Americans have long wanted a health care system that is accessible, comprehensive and affordable. Our failure to accomplish these goals has resulted in a resurgence of interest in national health insurance as a mechanism for increasing access, expanding the scope of services, and controlling costs.

Unfortunately, the health care industry (which is really a sick care industry) has fostered dependence on the two most expensive components of care: physician services and hospitalization. This situation has evolved from several historical themes, three of which threaten to perpetuate our inflationary system and prevent reimbursement for non-physicians:

1. 1. failure to distinguish between medical care and health care

2. 2. control of the industry by physicians and hospital administrators

3. 3. lack of recognition for and undervaluing of the services of nurses

All of these factors have reduced the health options for consumers and have been demoralizing for nurses. This discussion will focus on various ways these issues impact upon the contributions nurses can make.

The title of Tom Wolfe's current best seller, The Right Stuff, refers to those qualities — manliness, fearlessness, survivability, and recklessness — that characterize successful test pilots in general, and Mercury astronauts in particular. A similar list could be compiled to characterize successful surgeons. It would likely include decisiveness, confidence, dexterity, and dedication. The list would be unlikely to include open-mindedness or a concern to present patients with all the options available for particular disease conditions.

This “self-righteous silence” has recently brought the wrath of the women's movement down on surgeons who perform breast cancer operations without informing their patients about alternatives. And in 1979 Massachusetts became the first state to enact a law requiring physicians to provide “a patient suffering from any form of breast cancer” with “complete information on all alternative treatments which are medically viable.” This column examines the reaction to the law.

There is little argument against the principle that the health care consumer has the right to all pertinent information regarding his condition and treatment. Nevertheless, there is resistance and patients frequently have difficulty obtaining important information.

Generally, it is the responsibility of the physician to inform the patient of his diagnosis and condition, the recommended treatment, its risks and its side effects, and any alternative treatments. This is the essence of obtaining the patient's informed consent, without which treatment is illegal and unethical. An important aspect of the nurse's role is to safeguard the patient's right to receive this information, and, when necessary, to assist the patient in obtaining it. Since she is in frequent close contact with the patient, the nurse should evaluate the patient's understanding and should inform the physician when further information or clarification is needed. Furthermore, when the nurse realizes that the patient has not received or understood the necessary information, the nurse should advise the patient of his right to receive it before consenting to any treatment or procedure.