Special article
The right to patient autonomy. Updating in daily clinical care
El derecho a la autonomía del paciente. Actualización en la clínica asistencial diaria
Eduardo Osuna, Aurelio Luna, María D. Pérez-Cárceles
Corresponding author
Área de Medicina legal y forense, Instituto de Investigación Biomédica de la Región de Murcia (IMIB), Campus de Excelencia Internacional Campus Mare Nostrum, Universidad de Murcia, Murcia, Spain
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"apellidos" => "Pérez-Cárceles" "email" => array:1 [ 0 => "mdperez@um.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Área de Medicina legal y forense, Instituto de Investigación Biomédica de la Región de Murcia (IMIB), Campus de Excelencia Internacional Campus Mare Nostrum, Universidad de Murcia, Murcia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El derecho a la autonomía del paciente. Actualización en la clínica asistencial diaria" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Patient autonomy: From the past to the present day</span><p id="par0005" class="elsevierStylePara elsevierViewall">The clinical relationship is at the heart of healthcare. For centuries it has been characterised by a paternalistic approach, in which the patient came to the physician for services and the physician made the decisions. A central assumption of the paternalistic framework was that physicians, due to their professional expertise, knew what was best for patients and, therefore, patients had to accept their decisions. Today, however, care is governed by the principle of autonomy, as a manifestation of the right to individual freedom with the capacity to make decisions, whereby the patient assumes the role of the protagonist in the care relationship.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> To this end, it must be presided over by trust and communication between the participants. As Broggi<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> points out, in the past, when patients entered a doctor's surgery, they entered a world of established values to which they had to adapt submissively. Now, the change is radical since the patient’s own world of values have to be taken into account and respected.</p><p id="par0010" class="elsevierStylePara elsevierViewall">This relationship involves dealings between people, with a high degree of interpersonal variability, in a context in which the scenarios are very diverse and in which there is an experience of illness present. We must therefore consider it as a meeting place for participants in which values, beliefs and ideas about health and illness converge in an environment of values management that may coincide or diverge.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The doctor-patient relationship, so complex and sensitive, involves not only health, but also freedom, autonomy and the subjective conception of the dignity of the person.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Patient information is key to decision-making and constitutes an obligation for the health professional. In the early days, the rejection of medical paternalism in favour of respect for patient autonomy did not result in the removal of doctors' control over their relationships with patients. In theory, professionals could no longer make unilateral decisions about their patients' care, but in practice they retained control by virtue of their monopoly on medical information and most medical resources.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Today, this relationship model has evolved into a shared decision-making process in which the physician and patient participate in accordance with the patient's values and preferences. Ideally, for many decisions, there is an exchange of information: the physician presents different options and the patient expresses his or her values and preferences. In some cases, the practitioner may need to help the patient identify or clarify his or her values and care goals in light of the available treatment options.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The acquisition of the autonomy model requires the patient to undergo a process of self-knowledge and integral reflection in order to adopt a critical attitude towards his or her own values and preferences. This enables the patient to then choose the most appropriate course of action freely from among the options presented, in accordance with his or her values as a person. The achievement of the principle of autonomy banishes the vertical and authoritarian system of the previous clinical relationship and develops a horizontal and balanced relationship that gives a greater role to the patient as an active agent within the healthcare system with the capacity to make the relevant decisions related to his or her health.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It entails an important change in the relationship, both for the patient and for the professional, with the latter experiencing a particularly profound shift. In the paternalistic model, the professional was the decision-maker, whereas in this new model, the patient is now at the centre of the decision-making process.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the current model, after inquiring and learning about the patient's values and opinions about the health problem in question, a joint deliberation is initiated to analyse the interests present in order to find an individualised solution. A collaborative dialogue takes place, resulting in a decision for which both the professional and the patient are responsible. Thus, patient autonomy is seen as a personal development, which is embodied in the achievement of informed consent, achieved after a process of reflection rather than a mere formality. The aim is for the patient to authorise or refuse a healthcare action after a deliberative process. Professionals are largely responsible for the execution of this decision. The clinical benchmark for assessing patient autonomy in this paradigm focuses on the patient's capacity to participate in the consent process, through which he or she grants or refuses authorisation for a given procedure.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In Spain, Law 41/2002, of 14 November, the basic law regulating patient autonomy and the rights and obligations regarding clinical information and documentation, known as the Patient Autonomy Law, was enacted 5 years after the Oviedo Convention was signed and just over 2 years after its entry into force in our country. It entailed the reinforcement of the right to patient autonomy, materialised in informed consent.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We believe that a little more than 20 years after its entry into force, it may be an opportune moment to assess the impact and level of compliance in day-to-day clinical practice. The following questions arise from the objectives set at the time by the regulatory framework established with regard to informed consent: how is the process of obtaining informed consent carried out, does it coincide with what is stipulated in the law, does it follow the ethical premises on which the regulation is based?</p><p id="par0035" class="elsevierStylePara elsevierViewall">In this context, informed consent is shaped as a meeting of 2 autonomies: the autonomy of the health professional who, based on his competence and experience, informs the patient and helps him to understand his state of health, and the autonomy of the patient, who is free to assert his individuality and moral dimension in the decision.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Many definitions have been published on what we should understand by informed consent. The most classic definition is that of Beauchamp and Childress,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> who consider it to be an “autonomous authorisation for the practice of a certain intervention and implies that the individual must not only accept and comply with a proposal, but must also give his or her authorisation by means of voluntary consent, which only exists when a patient with sufficient capacity for understanding and without external control intentionally authorises a professional to do something”. It does not add much more than the patient autonomy law, which defines it as: “The free, voluntary and conscious agreement of a patient, expressed in the full use of his or her faculties after receiving adequate information, for an action affecting his or her health to take place”. These are clear definitions, but do not specify how the procedure for obtaining consent is to be implemented.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The Galician Palliative Care Plan<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> defines the procedure for obtaining informed consent in the following words: “the gradual and continuous process, sometimes embodied in a document by means of which a capable and adequately informed patient accepts or does not accept to undergo certain diagnostic or therapeutic processes according to his or her own values. It is not a document but a process, as the information will be offered on an ongoing basis so that the decisions that are taken can be assumed in a shared manner. It requires an appropriate clinical relationship, with a premise of great respect for people, while at the same time it is a parameter for measuring the ethical quality of this relationship, and therefore the quality of healthcare and research activity”.</p><p id="par0050" class="elsevierStylePara elsevierViewall">It refers to a “gradual and continuous” process, so that the information will be provided on an ongoing basis and should not be understood as something that ends after it has been obtained. Thus, we must avoid equating the process with the signature on the written document. Decisions are present as long as the care relationship continues. Some will be verbal and no written support will be required; others, in accordance with the regulations, will have to be documented.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Consent is in line with the patient's values and the healthcare action is aligned with the patient's principles and experience of the illness within a framework of an appropriate clinical relationship, in which decisions are taken on a shared basis. In this respect, the right to refuse treatment, whether vital or not, is recognised. We are therefore faced with a collaborative process channelled by communication between the professional and the patient which extends beyond the mere exchange of information. Rather, it is an active process in which statements can be verbal or non-verbal, taking into account the patient's preferences and, as far as possible, it strives to reach a mutual agreement on the best course of action.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The healthcare professional has the scientific knowledge and experience that allows him/her to discern the option that is most beneficial and most appropriate to the patient's qualities, and it is the patient who knows his/her values and vital priorities, so as to interpret the information received and participate in shared decision-making. In this context, professionals provide information about the available options, including risks, benefits and possible consequences, and listen to the patient's preferences, through a joint deliberation that will lead to a decision based on both the objective evidence provided by the physician and the patient's personal values in accordance with his or her preferences. This discussion generates and ensures a relationship of trust between doctor and patient that enriches the clinical relationship.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Informed consent should not, therefore, be understood as mere authorisation or assent.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The process of shared decision-making involves 3 successive phases. The first of these is information, which is essential to comply with the principle of respect for the individual's freedom of self-determination. This is followed by the reflection phase, whereby the patient processes the information from the professional and makes a decision, which can then be defined as informed. This would be the third phase of the procedure. This entire process requires the patient's competence, considered as the ability to ultimately make decisions.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Firstly, competence refers to the patient's ability to receive information, to understand it and to select the main contents (<span class="elsevierStyleItalic">informability</span>). The patient must have the capacity to evaluate his/her own situation, recognising him/herself as a patient, reflecting on the different possibilities of choice, identifying the consequences of each alternative in his particular value system <span class="elsevierStyleItalic">(cognitive capability).</span> Finally, he/she must have the capacity to arrive at a conscious choice of the reasons that have led him/her to prefer one option over another <span class="elsevierStyleItalic">(deciding),</span> coherent with his/her value system and, to a certain extent, with his/her biographical project. Unfortunately, this whole procedure has a complex application in daily healthcare practice.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In this sense, for Faden and Beauchamp<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> the autonomy model should integrate the assessment of the capacity both to decide, “decisional autonomy”, and to implement decisions for their care, “executive autonomy”. For example, in the face of frequent readmissions due to illness, adverse effects of treatment, fluctuations in functional status and other possible situations where there is a lack of adherence to treatment, professionals should consider whether the patient has executive autonomy to manage complex treatment plans and integrate them into daily life, but always promoting autonomy in all areas of care. Appropriate treatment planning can be achieved through a dynamic and iterative process of identifying patients' limitations, tailoring appropriate interventions and supplementing deficits in executive autonomy with appropriate support. In some instances, family members and caregivers play an important role, but always taking into account values and without undermining the patient's decision-making capacity.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The health professional's assessment of the individual's ability to understand the information (a task that can be very complicated) will be the criterion established in relation to the content and possible alternatives. All of this is done from the perspective of the best interest and benefit of the patient. As one can easily understand, situations of possible collision between the right to information, confidentiality and privacy arise when information flows are directed to several recipients and in situations where there are frequent disparities of criteria among family members and paternalistic attitudes, especially in vulnerable patients.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In July 2021 the National Institute for Health and Care Excellence (NICE) published the <span class="elsevierStyleItalic">Shared Decision Making</span> guidelines,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> which includes recommendations to encourage and facilitate the deliberative process between the healthcare professional and the patient. The document highlights the importance of integrating the shared decision-making process into everyday clinical practice. It recommends an honest conversation with the patient, providing the patient with sources of information and consultation before, during and after the interview. It also includes measures for health service managers to raise awareness among professionals of the importance of involving patients in decisions related to their health.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The requirements for a shared decision-making process are as follows:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">The involvement of a well-integrated and coordinated multidisciplinary team that encourages patient participation in decision-making.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall">Open and honest communication between the patient, family/carers (where necessary) and members of the healthcare team through the use of open questions, active listening and discussion of proposed options.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0105" class="elsevierStylePara elsevierViewall">An appropriate doctor-patient relationship, based on mutual trust. The patient must perceive that he or she is the centre of the professional's attention and feel that he or she is being listened to and understood.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0110" class="elsevierStylePara elsevierViewall">A favourable atmosphere, in an environment where the privacy of the relationship is protected.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0115" class="elsevierStylePara elsevierViewall">Two-way information including all options to decide which best suits the individual and his or her particular situation.</p></li></ul></p><p id="par0120" class="elsevierStylePara elsevierViewall">A further challenge to the implementation of shared decision-making is the existence of barriers to its adoption. Some are patient-specific: lack of knowledge and experience of these procedures or the belief that doctors prescribe the only possible treatment. Others are related to the health professional: lack of time, lack of training or experience, underestimation of the patient to play an active role in decision-making, and difficulty in reconciling patient preferences. Stalnikowicz and Brezis<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> highlight 3 main barriers: lack of time, poor communication skills and lack of adequate listening.</p><p id="par0125" class="elsevierStylePara elsevierViewall">On the other hand, some studies point out that the decision-making process may be influenced by cultural background. In this respect, Ruhnke et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> have compared the perceptions of patients and physicians in Japanese and US health care facilities. In both countries it is emphasised that the patient's preferences should prevail over those of the family or the physician; however, in Japan, the opinion of the family and the physician is given more importance in clinical decision-making than in the United States. Thus, the cultural context determines the relationship between patient, physician and family in medical decision-making.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Communication must be accompanied by the necessary time to discover and articulate the subject's values in medical decisions, so consultation time must be increased to encourage dialogue between the leading actors of the clinical relationship.</p><p id="par0135" class="elsevierStylePara elsevierViewall">In the context in which we find ourselves, the deliberative model of the clinical relationship is the most appropriate, as it is based on effective communication. Informing is not the same as communicating. When it comes to the care relationship, communication is essential, not just the simple transmission of information. In this sense, the physician's communication skills play a decisive role in shared decision-making and, therefore, in informed consent.</p><p id="par0140" class="elsevierStylePara elsevierViewall">It is also important to note that the success of the deliberative model is underpinned by mutual trust between practitioner and patient, with communication as the means to achieve this. The development of a bond of trust between people necessarily implies a relationship, and when this is not achieved or is lost, it opens the door to litigation.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We must therefore opt for a model in which trust is the central value of the relationship, fostering autonomy based on interdependence.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> All these aspects of the doctor-patient relationship are reinforced and detailed in the recent <span class="elsevierStyleItalic">Code of Medical Ethics</span> approved by the Consejo General de Colegios Oficiales de Médicos de España.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">New challenges in a new era of increasing patient autonomy</span><p id="par0145" class="elsevierStylePara elsevierViewall">The use of novel technologies in the field of medical practice has ushered in a new era of patient autonomy. Nowadays, users inform themselves on the Internet and social networks, and the doctor's dominance over information has been reduced. In addition to visiting the practitioner, some patients come to the clinic having thoroughly investigated their symptoms and identified possible diagnoses. At the same time, there is an increasing availability of diagnostic tests that can be accessed without a prescription, creating new challenges for practitioners and a new reconceptualisation of their role in the doctor-patient relationship, in which the balance of power between doctor and patient is shifting.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Examples are numerous: electrocardiograms on smart-app devices, over-the-counter laboratory tests, genetic testing, etc., many of which do not meet clinical validity standards.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">On the other hand, telemedicine offers the possibility of improving health services, as it allows care for patients in remote areas or with reduced mobility, involving them in their own care, which means enhancing patient autonomy. However, it suffers from potential drawbacks such as unequal information or a possible depersonalisation of the clinical relationship, which affects autonomy on several levels. Self-management of the devices and unfamiliarity with their operation are factors to be taken into account. Nor should we forget that the relationship between patients and healthcare professionals, in addition to the clinical dimension, has a personal dimension, through which the professional perceives, among other factors, the patient's emotional state, which cannot be quantified simply in data packets. The face-to-face meeting is a cornerstone for assessing the clinical situation.</p><p id="par0155" class="elsevierStylePara elsevierViewall">When referring to autonomy, the main question is whether self-monitoring and self-management are a gain or a loss. The answer may be the same as in the conventional clinical situation. As long as informed consent and shared decision-making are guaranteed, telecare is not a threat to patient autonomy. On the contrary, it can even enhance it, by putting the individual in charge of his or her own health care. Nor should we forget, as we have previously pointed out, the importance of trust and empathy as the pillars of this relationship. Therefore, any telecare programme should include, on a regular basis, some form of communication between the patient and the health professional that accompanies the collection of biomedical data, to avoid possible depersonalisation.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> The assumption that increased access to information alone improves autonomy should be discarded, as information must be accompanied by the ability to interpret and apply it.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Initiatives proposed and implemented in some countries, such as the <span class="elsevierStyleItalic">OpenNotes</span> movement, which allow patients to access all the information in their medical records, pose new scenarios, which require reflection and action to ensure that the doctor remains relevant at all stages of care.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Finally, the use of artificial intelligence and robotisation in healthcare environments has experienced a rapid increase<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> and conceives new opportunities and challenges, so it is necessary to know its possibilities as well as the perception, acceptance and opinions of users about their application in these environments, analysing them in an ethical and moral context.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,26</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conclusions</span><p id="par0170" class="elsevierStylePara elsevierViewall">Today, the principle of autonomy needs to be repositioned, integrating the 2 protagonists of the clinical relationship in the decision-making process, which should be channelled by dialogue and joint deliberation leading to a shared decision. The decision-making process is a legal requirement for healthcare professionals. However, on many occasions its application as a manifestation of the ethical principle of autonomy is postponed and, from a defensive stance, it is used inappropriately by making the signing of the document the nerve centre of the clinical relationship.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">There has been a radical shift in the model of the clinical relationship, from paternalism towards patient autonomy, but we must bear in mind that both paternalism and extreme autonomism are models in which the beneficence-autonomy polarity is pushed to the limit and are now considered to have failed, so a more balanced model is needed.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> When autonomy is elevated to an absolute principle and pursued to the exclusion of all other considerations, the relationship between the patient and the healthcare provider may be negatively affected, potentially leading to harm.</p><p id="par0180" class="elsevierStylePara elsevierViewall">The decision-making process must move away from a simple transfer of information and needs to be approached as a means of supporting patients to make informed and self-determined decisions. Therefore, we must avoid both, the simple contractual formalism practised by the practitioner and an overemphasis on patient autonomy.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Ethical considerations</span><p id="par0185" class="elsevierStylePara elsevierViewall">The conduct of the study does not involve ethical considerations.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Funding</span><p id="par0190" class="elsevierStylePara elsevierViewall">This research has not received specific support from public, private or non-profit organisations.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflict of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Patient autonomy: From the past to the present day" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "New challenges in a new era of increasing patient autonomy" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conclusions" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Ethical considerations" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-10-18" "fechaAceptado" => "2024-01-31" "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:27 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "El consentimiento informado: teoría y práctica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. 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