Informed consent in surgical practice - bridging ethical principles and implementation challenges in the Democratic Republic of Congo: a mixed-methods exploration

This study explores the implementation challenges of surgical informed consent in the resource-constrained setting of the Democratic Republic of Congo (DRC). Using an online questionnaire disseminated nationally via social media, we captured experiences of 263 Congolese adults and guardians who underwent surgery. Despite a relatively educated cohort (66.92% tertiary-educated), critical deficiencies were identified: only 50.19% received explanations of surgical risks/complications, 45.63% were offered alternative treatments, and 38.02% never signed consent forms. Notably, 34.60% reported feeling pressured to consent, and 32.70% felt unable to refuse surgery. Decision-making authority was distributed among patients (41.83%), families (29.28%), and clinicians (28.90%), highlighting socio-cultural complexities. While 50.19% felt “well informed,” 49.81% reported partial (28.52%) or inadequate (21.29%) understanding. Thematic analysis of improvement suggestions revealed overwhelming demands for plain-language explanations (77.39%), improved clinician communication (58.26%), and explicit risk/alternative disclosures (32.17%). Linguistic barriers were significant, with 19.75% of signatories unable to comprehend consent forms. The findings indicate that consent in the DRC is undermined by systemic communication gaps, power imbalances, and institutional neglect. Contextual reforms are urgently needed, including: (1) Adopting “sufficient informed consent” standards (disclosing material risks ≥ 1%/severe harm) while integrating relational autonomy; (2) Developing accessible tools (pictograms, mobile modules) for low-literacy populations; and (3) Implementing clinician communication training and patient feedback systems. These interventions should balance cultural norms with ethical obligations to transform consent from a formality into a meaningful dialogue.