multimorbid patients), the impact of learning curves associated with new technologies such as the use of robotic platforms (where the first patients take on risks that are not fully quantified for the benefit of future patients) and publication bias that conceals negative surgical outcomes. Genuine SDM requires transparency regarding these collective knowledge limitations.

Integration of SDM and ignorance

Genuine SDM necessarily involves clinical decision-making in the presence of explicit or implicit forms of ignorance. While disclosure of probabilistic uncertainty (Type I) is mandatory, it is insufficient. SDM must also integrate unpredictable (Type II), strategic (Type III), and unknown-evidence (Type IV) ignorance to ensure that decisions are truly ethical and collaborative.

The relative contribution of each type of ignorance may vary substantially among patients. In such contexts, SDM shifts the focus toward patient values, clarifying how each therapeutic option aligns with individual priorities. SDM therefore elucidates the benefits, harms, and burdens a patient is willing to accept during deliberation.^13,14

A paradigmatic example is low rectal cancer, where options may range from radical surgery with permanent colostomy (better oncological control but poorer quality of life) to sphincter-preserving surgery combined with chemoradiotherapy (higher risk of local recurrence but preservation of continence). The optimal decision not only depends on oncological outcomes but also on the patient’s opinion regarding survival versus quality of life. The surgeon provides the map of ignorance; the patient provides values and preferences.

SDM must also address patient ignorance regarding anatomy, pathophysiology and procedures. Even when the patient is medically trained, this step is still essential. The goal is not expertise but sufficient understanding to make decisions aligned with personal values. Decision aids, such as diagrams, videos and written materials, together with the verification of patient understanding, are critical.¹⁵

Practical and ethical implications

The explicit acknowledgment of ignorance during SDM should not be interpreted as a sign of weakness. On the contrary, it may strengthen trust by demonstrating intellectual integrity, humility and respect for the patient.^16,17 Trust is not built on infallibility but on reliability, which in turn is based on competence, honest communication and acting in the patient’s best interest.¹⁸

Recognizing ignorance does not diminish surgical responsibility; it reframes it. Beyond outcomes, which are often only partially controllable, responsibility extends to the quality of the decision-making process itself. High-quality SDM requires identifying and communicating uncertainty, exploring patient values, and deliberating in good faith.¹⁹

Surgical training should therefore include SDM as a core competency, alongside technical skills. Future surgeons must learn to identify and categorize their own ignorance, communicate uncertainty without generating unnecessary anxiety, explore patient values through active listening, and critically reflect upon different forms of ignorance.^8,20 Recent evidence suggests that SDM provides a qualitative ‘return on investment’ by benefiting clinicians, patients and healthcare teams.²¹

Practical strategies for implementing SDM with controls for ignorance include: using visual decision aids; explicitly discussing unexpected findings and authorization for intraoperative decisions; separating informational and decisional consultations when possible; using SDM checklists; and creating registries to evaluate SDM outcomes and quantify uncertainty.

Comments

Surgery inevitably combines knowledge and uncertainty. SDM should not function as a superficial ethical gesture to conceal false certainty. Its true value lies in enabling surgeons and patients to confront ignorance collaboratively. Recognizing the multidimensional nature of ignorance enriches and legitimizes the surgical conversation.

For surgeons, this perspective does not undermine authority, nor does it imply incompetence. Rather, it supports a more reflective, humble, effective and ethically grounded practice. The notion that ‘data kill narratives’ is particularly relevant. Surgical narratives often reflect an illusion of control, whereas data expose variability, complications and individual responses. By integrating these data into SDM, outdated paternalism can be replaced by a genuine alliance between patient and surgeon.

Ethical considerations

This paper does not involve the use of human subjects.

Declaration of Generative AI and AI-assisted technologies in the writing process

In drafting this article, the authors used ChatGPT OpenAI (version ChatGPT 5.2) to assist with English grammar refinement. All content was subsequently reviewed and edited by the authors, who take full responsibility for the final version of the manuscript.

Funding

This article has received no funding of any kind.