Nurse Is Instructed to Have Patient with Low Literacy Level to Sign Consent for Treatment

Introduction

Informed consent is often treated as a routine step: a form, a pen and a signature before the procedure starts. Ethically and legally, it is much more than that. Consent is a process of communication in which a patient who has decision-making capacity receives enough understandable information to make a voluntary choice about his own body. The signature only records that this process took place.

Nurse Gloria’s situation shows what happens when that process breaks down. Mr. Isaacs appears to have low literacy, and a signature from him now would mean very little. To understand why this matters so much, it helps to begin with the history that made informed consent a cornerstone of modern health care ethics: the Nuremberg trials.

History of nursing ethics: the Nuremberg trials

After World War II, the Allied powers held a series of trials in Nuremberg, Germany, to prosecute leaders of Nazi Germany. Among them was the Doctors’ Trial (United States v. Karl Brandt et al., 1946–1947). Twenty-three defendants, most of them physicians, were charged with war crimes and crimes against humanity for medical experiments on concentration camp prisoners carried out without consent. The experiments included freezing, high-altitude, malaria, poison and sterilization experiments. Sixteen defendants were convicted, and seven were sentenced to death.

Nurses were not innocent bystanders in this period. Nurses took part in the Nazi “euthanasia” programs that killed tens of thousands of disabled patients. In the 1945 Hadamar trial, head nurse Irmgard Huber was convicted for her role in killings at the Hadamar psychiatric institution. Many of these nurses defended themselves by saying they were following physicians’ orders. The tribunals rejected this defense. The lasting lesson for nursing is that obedience to authority never replaces a nurse’s own moral and professional responsibility to the patient.

The Nuremberg Code (1947)

The judgment in the Doctors’ Trial produced the Nuremberg Code, ten principles for ethical research on human beings. Its first principle states that “the voluntary consent of the human subject is absolutely essential.” The Code said that valid consent requires a person who:

• has the legal capacity to give consent;
• is able to exercise free power of choice, without force, fraud, deceit or coercion;
• has sufficient knowledge and comprehension of the matter to make an understanding and enlightened decision.

From Nuremberg to today’s nursing codes

The Nuremberg Code was followed by the World Medical Association’s Declaration of Helsinki (1964) and the U.S. Belmont Report (1979), which named three core principles: respect for persons, beneficence and justice. The International Council of Nurses adopted its first Code of Ethics for Nurses in 1953, and the American Nurses Association (ANA) code, most recently revised in 2025, makes respect for human dignity and advocacy for the patient central duties of every nurse (ANA, 2025). These documents moved consent from research into everyday clinical care. Today, a patient’s right to understand and agree to treatment is a legal and ethical standard in every hospital.

The link to Nurse Gloria’s dilemma is direct. The Nuremberg Code requires comprehension, not just a signature. A patient who cannot read the form or does not understand what he is signing has not given informed consent, however busy the endoscopy schedule is.

Emotional focus

Nurse Gloria

Gloria is likely to feel conflicted and pressured. She has a direct instruction from the physician, a scheduled procedure and probably other patients waiting. Calling the physician back may make her feel she is slowing down the team or questioning a colleague. She may worry about being seen as difficult. At the same time, she may feel uneasy and anxious, because her professional instincts tell her something is wrong. When a nurse knows the right thing to do but feels blocked by time or hierarchy, the result is moral distress, a well-documented cause of burnout in nursing.

Mr. Isaacs

Mr. Isaacs is also likely to be under emotional strain. Adults with low literacy often feel shame and embarrassment and hide their difficulty by nodding along, saying they forgot their glasses, or signing whatever is put in front of them. He may also feel fear and vulnerability before an invasive procedure that involves sedation. He may not feel able to ask questions in a busy clinical setting. If he signs without understanding, he gives up control over what happens to his body, and he may later feel betrayed if a complication occurs that no one explained.

Why emotions matter

Recognizing these emotions helps Gloria respond with empathy rather than speed. Her discomfort is a useful ethical signal, not an obstacle. Protecting Mr. Isaacs’ dignity, by approaching his reading difficulty privately and without judgment, is as important as the information itself.

Ethical principles

The principles all point the same way. The only competing value is efficiency, and efficiency is not an ethical principle that outweighs a patient’s rights. Gloria should pause the consent process and involve the physician.

Who is responsible for informed consent?

The physician performing the procedure is legally responsible for explaining the diagnosis, the nature of the procedure, its risks, benefits and alternatives (including no treatment), and for answering the patient’s questions. The nurse’s usual role is to witness the signature and confirm that the patient signed voluntarily and appears to understand. When a nurse signs as a witness, she is confirming more than the signature itself. If Gloria sees that the patient does not understand, she has a duty to stop and report it.

Implications of nursing actions

Option 1: Explain it herself and get the signature

• For the patient: he goes ahead without real understanding. His autonomy is violated, and if a complication happens he faces it without having agreed to the risk.
• Legal: consent obtained without comprehension may be invalid. Treatment without valid consent can lead to claims of battery or negligence against the physician, the nurse and the facility. Nurses who explain risks they are not qualified to discuss also act outside their scope of practice.
• Professional: Gloria’s license and integrity are at risk, and she is likely to carry moral distress afterward.
• Organizational: the practice weakens a culture of safety and normalizes “getting the signature” rather than obtaining consent.

Option 2: Delay and have the physician return

• For the patient: he receives an explanation at his level, has a chance to ask questions and makes a real decision. His dignity and trust are protected.
• Legal: the consent is valid and properly documented, which protects the patient, the nurse and the institution.
• Professional: Gloria acts as a patient advocate, as the ANA Code of Ethics requires. She may face short-term frustration from the team, but she models good practice.
• Organizational: a short delay of perhaps 10–20 minutes is minor compared with the cost of an invalid consent, a complaint, a lawsuit or harm to the patient.

The more ethical and legally safer action is clearly Option 2.

Personal reflection and current actions

Personal reflection

Reflecting on this case, I recognize that I could easily be in Gloria’s position. In busy clinical settings, there is a quiet pressure to “keep things moving,” and consent forms can start to feel like paperwork rather than a patient’s right. The Nuremberg trials remind me that “I was just following orders” has never been an acceptable defense for a health care professional. Few clinical moments carry the weight of those trials, but the principle is the same: my responsibility is to the person in front of me.

I also recognize that low literacy is often invisible. National data have long suggested that only about 12% of U.S. adults have proficient health literacy (Kutner et al., 2006). Many patients who seem to understand do not. This has changed how I approach patient education. I can no longer assume understanding because a patient nods or signs. I must check it.

Current actions: what I would do as Nurse Gloria

1. Pause the process. I would not ask Mr. Isaacs to sign while he appears confused.
2. Assess respectfully and privately. I would use a non-judgmental question such as, “A lot of people find these forms hard to follow. Would it help if I read it with you?” I would also check whether he needs glasses, a hearing aid or an interpreter, since his confusion may not be about reading at all.
3. Check understanding with teach-back. I would ask him to explain in his own words what the procedure is, why he is having it and what the main risks are.
4. Notify the physician. I would tell the physician clearly and professionally that the patient does not demonstrate understanding, using a structured format such as SBAR, and ask the physician to return to explain the procedure in plain language.
5. Support the explanation. I would suggest plain-language or picture-based materials, read the form aloud, involve a family member if the patient wishes, and use a qualified interpreter if there is a language barrier.
6. Witness appropriately. Once the patient understands, he may sign, or make his mark (“X”) if he cannot write. I would witness this according to facility policy.
7. Document. I would record my observations, the physician notification, the education provided, the teach-back results and the patient’s decision.
8. Escalate if needed. If the physician refused to return, I would follow the chain of command to the charge nurse or nurse manager, because proceeding without valid consent is not an option.

Going forward, I will advocate for universal health literacy precautions: using plain language and teach-back with every patient, not only those who appear to struggle. This approach protects patient dignity and ensures that consent is informed.

Conclusion

Nurse Gloria’s dilemma looks like a conflict between a busy schedule and a patient’s understanding, but ethically it is not a difficult choice. The Nuremberg trials established that consent must be voluntary and based on real comprehension, and that health professionals cannot hand their moral responsibility to authority. Autonomy, beneficence, nonmaleficence, justice, veracity and fidelity all support pausing the consent process, assessing Mr. Isaacs’ literacy with respect, and having the physician return to explain the colonoscopy in terms he understands. The short delay is a small price for protecting the patient’s rights, the nurse’s integrity and the trust that health care depends on.

References

American Nurses Association. (2025). Code of ethics for nurses. American Nurses Association.

International Council of Nurses. (2021). The ICN code of ethics for nurses (Rev. ed.). International Council of Nurses.

Kutner, M., Greenberg, E., Jin, Y., & Paulsen, C. (2006). The health literacy of America’s adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006-483). U.S. Department of Education, National Center for Education Statistics.

National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979). The Belmont report: Ethical principles and guidelines for the protection of human subjects of research. U.S. Department of Health, Education, and Welfare.

Shuster, E. (1997). Fifty years later: The significance of the Nuremberg Code. New England Journal of Medicine, 337(20), 1436–1440. https://doi.org/10.1056/NEJM199711133372006

Trials of War Criminals before the Nuernberg Military Tribunals under Control Council Law No. 10. (1949). The Nuremberg Code (Vol. 2, pp. 181–182). U.S. Government Printing Office.

World Medical Association. (2024). Declaration of Helsinki: Ethical principles for medical research involving human participants. World Medical Association.