Money matters: a critique of ‘informed financial consent’

Abstract In recent years, concerns about the financial burdens of health care and growing recognition of the relevance of cost to decision making and patient experience have increasingly focused attention on financial ‘transparency’ and disclosure of costs to patients. In some jurisdictions, there have been calls not only for timely disclosure of costs information, but also for ‘informed financial consent’. However, simply putting the ‘financial’ into ‘informed consent’ and invoking an informed consent standard for cost information encounters several ethical, legal, and practical difficulties. This article will examine the viability and desirability of ‘informed financial consent’, and whether it is possible to derive ideas from traditional informed consent that may improve decision making and the patient experience. We argue that, while there are important legal, ethical, and practical challenges to consider, some of the principles of informed consent to treatment can usefully guide financial communication. We also argue that, while medical practitioners (and their delegates) have an important role to play in bridging the gap between disclosure and enabling informed (financial) decision making, this must be part of a multi-faceted approach to financial communication that acknowledges the influence of non-clinical providers and other structural forces on discharging such obligations.


I. INTRODUCTION
Patients need information in order to make informed decisions about their health care.While it has long been recognised that this needs to include information about physical and psychological risks and benefits, policymakers, physicians, health economists, and bioethicists have become increasingly concerned about the financial burden of healthcare on patients. 1Even in contexts with substantial publicly funded healthcare systems, such as Australia, patients may receive government subsidy for some, but not all consultations, treatments, and tests (which may be partially subsidised or not subsidised at all, and may or may not be covered by private insurance).This means that patients may have to face financial uncertainty, surprises, and difficult financial choices.Concern about financial burden has translated into a perceived need to include information about pricing and costs of healthcare in processes of communication and shared decision making. 2 There is variation in how different jurisdictions have responded to this need.In the USA, for example, this has primarily taken the form of calls for greater financial 'transparency', 3 with an emphasis on pre-commencement disclosure of prices or costs.There have also been references to costs and financial information in the contexts relating to informed consent to medical treatment, with some scholars and policymakers looking to the doctor-patient relationship as the historical 'locus of disclosure'. 4In Australia, the Medical Board of Australia's Good Medical Practice Code of Conduct stipulates that patients should be informed about fees and charges 'in a timely manner to enable them to make an informed decision about whether they want to proceed'5 and that doctors should advise patients where there may be additional costs when referring for investigation, treatment, or a procedure. 6In the UK, General Medical Council guidance provides that doctors should give information about any out-of-pocket costs as part of informed consent to treatment. 7In New Zealand, the Code of Health and Disability Services Consumers' Rights creates a right for costs associated with healthcare to be 'fully explained'. 8Of course, approaches to costs communication are likely to be influenced by differing systems of healthcare funding and magnitudes of out-of-pocket costs to patients in each jurisdiction.In some settings, there have been calls not just for disclosure of information, but for so-called 'informed financial consent'.
This has received academic attention, 9 and has been advocated by professional bodies 10 and policymakers 11 in some jurisdictions.
In Australia, as part of government initiatives in the early 2000s, 12 'informed financial consent' emerged as a political response to rising out-of-pocket costs for individuals who have private health insurance but still need to pay sometimes substantial 'gap' costs above their coverage.In hospital settings, statutory requirements mandate disclosure of out-of-pocket costs before undergoing treatment, and describe this as 'informed financial consent'. 13Use of 'informed financial consent' has also been advocated and affirmed by the Australian Medical Association (AMA) in concert with the Australian Government Department of Health in the form of voluntary guidance for medical professionals released in 2019. 14While the AMA statement does not support a legal obligation to obtain informed financial consent, 15 medical professional disciplinary proceedings have invoked 'informed financial consent,' for example, to indicate the necessity for disclosure of lower cost alternatives in the public system for private patients. 16There has also been a limited development of the concept in contract law regarding provision of care involving public subsidy. 17In interpreting a contested contract for services between an anaesthetist and a patient, one Australian court decision addressed the absence of provider disclosure of private fees as absence of agreement to a price term. 18The court implied a reasonable fee at the standard rate of public subsidy for the service (rather than the higher private fee). 19This decision has also been referred to as establishing a legal basis (albeit limited) for 'informed financial consent' in contract law. 20he idea of 'informed financial consent' has also received some academic attention. 21These discussions posit to varying degrees that financial information-giving should be part of informed consent to treatment.In the USA, scholars have proposed 'informed financial consent' primarily in the form of advance costs disclosure in an environment of minimal transparency, 22 viewing the introduction of the No Surprises Act by US Congress in 2020 as a limited but 'meaningful nudge' towards informed financial consent. 23nvocations of 'informed financial consent' have, however, come without clear or stable definitions of the concept or express recognition of its limitations-even within jurisdictions such as Australia where the concept has been explicitly (albeit unevenly) adopted into health policy and regulation.For example, some policymaking has equated 'informed financial consent' with mere receipt of information,24 while others have alluded to obligations to provide something more than costs disclosure. 25Guidance from the AMA about informed financial consent primarily focuses on pre-commencement episode-based disclosure, although it does recommend discussing a patient's ability to pay for surgical or other medical interventions (including ongoing consultations), 26 shifting focus somewhat towards a patient's likely, holistic pathway.This can be contrasted to informed consent to treatment, where there is an emphasis on patient understanding and dialogue between doctor and patient, including about alternative options and contingencies, and ongoing discussions as investigations and treatments progress and evolve. 27Calls for doctors to provide information about costs also do not substantially consider the practical barriers that patients and practitioners face accessing and communicating about financial information. 28n this article, we argue that there are important ethical, legal, and practical considerations that limit the viability and desirability of 'informed financial consent' as a complete approach to financial communication in the medical context.There are, however, some elements of informed consent that can usefully be applied to financial communication in order to bridge the gap between mere disclosure and promoting informed decision making.This has particular resonance when care is not an emergency (so conversations can be had) and where care is open-ended and complex.
In Section II, we describe the key justifications for financial transparency in health care.In Section III, we discuss the arguments for, practicalities of, and challenges of applying 'informed financial consent' to communication about the financial aspects of care.We suggest that while the concept has important limitations, it is possible to derive ideas from informed consent that could improve decision making and the patient experience.In Sections IV and V, we conclude that practitioners (and their delegates) have an important role to play in bridging the gap between disclosure and enabling informed (financial) decision making, but that this must be part of a multi-faceted approach that acknowledges the influence of non-clinical providers and other structural forces on discharging such obligations.We consider some key elements of a multi-faceted, consent-oriented approach to financial communication in health care.
While healthcare systems will have different demands upon and barriers to good costs communication, we focus here on the Australian context that has developed notions of 'informed financial consent' in ethics, law and policy. 29The Australian approach is also internationally influential and has been referred to approvingly by scholars in the USA. 30

II. JUSTIFICATIONS FOR FINANCIAL TRANSPARENCY
Demands for financial transparency in health care have been driven primarily by the increasing recognition of the financial burden of health care on patients and the knowledge that patients do sometimes, in fact, base their treatment decisions on cost. 31Some of the effects of these costs include patient non-adherence to treatment 32 and 'financial toxicity' (harms to patients resulting from financial stressors). 33Importantly, these problems arise even in countries with substantial public healthcare and insurance systems, such the UK and Australia, where care is free at the point of delivery for certain treatments.Even in these jurisdictions, there may be out-of-pocket costs, because some services are not fully covered, and some are excluded from public subsidy, and patients receiving entirely 'free' care to begin with may require additional interventions or referral in future with associated costs.In an attempt to mitigate some of the effects of unexpected costs, scholars, policymakers, practitioners, and consumer advocates have highlighted the need to ensure that (outside of emergency situations) patients receive timely information about costs to prevent 'bill shock' and enable informed decision making about care. 34he need for financial transparency is also justified on a number of moral grounds.Most fundamentally, it is seen as a way of respecting patients' autonomy, avoiding exploitation, fulfilling the obligation of veracity, and actualising the goals of shared decision making. 35inancial transparency is also seen by some to respect patients' choices as 'consumers' of healthcare goods and services. 36The notion that patients are consumers (rather than passive recipients of care) places more responsibility and accountability on patients to seek information, and correspondingly, places a strong obligation on healthcare organisations and physicians to be transparent. 37In placing responsibility on patients, a side effect of transparency is reducing professional and provider liability.
Financial transparency is seen as a means of a managing providers' financial conflicts of interest (by making financial interests visible to patients), managing unequal access to information between producers and consumers (ie, 'information asymmetry') and ensuring the effective functioning of healthcare markets. 38The latter requires patients as 'consumers' to be able to access relevant information upon which to make their decisions.Indeed, requiring pre-treatment disclosure of costs brings the purchase of medical services into line with most other economic transactions.
Financial transparency has also been advanced as means of ensuring provider accountability 39 and resource stewardship 40 and countering price inflation in medical marketplaces by creating competitive market price pressure. 41In this regard, it is significant that both patients and health professionals have rapidly increasing access to online tools 42 that seek to facilitate both the provision and comparison of financial information.
Finally, it is argued that financial transparency can address, to varying degrees, several legal obligations and norms that govern health and medical care, relating to contracting, consumer protection and fair trading, consent and risk disclosure, health practitioner professional responsibility, and fiduciary obligations.For example, transparency may contribute to the conditions for forming a valid contract and provider disclosure is incentivised where a court's approach to contract construction would imply a lower price. 43ransparency also fulfils some of the requirements of consumer protection regulation, which seeks to incentivise or mandate disclosures that producers and providers might be reluctant to divulge. 44

III. INFORMED FINANCIAL CONSENT
There are several ways in which financial transparency can be achieved and, as noted above, several ways it has been interpreted and instantiated around the world.The most basic and least demanding form of financial transparency is price disclosure, which provides information about the standard price of a health good or service.This may take the form of list prices or a 'menu' of services.While price disclosure is relatively straightforward, it has been argued that this is not sufficient in healthcare and that information needs to be specific to the individual patient. 45Cost disclosure is therefore preferable because it provides information about the amount that a patient will likely pay out-of-pocket for a service.This may take the form of a medical bill that includes out-of-pocket cost to an individual patient after taking into account applicable insurance coverage.Another approach towards financial transparency goes further than cost disclosure, and applies the notion of 'informed consent' to financial communication about the financial aspects of care.As noted earlier, however, calls for 'informed financial consent' are often lacking in clear justifications for invoking the concept of informed consent, explanations for how to enact it, and recognition of its limitations.Here, we address these lacunae by: (i) summarising the general functions that consent has in ethics and law, which could also be applied to financial communication; (ii) considering what genuine 'informed financial consent' would entail; and (iii) considering whether it is achievable given the legal, ethical, and practical challenges such an approach raises.

A. Functions of informed consent
The potential justifications for informed financial consent are similar to the justifications for consent more generally in ethics, law and professionalism, where the concept serves three main functions.
The first is a permissive function, where consent processes formalise the way that permission is granted to touch and/or treat a patient's body or mind.This normally requires the patient to understand basic information about the nature of the health intervention. 46he second function is a risk function whereby consent processes are used to provide information about material risks to patients to help them make decisions about treatment. 47he level of information that needs to be provided about risk may vary depending on the patient's desire for information and their personal assessments about what risks are material to them.
Both the permissive function and the risk function are concerned with ethical values of autonomy and respect for persons and those ethical values are also featured in legal accounts of consent, such as via the tort of battery, the crime of assault and claims for negligent advice in medical treatment (informed consent in negligence). 48The practical effects of compliance with these legal standards is a reduction in liability and a measure of control by the patient over the risk they wish to undertake.
A third function of consent is a relational function, where the consent process provides a framework for the therapeutic relationship, in which relationships of trust and understanding may develop within the power dynamics of patients, families and health professionals. 49The relational function of consent is featured in ethical discussion of relational autonomy and in ethical discussions about hope, trust and power. 50Legally, the relational function is featured in discussions around fiduciary duty, unconscionable transactions, undue influence and the question of adequate disclosure of conflicts of interest.
All of these functions, alongside the justifications for financial transparency discussed earlier, could potentially be used to justify the provision of financial information as part of consent (either viewing this as part of consent to treatment or as an additional consent requirement).

B. Requirements for valid informed financial consent
As discussed above, the risk function of consent represents an individual's autonomous authorisation of a medical intervention, based on dialogue between doctor and patient about a proposed treatment, alternative options, including non-treatment, and the risks and benefits of each. 51A true informed financial consent standard would, therefore, require doctors to consider both what up-front costs and initial treatment costs are likely to be, and what additional financial information would be required.For example, if the patient is likely to have a complex clinical and therefore financial trajectory, or if their clinical outcomes are likely to be impacted by the financial decisions that they make, such as by delaying their treatment.It would also require that information is given not only about the financial implications of a recommended treatment but also about the costs of alternatives (including the costs of not proceeding with treatment at all).Discussions of cost would also need to be integrated with discussions about clinical risks and benefits 52 so that patients can determine not only what they can afford, but also what represents value for money to them.In order for informed financial consent to be valid, at least from an ethical perspective, information would have to address patients' unique circumstances, conversation would elicit patients' values and preferences (including regarding finances), and some attempt would need to be made to ensure that patients sufficiently understand the information provided and have had the opportunity to ask questions. 53

C. Challenges of applying informed consent to financial communication
Despite efforts to invoke and operationalise the concept of 'informed financial consent', 54 there are several challenges to doing so, which may explain why it has not been uniformly supported or translated into policy and practice.Some of these-such as the difficulties with knowing or predicting costs-apply to any kind of financial transparency, while others are specific to an informed consent standard.

Challenges that apply to any kind of financial transparency
One of the main challenges for any approach of financial communication-whether transparency through pre-commencement disclosure or as part of an informed consent framework-is the difficulty of knowing the full costs of an individual's treatment journey at the time of the key decision points.While providing information about standard prices (price disclosure) is relatively straightforward, it has been argued that this is not sufficient and that information needs to be specific to the individual patient. 55Providing patients with information about personal costs can, however, be difficult to achieve in practice. 56This is because healthcare costs are often complex, unbundled (based on a procedure rather than an episode of care) or generically bundled (where a single price covers a group of separate procedures commonly performed together), and unpredictable at the start of a course of treatment. 57hus, it can be difficult for pre-commencement costs disclosure to be accurate and comprehensive.Meaningful cost disclosure is particularly difficult for treatment that is open-ended and occurs in cycles over extended periods of time (such as cancer treatment, assisted reproductive therapy, or management of chronic disease).
Even for so-called 'shoppable' services (non-urgent care that is time-limited and can be scheduled in advance), price or pre-commencement costs disclosure will not always be sufficient to deliver meaningful personal costs transparency. 58For example, a person considering in vitro fertilisation (IVF) may be able to compare a generic per-cycle price of IVF among providers, but price listings do not tell them how many cycles of treatment a patient like them will likely undertake, how much of certain drugs they may require, and what aspects of treatment might be 'must have' versus 'nice to have'.Further, the basic per-cycle price of IVF may not be standard in what it includes and excludes, making meaningful comparison difficult. 59dditional barriers to both price and cost transparency include the difficulty of generating lists of standard prices when a wide variety of services are offered-particularly where these services involve third-party payers or providers, individual insurance coverage, and a variety of specialists working together, each with different billing structures.Some pricing structures may also mean that personalised cost information might only be available after treatment consultation, when the patient has already 'invested' in a provider (ie, it can cost money to get information about treatment costs).Doctors may also have financial interests in the products and services that they provide, 60 which may influence their ability and willingness to discuss issues of cost.
These challenges are not unique to the healthcare setting, and there are numerous common scenarios, such as house renovation or building, where it may be difficult to predict precise costs.Standard approaches to imprecise costs disclosure in contracts (for eg, trade services) do not, however, necessarily provide a good model for communication in medical care.Further, in hybrid or mixed public and private payer health systems, patients may not be accustomed to paying for complex treatment (and thus complex billing) or, indeed, for any treatment at all, or may not anticipate the financial considerations of commercial providers that can influence treatment offering, such as the profitability of some treatment options compared to others, or to non-treatment.Additionally, in Australia, there is commonly a publicly funded component to private care, which distinguishes contracts for medical services from purely private transactions.

Challenges of communicating about finances through 'informed financial consent'
In addition to there being challenges that apply to any kind of financial transparency, there are also additional challenges to applying informed consent as an approach to financial communication.For, as much as financial communication through 'informed financial consent' seeks to adopt the strengths of an informed consent framework, it also assumes some of the difficulties of informed consent based on information about (non-financial) risks and benefits, exacerbates these difficulties and creates new ones.Some of the ongoing challenges of any kind of informed consent to treatment include knowing how to define materiality and minimum standards of information provision, and ensuring that decision making is genuinely 'shared' when communication is not always easy and time is often limited. 61There is ongoing legal uncertainty about informed consent to treatment.For example, materiality is often determined subjectively to some degree, and that will tend to turn on the circumstances of a particular case.In this regard, it is important to bear in mind that even if costs can be predicted and clinicians are willing to discuss them, individuals' financial situations may change over time, so the financial implications of ongoing treatment, and the relevance of finance as a decision-making factor, cannot be presumed from disclosure of likely costs before commencement.It can also be difficult to determine what a 'reasonable patient' would consider to be material, though there are arguably some common components of materiality.These ethical and legal challenges in informed consent 59  to treatment would likely be replicated, or even exacerbated if demands were placed on clinicians to obtain genuine informed financial consent.For example, can a doctor know what is significant to someone in terms of their finances?Determining this is difficult enough when it comes to physical and psychological risks and benefits, but these are at least concerns that fit within the general area of expertise of healthcare professionals.The same is not true of financial risks, harms and benefits, which could require an understanding not only of a patient's values but also of their insurance coverage, their other (competing) financial commitments and their various financing options (eg, accessing retirement funds, asking family or friends, crowdsourcing, etc).
The requirement for informed financial consent is also complicated legally by questions about whether medical practitioners are under a fiduciary duty to their patients (ie, whether they have to act in the best interests of their patients).In the USA and Canada where doctors are presumed fiduciaries, this implies an obligation not just to disclose costs but also to inform them about potentially competing or conflicting financial interests. 62In other jurisdictions such as England, Wales, Australia, and New Zealand, medical practitioners are not presumed fiduciaries and patients need to be able to prove that their doctors owed them a duty to disclose financial information and conflicts of interest.Irrespective of whether doctors are fiduciaries or not, what doctors discuss, and how they discuss it, may vary according to their own financial interests.
There is also a risk that if doctors attempt to engage more closely in the financial aspects of an individual's care, this may engender incorrect assumptions about what people can afford which, in turn, may limit what treatment options are discussed with them.In this regard, it is noteworthy that the financial status of patients (assumed or otherwise) has been shown to influence health professionals' decision making even in contexts where patients are not paying directly for their care (ie publicly or privately insured). 63Similarly, in user-pays contexts, concerns have been raised about the balance between not providing a service, which may be discriminatory or prejudicial, versus the potential harm of offering treatment to a patient beyond their financial means, 64 particularly where treatment has low chances of success.On the other hand, for patients to share in decision making and be fully informed about the risks and benefits of their options, informed consent to treatment may need to encompass discussion with a patient about their financial constraints, especially where options offer similar clinical results.While a patient's expressed concerns about finances may go to materiality of information under informed consent, some objective indicators such as insurance status will also be relevant because of the predictable impact on patient out-ofpocket costs. 65nother challenge with informed financial consent is that it requires that information be given not only about the financial implications of recommended treatment but also about the costs of alternatives (including the costs of not proceeding with treatment at all).In mixed health systems, consent in the private setting would need to include advising on the availability of the treatment in the public system. 66But while it is reasonable to expect healthcare professionals to know about the physical and psychological risks and benefits of alternative treatments (or of no treatment), it is arguably not always reasonable to expect healthcare professionals to have a complete knowledge of the costs associated with alternative clinical decisions or with care offered by other practitioners.For example, a private billing orthopaedic surgeon may not be expected to know the detailed costs charged by other privately billing surgeons for the same knee replacement procedure.Competition law might also prohibit discussing prices with competitors to prevent price-fixing.Arguably, however, it would be reasonable for a practitioner to be able to discuss, at least in ball park figures, the relative expense of alternative pathways that are clinically appropriate, particularly where there is high potential financial impact in undergoing treatment. 67dditionally, it is difficult, if not impossible, to know where to draw the line about what counts as a cost.For some interventions, 'direct' costs may be definable and able to be costed.For example, the Medical Board of Australia provides guidelines for the range of costs required for informed (financial) consent in cosmetic surgery, including costs of other practitioners involved in care and possible costs of further, consequential treatment. 68mportantly, these guidelines stipulate that if costs of third party treatment providers are not known, a practitioner should provide indicative costs and at the least, direct the patient on how to obtain that information. 69Yet, decisions about care may entail a broader calculus.For example, a clinician might not be reasonably expected to calculate indirect costs such as the costs of travelling for attending medical care or the costs of taking time away from work or needing to pay for childcare.Thus, while some advocate for costs disclosure to be inclusive of a broader range of costs, 70 it is not clear what can be reasonably expected of clinicians in providing this information because of the degree to which indirect costs are opaque, unknown, complex, and variable according to patients' circumstances.That said, there may be some clinicians who can be expected to know and provide information about indirect costs.For example, a clinician who routinely works with patients in rural or remote areas may be expected to have and convey information about the comparative expense between local provision and travelling to a metropolitan area.
In terms of the elements that make informed consent valid, for informed financial consent to meet the standards of informed consent more generally, clinicians would need to ensure that patients have the capacity to make decisions about their own health care, and understand information disclosed to them about their healthcare costs.This may, however, be an unrealistic expectation for financial information.While it seems reasonable for healthcare professionals to have skills in assessing patients' capacity and understanding of information about physical and psychological benefits, it may be unreasonable to expect them to assess patients' financial literacy.
More generally, informed financial consent poses the risk of blurring the boundary between informing patients about costs and providing financial advice.In addition to providing information about costs, clinicians may go further, discussing the availability of financing options, such as personal loans, buy-now-pay-later schemes, early access to retirement funds 71 or financial aid programs.Not only is providing advice about certain financial 67 Whether physicians have a duty to disclose more cost-effective ways to access medicines has been considered elsewhere: N Ghinea, ' products subject to restrictive regulation (such as licensing requirements in Australia 72 ), but it is also likely to create ethical conflicts for practitioners.In cosmetic surgery in Australia, where patients typically bear high out-of-pocket costs, ethical guidelines preclude practitioners from recommending or offering commercial financing schemes, but they may inform patients about such schemes as accepted payment methods. 73While the question 'which clinical option is most cost-effective for my desired outcome?' will not ordinarily constitute financial advice, it may involve assisting with a broader calculus which may be difficult or inappropriate for clinicians.These difficulties may point to the need for independent financial expertise to help patients navigate personal finance.
From a more pragmatic perspective, informed financial consent requires that both patients and clinicians are willing to engage in this discussion, which might be difficult for cultural or contextual reasons, or because one or both parties feel uncomfortable doing so. 74Patients may, for example, view finance as a private matter and/or a personal responsibility, or prefer to spend consultation time discussing the clinical aspects of treatment.Patients may fear being denied treatment or not being offered all available options should they express concerns about the costs of care or might be concerned about receiving lower quality care as a result. 75Doctors, in turn, may be uncomfortable or unwilling to discuss costs with their patients because of general societal norms that dictate that this is a personal issue and/ or not part of a clinical interaction between a patient and a doctor.Doctors may also be uncertain about how they should respond to financial information that is shared with them or the boundary with giving financial advice, as discussed above.Doctors may not have familiarised themselves with financial information or may not be trained in managing costs communication.Particularly in complex treatment contexts, costs discussions may also be time consuming.When consultation time is limited, doctors may prefer to focus on or prioritise providing their clinical expertise.While some communication support tools have been developed in an effort to overcome some of these challenges, they are not a panacea.We discuss these tools, alongside other strategies in Section IV.
There are additional legal explanations for why informed financial consent has not been uniformly supported or translated into policy and practice.In many jurisdictions, legal duties are grounded in the law of negligence and governed by concepts of materiality, meaning that valid informed consent requires communication of information which is likely to influence a patient's treatment decision.But legal duties focused on disclosure of material risks tend not to explicitly include information other than that pertaining to the physical and psychological risks of interventions. 76For example, in Australia medical practitioners have a duty in negligence to warn patients of material risks associated with a proposed treatment, but financial risk is not one of the classes of risks that have so far been recognised at common law. 77t is, however, conceivable that financial risks will come to be considered a type of material risk as there has been shift over time from profession-based determinations of materiality (professional practice/the 'reasonable professional') to more patient-centric approaches, 72 An Australian Financial Services Licence issued by the Australian Securities and Investments Commission (ASIC) may be required under ch 7 (s 911A) of the Corporations Act 2001 (Cth). 73  7 Rogers v Whitaker (1992) 175 CLR 479.In Australia, a doctor's duty to provide information to patients before undertaking a medical procedure derives principally from the law of negligence, but the law of trespass and contract are also relevant and the common law principles have been stated in legislation in some jurisdictions.
Money matters: a critique of 'informed financial consent' � 367 which focus on what a 'reasonable patient' or what a 'reasonable person' in position of the particular patient would like to know, including risks, side effects, and alternatives. 78The materiality of costs information might also come to be captured in the objective aspect of materiality, rather than needing to be raised as a significant factor by a patient in order to trigger a subjective standard of materiality.This idea that costs are an objective, or presumed, aspect of materiality is consistent with the trend towards patients being viewed as 'consumers'.It has also been argued that 'financial toxicity' should be framed as clinical risk or 'side effect' of treatment,79 and so could be just as material as any other effect of treatment.Together, these shifts in thinking about materiality and decision making could shift the balance legally, such that financial information could come to be considered (objectively or subjectively) material.In Australia, a jurisdiction with a legal basis for informed consent under negligence, the materiality of financial information has not been legally tested.

IV. CONVERSATIONS ABOUT MONEY
Given all these challenges, it may be a mistake to attempt to address the need for financial transparency and the limitations of mere disclosure by simply demanding 'informed financial consent.'At the same time, it seems mistaken to think that clinicians have no obligations beyond mere disclosure regarding costs information and to ignore what can be translated from informed consent to treatment.What is needed is an approach to communication that draws more consistently and substantially on consent to treatment-regardless of whether it is called 'consent' or not, or is considered part of consent to treatment or a separate obligation.The question of informed financial consent suggests an important patient need and a potential gap in clinician's fulfilment of their moral obligations to patients.In this section, we point to some potential ways of addressing some of the limitations of informed financial consent to support more effective financial communication.

A. Making information more meaningful and accessible
Improving financial communication requires considering structural forces impacting information and costs communication.In order for patients to inform themselves, they need access to good information that is understandable and relevant to the individual's circumstances.Similarly, health professionals need access to good information to facilitate financial communication.
The business practices and models of provider organisations (and insurers) can influence financial communication by controlling what information is available to clinicians and to patients and how it is structured.Business practices may also influence financial communication through the allocation of resources, such as the availability of professionals to provide counselling and answer patients' questions.Providers and billers may have a responsibility to provide information on the bundle of services that patients commonly require over a course of treatment, rather than per procedure billing, even if it is less convenient for an organisation to do so.It may be that we expect more transparent and organised financial information in large, corporate, vertically integrated medical conglomerates, where services are more likely to be internally bundled.
In jurisdictions with public funding and private co-payment, billing practices may be influenced by the structure of public subsidies.However, there is likely more that providers (both doctors and provider organisations) can do to improve patient cost experiences and communication.For example, negotiating with suppliers and other specialists to minimise uncertainty about costs for other elements of treatment, such as anaesthetist services.Another example is offering access to trained administrators or counsellors as standard, and ensuring those conversations can bridge financial information (and perhaps other relevant non-medical information) and the clinical options and pathways available to the patient.This may require coordination or briefing by the physician with the administrator or counsellor.
Aside from placing ethical and regulatory demands on the profession, consumer protection frameworks may also operate to address the financial information needs of patients.Because price is generally an essential term of contract, providers will generally be required to disclose to consumers a price to be paid for services.In jurisdictions such as the UK and Australia, consumer law governs contracts where a consumer pays for goods or services, even where the consumer is also a patient and the service is medical.The timing, manner, and quality of costs information and disclosure are likely to fall within consumer protections against unfair contracting and misleading or deceptive conduct.Not only is price a key term of a contract, but consumer protection may require providing information beyond merely a written contract or advertising, for example, as 'pre-contract information'. 80Treatment providers (including clinicians and non-clinicians, such as clinics) must also ensure they structure costs information in a manner that is not misleading or deceptive.For example, by including information about the main characteristics of treatment, the total costs of treatment and how the price of the treatment is calculated.

B. Educating and guiding patients/consumers
In recognition of the challenges of financial communication, some organisations have developed tools to help facilitate informed discussion about the financial elements of care with regard to patient needs and values (eg, Heathdirect Australia's 'Questions to ask your doctor' or American Hospital Association's 'Understanding Healthcare Prices: A Consumer Guide'). 81There is also growing interest in online tools for calculating the costs of care, such as the Australian Government's 'Medical Costs Finder'. 82One of the advantages of these tools is that they do not place all the burden of disclosure on time, resource and information-constrained health professionals and can provide resources for patient to inform themselves to some extent.Another advantage is that they can educate patients and health professionals about how costs can be part of conversations about treatment.For example, a conversation guide covering how to raise financial concerns may assist patients who fear being denied or given lesser quality treatment if they ask about costs and financial information. 83However, information tools may not work for all individuals and evidence of low uptake by patients 84 suggests transparency tools on their own are not a panacea for enabling informed decision making.

C. Using principles from informed consent
Even without formally applying a notion of 'informed financial consent' (with all of its ethical and legal ramifications as discussed above), there are strong reasons for applying some of its core tenets, such as understanding and ongoing dialogue between doctor and patient, including about alternative clinical options, eliciting values, and creating space to ask questions.It is also possible to derive ideas from emerging models of informed consent that could improve decision making and the patient experience.For example, drawing on the idea from research ethics of 'meta-consent', 85 a health professional could ask all patients whether or not they would like to discuss the financial implications of recommended and alternative treatments.If the answer is 'yes', then health professionals could ask patients a range of other open-ended questions-for example, if they have specific concerns about costs they would like to discuss; if they would like information about alternatives that differ only financially from what is being suggested; and if they would like information about potential sources of funding.If patients have questions that are highly specific, it would be quite reasonable for the health professional to refer to or suggest discussion with others, such as trained administrators, financial planners, or counsellors.Importantly, these delegates and agents must be available and accessible to patients.
There are ongoing debates about meta-consent, including its impact on ethical considerations such as autonomy 86 and whether it can be used as a way to circumscribe a professional or ethical obligation in the clinical context.It also remains an open question what the legal implications of such an approach might be.One possibility is that doctors could be seen to fail in their legal obligations if they fail to at least ask patients whether they would like to discuss financial issues, fail to raise issues that would be considered objectively material (eg, the existence of a heavily subsidised or free alternative to a procedure that would be considered expensive by most people) or provide any false or misleading information about costs (although the latter would already be subject to consumer protection laws).
In this regard, tools developed to help facilitate informed discussion about the financial elements of care, such as the patient and consumer guides or online price estimate tools mentioned above, may support an approach to costs conversations that utilises metaconsent, buttressed by healthcare providers and professionals informing patients about and directing patients to relevant tools, and being prepared to facilitate personalisation of costs information to an individual patient's clinical circumstances as required.

D. Bolstering financial communication in consumer protection law
The application of consumer protection to the medical context is attracting increasing attention.For example, recent guidance from the UK's Competition and Markets Authority (CMA) for fertility clinics provides some useful insight into how consumer protection may apply in instances of medical treatment.Importantly, going beyond arms-length interactions such as accuracy in advertising, the guidance highlights that consumer law governs interactions between providers and patients before and during treatment, including individually costed treatment options. 87While the development of guidance sheds light on how consumer protection can bolster aspects of disclosure and assist in informed consent, consumer law is more limited than an informed consent standard.For example, even where consumer law may require tailoring of costs information about an individual's treatment options (such as following diagnostics), there is not likely to be responsibility to discuss alternatives to treatment.Further, the application of consumer protection should not obscure the importance of the doctor-patient relationship and the need to address the special vulnerabilities of patients that make them a unique category of consumers.

V. CONCLUSION
Good and timely costs information is generally necessary, but not always sufficient to enable patients to make informed decisions about their care.Complexity, uncertainty, and individual variance in healthcare costs tend to make disclosure and financial transparency challenging.Disclosure of patient-specific costs may be adequate in some, simple circumstances, but it may not fully satisfy doctors' moral obligations to their patients in others.In particular, mere disclosure does not satisfy the criteria for genuine 'informed consent' or 'shared decision-making', in which discussions of cost need to be integrated with discussions about clinical risks and benefits, enabling patients to determine not only what they can afford, but also what represents the most value for money to them.Thus, even if financial information can be effectively disclosed, this may fail to achieve the ethical, economic and legal goals that underpin and justify disclosure requirements.
Simply putting the 'financial' into 'informed consent' and invoking an informed consent standard for cost information as a complete approach to financial communication in the medical context has several ethical, legal, and practical difficulties, including determining patient values regarding financial risks, harms, and benefits in order to tailor the consenting process; identifying what might count as a 'cost'; determining the materiality of costs information; in obtaining costs information about alternative treatments or providers; managing assumptions about affordability; managing unwillingness of patients or clinicians to engage in discussions about costs; managing lack of expertise to assess financial capacity; and navigating the boundary between discussing the financial aspects and implications of treatment, with providing financial advice.Furthermore, informed financial consent also faces the ongoing challenges of obtaining informed consent based on information about non-financial risks and benefits.
But even without formally applying a notion of 'informed financial consent' (with all of its ethical and legal ramifications), it is possible to derive ideas from informed consent that could improve decision making and the patient experience.It is clear that practitioners (and their delegates) have a unique role to play in bridging the gap between disclosure and enabling informed (financial) decision making, including in contextualising costs among clinical options for individual patients and being a touchpoint to link patients with resources.The next step is to consider whether a consent-oriented approach should be considered part of, or additional to, consent to medical treatment itself.The extent to which consent to costs might be considered part of consent to treatment will likely depend on the legal bases, structures, and goals of professional regulation in a particular jurisdiction.
Whether or not our suggested approach to financial communication is integrated into consent to treatment, financial communication between doctors and patients must be part of a multi-faceted approach.Any ethical and regulatory demands on professionals regarding informed and shared decision making must be cognisant of the influence of non-clinical providers and other structural forces on discharging such obligations.There is need to incentivise providers to make good, timely and meaningful information available to individuals and practitioners, and recent developments in the UK suggest that the consumer law may be an effective tool to align provider behaviour with good informing processes.More broadly, as Money matters: a critique of 'informed financial consent' � 371 out-of-pocket costs associated with health care will likely continue to grow, there is need to make financial expertise and counselling accessible to patients in healthcare contexts with high potential for financial harm.
There is no way of escaping the need to discuss the financial aspects of care with patients.This cannot, however, be achieved simply by invoking legal and ethical ideas of 'informed financial consent' without considering the challenges that surround consent in general and the specific challenges related to applying notions of consent to financial communication.

FUNDING
This research was funded by the National Health and Medical Research Council (NHMRC Ideas Grant APP1181401).
United Kingdom Competition and Markets Authority, Guidance for Fertility Clinics on Consumer Law: Helping Fertility Clinics Comply with Their Consumer Law Obligations (CMA127, June 2021) para 1.6.
Physicians' Legal Duty to Disclose More Cost-Effective Treatment Options: An Examination of Australian Civil Law Applied to Personal Importation' (2023) 47 Australian Health Review 314.
68Medical Board of Australia, Guidelines for Registered Medical Practitioners Who Perform Cosmetic Medical and Surgical Procedures (Medical Board of Australia 2019). 69ibid. 70See Currow and Aranda (n 9); Cancer Council of Australia, Standard for Informed Financial Consent (April 2020) <https://www.cancer.org.au/assets/pdf/standard_for_informed_financial_consent>accessed 15 June 2023. 71N Bhatia and L Porceddu, 'Emptying the Nest Egg to Fill the Nursery: Early Release of Superannuation to Fund Assisted Reproductive Technology' 2021 University of New South Wales Law Journal 513.
Medical Board of Australia (n 68). 74M Pisu and others, 'Perspectives on Conversations About Costs of Cancer Care of Breast Cancer Survivors and Cancer Center Staff' (2019) 170 Annals of Internal Medicine S54; SY Zafar and others, 'Cost-Related Health Literacy: A Key Component of High-Quality Cancer Care' (2015) 11 Journal of Oncology Practice 171.Materiality of Conflict of Interest in Informed Consent to Medical Treatment in the United Kingdom' (2022) 32 Ethics & Behavior 375, which argues that disclosure of financial interest should be included in the duty to warn (UK).