{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T06:07:22Z","timestamp":1789538842934,"version":"build-2803163510"},"reference-count":24,"publisher":"BMJ","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["J Med Ethics"],"accepted":{"date-parts":[[2026,7,22]]},"abstract":"<jats:p>Ethical accounts of informed consent require that patients understand the risks, benefits and alternatives of a proposed intervention. Recent philosophical work has examined what content must be understood and how much understanding is sufficient, but a prior question remains unresolved: what kind of concept \u2018understanding\u2019 is in this context. In current institutional practice, understanding is treated as a private mental state produced by receiving information. On this reception model, the consent process is organised around information transfer, and understanding is presumed to follow from adequate disclosure. This article argues that the reception model rests on a grammatical confusion that Wittgenstein diagnoses in Philosophical Investigations \u00a7\u00a7148\u2013155. Wittgenstein shows that \u2018understanding\u2019 is not a mental process or inner event but a capacity demonstrated in use: to say that someone understands is to say something about what they can do, not about what has occurred inside them. Applied to informed consent, this analysis reveals that the consent process as standardly practised verifies understanding using the wrong kind of evidence, collecting self-reports about an interior state rather than demonstrations of a capacity. The diagnosis explains an otherwise puzzling empirical pattern: readability-focused consent interventions produce inconsistent improvements in comprehension, while demonstration-based methods such as teach-back succeed more consistently. The article develops four implications for consent process design: evaluating adequacy by demonstrated comprehension rather than disclosure completeness; adopting teach-back as the standard approach to verification; redesigning consent forms for elicitation rather than readability alone; and narrowing the conceptual gap between ordinary consent and formal capacity assessment.<\/jats:p>","DOI":"10.1136\/jme-2026-112077","type":"journal-article","created":{"date-parts":[[2026,8,6]],"date-time":"2026-08-06T17:20:33Z","timestamp":1786036833000},"page":"jme-2026-112077","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Grammar of \u2018understanding\u2019 in informed consent: a Wittgensteinian diagnosis"],"prefix":"10.1136","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3422-0373","authenticated-orcid":false,"given":"Henry","family":"Bair","sequence":"first","affiliation":[{"name":"Wills Eye Hospital, Philadelphia, Pennsylvania, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,8,6]]},"reference":[{"key":"2026081910201741000_jme-2026-112077v2.1","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1111\/papa.12164","article-title":"Informed Consent, Disclosure, and Understanding","volume":"48","author":"Dougherty","year":"2020","journal-title":"Philos Public Aff"},{"key":"2026081910201741000_jme-2026-112077v2.2","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1080\/15265161.2020.1863511","article-title":"Informed Consent: What Must Be Disclosed and What Must Be Understood?","volume":"21","author":"Millum","year":"2021","journal-title":"Am J Bioeth"},{"key":"2026081910201741000_jme-2026-112077v2.3","unstructured":"National commission for the protection of human subjects of biomedical and behavioral research . The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research. Washington, DC: Department of Health, Education, and Welfare, 1979."},{"key":"2026081910201741000_jme-2026-112077v2.4","unstructured":"Faden RR , Beauchamp TL . A history and theory of informed consent. New York: Oxford University Press, 1986."},{"key":"2026081910201741000_jme-2026-112077v2.5","unstructured":"Beauchamp TL , Childress JF . Principles of biomedical ethics. 8th edn. New York: Oxford University Press, 2019."},{"key":"2026081910201741000_jme-2026-112077v2.6","unstructured":"Canterbury v. Spence, 464 F.2d 772 (D.C. Cir. 1972)."},{"key":"2026081910201741000_jme-2026-112077v2.7","doi-asserted-by":"publisher","DOI":"10.2471\/BLT.14.141390"},{"key":"2026081910201741000_jme-2026-112077v2.8","doi-asserted-by":"publisher","DOI":"10.1016\/j.amjsurg.2009.02.010"},{"key":"2026081910201741000_jme-2026-112077v2.9","unstructured":"Wittgenstein L . Philosophical investigations. Anscombe G , Hacker P , Schulte J , trans. 4th rev. Oxford: Wiley-Blackwell, 2009."},{"key":"2026081910201741000_jme-2026-112077v2.10","doi-asserted-by":"crossref","unstructured":"Baker GP , Hacker PMS . Wittgenstein: understanding and meaning. Volume 1 of an analytical commentary on the philosophical investigations. Part I: essays. 2nd edn. Oxford: Blackwell, 2005.","DOI":"10.1002\/9780470753101"},{"key":"2026081910201741000_jme-2026-112077v2.11","unstructured":"Hacker PMS . Wittgenstein: meaning and mind. Volume 3 of an analytical commentary on the philosophical investigations. Oxford: Blackwell, 1990."},{"key":"2026081910201741000_jme-2026-112077v2.12","doi-asserted-by":"crossref","unstructured":"Manson NC , O\u2019Neill O . Rethinking informed consent in bioethics. 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