The ritual of the patient’s reading and signing a form or chart note is meaningless if the patient is illiterate. Studies in the United States have found a substantial fraction of the population to be functionally illiterate—unable to read well enough to carry out day-to- day tasks. When the material that must be read is relatively technical in nature, such as a description of the risks and benefits of medical treatment, the number of persons capable of understanding the material drops substantially.

The first problem is determining if the patient is literate. This is not always easy, for there are some intelligent, successful people who have developed elaborate strategies to conceal their illiteracy. Moreover, many people in the United States are literate and well educated in a language other than English, so for them an English- language form is useless. Although this is obvious to the physician obtaining the consent, it seldom stops administrative personnel from having the patient sign the routine consent form. This undermines the documentation of the oral consent by calling into question the integrity of the process.

This problem requires a translator familiar with the patient’s dialect and with the medical terms. The translator should be identified in the medical record. If possible, the translator’s address and background should be on file with the hospital or physician. The translator may also serve as the witness if no one else fluent in the patient’s language is available. The translator should be cautioned not to speak for the patient but to indicate if the patient’s answer is inappropriate. The translator should write a brief note in the chart as to the patient’s understanding and linguistic abilities.