Shared decision-making and the management of surgical ignorance: A short proposal for classification

Surgery is an irreversible, invasive intervention associated with immediate and long-term risks, which make surgical decision-making particularly complex. In recent decades, Shared Decision-Making (SDM) has emerged as the ethical and practical standard, replacing traditional paternalism and addressing the limitations of informed consent. However, the actual implementation of SDM in surgery faces a fundamental challenge: the inevitable presence of surgical ignorance. This article aims to analyze the role of ignorance in SDM and propose a brief conceptual classification to facilitate its identification, communication, and ethical management. Four types of surgical ignorance are described: ignorance based on known evidence (Type I), unpredictable ignorance (Type II), strategic ignorance (Type III), and ignorance due to unknown evidence (Type IV). We argue that an authentic SDM process should not be limited to the communication of probabilistic risks but should explicitly incorporate different forms of ignorance, tailoring decision-making to the patient's values, preferences, and goals.