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Aging consumer vulnerabilities influencing factors of acquiescence to informed consent.

Rapid growth in the older population raises concerns about increasing demands that aging consumers experience in service encounters. In particular, they face challenges of informed consent that require them to make decisions that support their well-being. Building on current knowledge of factors that diminish decision-making capacity with age, this study examines conditions under which aging consumers acquiesce to informed consent, when not fully informed. The conceptual framework and research propositions regarding the key factors influencing consumer vulnerability during the informed consent process are (1) cognitive changes, (2) sensory factors, (3) financial changes and (4) sender and receiver interaction. Theoretical and practical implications of the framework are discussed.

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Numerous services directed toward aging consumers require some form of informed consent prior to or in the process of service being administered. Health and living care services, including independent/dependent and assisted living, respite, memory, rehabilitation and nursing care for example, all require considerable documentation of consent for treatment and care, as well as consent for restrictions in care. This is also the case for health/life insurance, retirement planning and home financing options like reverse mortgages. Consent forms are often written with dense legal jargon that is difficult to comprehend and emphasizing the priorities of the service provider and less so the interests of the consumer (Hopper et al. 1998).

Much is known about the process of informed consent from its widespread practice in the medical arena. An array of regulations, policy statements and laws emphasizing the need for obtaining meaningful informed consent has been directed toward medical and clinical services (Fuller, Dudley, and Blacktop 2002; Leino-Kilpi et al. 2000). The necessity for obtaining informed consent from patients and the implications of failing to do so bears greatly on the risks of fatalities and other irreversible outcomes for the patient. The impact also underscores the invasive nature of these services and the legal and ethical implications involved. However, questions still remain about the practical meaning of consent for the patient and whether meaningful consent is ever achieved in practice.

In spite of the growing use of informed consent in noninvasive services (i.e., education, transportation, etc.) the practice of obtaining informed consent from consumers outside medical and clinical services has been less emphasized. Regulations and policies of standards for the content of informed consent documentation in nonmedical services are inconsistent and undefined. Even less understood is the practice and process of obtaining informed consent from vulnerable consumers whose decision making capacities and sensory competencies may be compromised as a result of aging.

Research has shown that consumers lack comprehension of the information given during informed consent discussions (Taub, Kline, and Baker 1981) and a majority of consent documents used in health-related situations are incomprehensible to most patients (Hopper et al. 1998). While the difficulty of incomprehensible informed consent documents and discussion may also exist for other groups of consumers, the problems may be of greater significance for aging consumers. Some aging consumers are faced with declining cognitive, biological and physiological abilities which heighten the feelings of vulnerability, especially in health-related service encounters that require informed consent (Pak and Kambil 2007). Evidence exists that in problem solving, some aging consumers may deliberate less, others may have less memory capacity for short-term recall, and some may lack speed in information processing (Johnson 1990; Salthouse 1996). Yet research examining the impact of imposing informed consent on aging consumers in service encounters is sparse.

Aging consumers, more than any other consumer segment value their autonomy and ability to maintain control of their daily life as they progressively mature. Many strive to hold on to their independence and self-sufficiency and avoid feelings of helplessness (Leventhal 1997). In spite of their declining abilities, aging consumers tend to base their self image on their cognitive age rather than their chronological age (Szmigin and Carrigan 2000), and often behave in ways that allow them to save face and maintain personal pride. In a study of age perceptions, Underhill and Cadwell (1984) found that 80% of adults between the ages of 40 and 60 feel 15 years younger than their actual ages. However, regardless of the youthful perception of age, for some their impairments may grow as they age, which may cause them to experience frustration and anxiety in relinquishing control. Not wanting to be perceived as incompetent, compared to young adults, aging consumers are less likely to risk making an incorrect decision or response (Dror, Katona, and Mungur 1998). Rather than seek assistance, aging consumers may make decisions based on impression management, rather than on self-preserving interests. In other words, aging consumers, in an effort to preserve self-dignity, are likely to acquiesce to informed consent without being truly informed.

Countless reports chronicle the myriad of ways aging consumers are taken advantage of in the marketplace through a range of deceptive practices as well as legitimate offers (e.g., telemarketing fraud, reverse mortgages, Medicare drug pitches; Consumeraffairs.com 2008, 2010; Huffman 2007). We posit that informed consent is not an indication of informed choice. This means that when an individual gives informed consent, it is assumed by the requestor that they understand the information given and make a decision after considering each possible option. However, one of the major findings that have emerged from research primarily in the legal and medical fields is that a preponderance of individuals signed informed consent documents without being fully informed.

Categorizing consumers as vulnerable based on demographics like age has been shown to be problematic as it is often situational conditions that create experiences of vulnerability (Adkins and Jae 2010; Baker, Gentry, and Rittenburg 2005; Ringold 2005). In light of this, Baker, Gentry, and Rittenburg (2005, p. 134) offer the following conceptualization.
   Consumer vulnerability is a state of powerlessness that arises from
   an imbalance in marketplace interactions or from the consumption of
   marketing messages and products. It occurs when control is not in
   an individual's hands, creating a dependence on external factors
   (e.g., marketers) to create fairness in the marketplace. The actual
   vulnerability arises from the interaction of individual states,
   individual characteristics, and external conditions within a
   context where consumption goals may be hindered and the experience
   affects personal and social perceptions of self.


This definition is adopted here as it captures individual characteristics (e.g., age, health, cognitive capacity, self-concept, and socioeconomic status), states (e.g., mobility, life transitions) and external conditions (e.g., resource distribution, discrimination) that contribute to experiences of vulnerability.

The concept of acquiescing to informed consent is an important element in understanding how aging consumers interact with service providers in light of changes in their vision, hearing and cognition. The request for informed consent in the service context is more than simply giving permission, but is instead intricately rooted in the individual consumer relinquishing personal autonomy. Aging consumers may lack the cognitive and physical capacity to facilitate meaningful decision making and thereby likely to acquiesce. In this respect, marketers must understand how the aging consumer, many with decreasing intellectual functioning, responds to various marketing activities.

The goal of this study is to explore the impact of age-based changes on aging consumers that may increase their feelings of vulnerability, resulting in acquiescing to informed consent even though in reality they may be uninformed. Our intent is not to suggest that aging consumers are stereotypically without autonomy, competence and capacity for decision making (Leventhal 1997). Rather, as aging consumers experience more vulnerability, they are likely to adapt to the changing stimuli (marketplace demands) by acquiescing, rather than concede to the need for assistance or advocacy. As a consequence, these consumers are more likely to be taken advantage of in the marketplace.

In the following sections, we explore the nature of informed consent, and the concept of acquiescence in consumer markets. With a discussion of the cognitive, sensory and financial changes that affect consumers as they age, we propose a framework for acquiescence to informed consent and present research propositions. We conclude with a discussion on the implications for service providers and policymakers relative to consumer protection.

THE NATURE OF INFORMED CONSENT

Informed consent has its origins in the medical and legal area and is most known in the context of human subject research and the Nuremberg Code 1947. This code stipulates that the patient must give consent prior to participating in clinical research, and thereby requires legal capacity to give consent, free power of choice, without force or duress and with full comprehension of what is involved (Aveyard 2002). Over the past two decades, the importance of informed consent and the related issues of individual privacy and autonomy have received much attention in the nursing and health care ethics literature (Leino-Kilpi et al. 2000, 2003). Today, the concept of informed consent is not an unfamiliar precept in everyday transaction, as it has ethical implications for legitimacy in marketplace exchanges. As O'Neill (2003, p. 4) describes:
   Informed consent is nothing strange. It is a familiar and ethically
   important aspect of everyday transactions. Shopping and borrowing a
   book from the library, taking one's clothes to the cleaners and
   buying a train ticket are ethically acceptable, but only if all
   parties to the transaction take part willingly in awareness of ways
   in which others' proposed action will bear on them.


The point of consent is to minimize deception and coercion. In the more formal context (i.e., contractual and obligatory exchange), the value of informed consent is used as a tool to educate consumers by providing information considered to be important for each individual to know before agreeing to be administered service. From a legal and ethical standpoint, Faden and Beauchamp (1986, p. 275) defines informed consent as:

X is an informed consent by person P to intervention I if and only if:

* P receives a thorough disclosure regarding I.

* P comprehends the disclosure.

* P acts voluntarily in performing X.

* P is competent to perform X.

* P consents to I.

Legally, informed consent must be based on three fundamental elements; (1) the consumer must understand risks, potential benefits and the alternatives, if any; (2)consent must be given willingly and without duress; and (3) the consumer must be mentally competent (Hopper et al. 1998). In principle then, informed consent should involve disclosure of the risks involved and provide the individual consumer with tangible assurance of being adequately informed. With these requirements of legal informed consent, the expectation is that if one has the capacity to give consent, one also has the capacity to make decisions based on fully informed choice. Thus, for valid informed consent, the consumer must be able not only to understand, but also to retain the information and comprehend the consequences of consent (Fuller, Dudley, and Blacktop 2002). For aging consumers with decreasing memory and processing capabilities, this presents an increasing challenge.

ACQUIESCENCE IN THE MARKETPLACE

The concept of acquiescence has a long history of importance to researchers, in particular, personality theorists and measurement specialists who maintain that acquiescence is a style of responding that interjects biases in the response given by a respondent (Cronbach 1946, 1950; Winkler, Kanouse, and Ware 1982). Personality theorists define acquiescence as "the tendency to agree rather than disagree with propositions in general" (Paulhus 1991, p. 46). Social psychologists consider acquiescence to be a personality trait that causes responses driven more by social desirability (Couch and Keniston 1960; Miller et al. 1965; Rorer 1965). The motivation for agreement by the respondent is to avoid a negative self image and thereby attempts to be agreeable to avoid the discontentment of the person in authority.

From a marketplace perspective, Morgan and Hunt (1994, p. 25) examines the concept of acquiescence from a commitment-trust theory perspective in relationship marketing. They define acquiescence as "the degree to which a partner accepts or adheres to another's specific requests or policies." The notion of partnership suggests an existing relationship or commitment that influences the likelihood of acquiescence. Along this line, the authors propose that relationship commitment between the parties involved will positively influence acquiescence. However, as commitment entails vulnerability, trust between partners in the relationship, influences acquiescence only as a result of relationship commitment. From a consumer perspective, a partnership-based committed relationship may not exist with a service provider, and thus less likely a positive factor in the process of acquiescing to informed consent. But, the uncertainty that may exist from the lack of a prior relationship with the service provider may negatively influence consumer acquiescence.

Studies show that when consumers are comfortable with their upfront decisions and subsequent consumption behaviors, the feelings of regret are minimized and dissonance is lowered (Coulter and Coulter 2002). Studies have also shown that acquiescence correlates negatively with intelligence, and individuals mentally challenged are most prone to acquiesce (Gudjonsson 1986; Sigelman et al. 1981). Thus, regret and dissonance are likely outcomes of acquiescing to informed consent when not completely informed and when doubt exists as to what one is consenting to. It has been proposed that acquiescence should be greatest when people are uncertain about their memory and are pressed to answer questions about the details relating to personal experiences (Gudjonsson 1987, 1989; Gudjonsson and Clark 1986). It has been quietly assumed that acquiescence is a proxy for consumer comfort with complex decisions (i.e., informed consent) especially for the aging consumer segments. This assumption stems from consumers failing to disclose their incomprehension of the process and meaning of consent.

FRAMEWORK OF ACQUIESCENCE TO INFORMED CONSENT

With an understanding of the concepts of informed consent and acquiescence, our framework holds that acquiescing to informed consent implies cognitively evaluating the choice to accept the request or proposition for consent, even though privately one's preference may differ from the decision to acquiesce. Given that aging consumers face specific patterns of change along several dimensions, our framework confronts the cognitive, sensory and financial changes that may impede older consumers. While we address these three dimensions, the proposed framework does not claim to be exhaustive of the challenges faced by aging consumers. Rather, it offers a springboard from which to gain deeper understanding of the trends and inclinations imposed on this consumer segment and the resulting challenges of interfacing in a marketplace with increasing demand for informed consent. The acquiescence to informed consent framework is illustrated in Figure 1 with research propositions following the discussion of each dimension.

Cognitive Changes

Aging triggers changes in cognitive functioning especially with one's memory, learning and information processing capabilities. Considerable evidence shows that a deficit in short-term memory is strongly associated with aging, and these deficiencies are due to the decrease in mental flexibility in processing (Anders, Fozard, and Lillyquist 1972; Dobbs and Rule 1989). These changes affect the consumer's mental processes underlying their full understanding of informed consent. Studies have also shown that both visual and auditory learning are impaired, forcing consumers to rely on immediately relevant cues with little textual information content to understand what is being communicated (Bromley 1958; Inglis and Caird 1963). Evidence of information processing challenges faced by aging consumers can be seen in the decline of their ability to ignore "noise," or disregard extraneous visual or audio information (Pak and Kambil 2007; Rabbitt 1965).

[FIGURE 1 OMITTED]

In a study evaluating the reading levels of informed consent documents used in psychology research and other fields (medical, social science and education, health, physical education and recreation research), researchers found that informed consent documents are typically written at a much higher reading level than that appropriate for the intended population. These documents are typically written at the twelfth-grade reading comprehension level or beyond, while the average American adult typically reads at the eighth-grade level (Baker and Taub 1983; Mortensen, Kiyak, and Omnell 2003; Ogloff and Otto 1991). As a result of the high reading levels of the consent documents, these authors questioned whether individuals can comprehend the information contained in the consent forms.

Rempusheski (1991) suggest that memory is a critical factor in understanding the information content of informed consent forms. Most documents are dense and lengthy, and most individuals can process only small amounts of information at a time while retaining what is read. For aging consumers with even mild memory impairment, it becomes difficult to engage in the simultaneous task of reading and comprehending. This heightens feelings of insecurity which may prevent the consumer from asking questions for fear of being perceived as unintelligent or lacking in intellect. However, comprehension is assumed if the consumer asks no questions or makes inquiries for further clarification before signing the documents. Lack of comprehension violates the competency factor for valid informed consent. Thus hard-to-understand informed consent forms may prove challenging for aging consumers.

P1: Aging consumers with cognitive impairments will be more (less) vulnerable to acquiescing to informed consent the more (less) difficult is it to comprehend the informed consent document.

In health care and other service contexts, informed consent is a process of shared decision making between the individual and the provider. To be an effective decision maker, not only must the individual consumer have sufficient capacity to participate and make choices affecting their care, but they must also comprehend the nature, significance and potential outcome of their choices. This capacity can be inhibited among aging consumers, as the rate at which new information is learned also declines with age. However, to assume all aging consumers have difficulty learning new information in making rational and reasonable decisions would reflect unfortunate stereotyping. While some may experience deficits in short-term memory capacity and memory strategies, they still maintain high knowledge basis of their values and opinions (John and Cole 1986). Spotts and Schewe (1989) found that when individuals are allowed to self-pace learning new information, the learning deficiencies typically attributed to aging does not occur. As such, aging consumers may have different ability levels in new task and comprehension situations that require the service provider to adjust their process of obtaining consent. Therefore, service practitioners must critically assess their procedures for obtaining informed consent and their methods of communicating with aging consumers who have slower rates of learning, to ensure these consumers are fully informed.

P2: Aging consumers with cognitive impairments that learn new information at a slower (faster) rate will be more (less) vulnerable to acquiesce to informed consent the more (less) difficult is it to comprehend the informed consent document.

Sensory Changes

Changes in sensory functioning can impact aging consumers' sense of control. Physical changes among older consumers reduce the ability to remain independent and conduct activities of daily living. More than 37% of people 65 years of age and older in the United States have some degree of visual impairment (Desai et al. 2001). Kosnik et al. (1988) found that when their vision is impaired, older adults are more bothered by glare, faint lighting and near visual tasks. They experience difficulty extracting information and completing routine activities. Pak and Kambil (2007, p. 8), argue that aging can "lead to less light entering the eye, delays in adapting to the dark, and problems with color vision or 'floaters' in the visual field. Common aging diseases of the eye and ear (e.g., glaucoma, macular degeneration, ear infection or nerve damage) can further diminish these senses." Changes in vision make it difficult to perform visually dependent tasks. This can lead to feelings of vulnerability for some aging consumers who may be unable to compensate for visual loss. These feelings are even more heightened and debilitating when confronted with an informed consent document.

P3: Aging consumers with visual impairment will be more vulnerable to acquiesce to informed consent, compared to older consumers without visual impairment.

Decline in hearing may also lead to feelings of ineptness, as aging consumers are forced to seek assistance with tasks typically done independently. One-third of persons 70 years or older in the United States suffer from some level of heating impairment (Desai et al. 2001). Reduction in heating capacity interferes with effective communication, and aging consumers with this impairment tend to experience difficulty understanding simple conversational speech in everyday settings. Often, they miss segments of what is said and with a lack of accuracy and confidence in what they do understand, aging consumers tend to experience anxiety and frustration and may choose to avoid or exclude themselves from some conversations and interactions altogether (Murphy, Daneman, and Schneider 2006). Even verbal consent can be affected by their inability to engage in a dialogue with a service provider.

P4: Aging consumers with hearing impairment will be more vulnerable to acquiesce to informed consent.

Understanding the sensory challenges and the sensitivities of aging consumers relative to these growing impairments, service providers must take into consideration all aspects of acoustics and auditory levels as well as the speed of speech when dealing with aging consumers. Reevaluation of the methods of obtaining informed consent must also take into account these considerations in face-to-face interactions as well as communication through telephone and other devices.

Financial Changes

Consumers in the 65+ age category in the United States have achieved the highest levels of accumulated wealth than any other consumer segment; have more spending power than any other group; and control at least half of the consumer economy. However, in making financial decisions, some may not have adequate understanding of financial and investment terms and many rarely do the due diligence necessary in checking their credit reports (Pak and Kambil 2007). Nevertheless, the financial outlook for aging consumers is not a saga of losses. Next we address the positive and negative financial changes that influence vulnerability among aging consumers.

Positive financial changes that occur among aging consumers include increase in wealth from retirement savings, long-term trust, inheritances and investments. AARP (2007) indicates that on average, financial asset values for consumers 50 to 64 years old increased by 80%, and 55% for those 65+ in the past decade. Further, in 2005, more than half (54.9%) of consumers 62 and older received income from nonsocial security services. While social security may be considered the mainstay of income source for some aging consumers, many have secured their futures with nonretirement wealth and other sources of funds. For these consumers, having financial security increases feelings of empowerment and stability in maintaining their desired lifestyle. However, this security is not without its challenges.

Being wealthy and aging can disproportionately make these consumers targets for deception and abuse. For some, lack of financial literacy makes it difficult to navigate the complex and ubiquitous marketplace. For others, risks embedded in both simple and sophisticated offerings are indiscernible. Still, others may lack basic money management skills or have differential access to credible financial service providers. Taken together, these challenges increase aging consumers susceptibility to predators, deception and fraud, and make them therefore vulnerable (Lee and Soberon-Ferrer 1997). Many may rely on others to manage their finances which increase the risk of being financially exploited (Rabiner, Brown, and O'Keeffe 2004).

P5a: Positive financial changes will increase actual vulnerability and increase the likelihood of acquiescence to informed consent.

Negative financial changes relate to declines in income and wealth due to economic changes, job loss, change in living situation (e.g., loss of spouse) and retirement with little or no pension or savings. Some older consumers may have limited or fixed incomes which restrict their ability to live as comfortably as desired. They become targets to be preyed upon and they respond because of fear of an uncertain future. It has become commonplace to hear news reports of aging individuals being victimized by a range of fraudulent offers, including credit assistance, loan consolidation, free prize offers, home repairs and charity scares among many others (Titus and Gover 2001). Friedman (1992) describes confidence swindles as a growing form of financial abuse directly targeting aging consumers with several notable characteristics. Specifically, in addition to declining cognitive and physical capabilities, some aging consumers can be easily found at home, malls, banks and medical buildings. Those living alone may be socially isolated. Craving social interaction they are more willing to communicate with strangers. Being less knowledgeable about the nature and consequences of the transaction, they are less likely to discern undue influence or make intelligent choices that serve their best interest (Nerenberg 1996). These financial abuses like swindles require the individual to consensually disclose personal information which further facilitates victimization.

P5b: Negative financial changes will increase actual vulnerability and increase the likelihood of acquiescence to informed consent.

Financial Self-Efficacy

Some aging consumers may have strong efficacy beliefs in their ability to influence and manage financial changes. These self-efficacy beliefs will impact the vulnerability that may be experienced in the face of financial changes. Self-efficacy refers to "beliefs in one's capabilities to mobilize the motivation, cognitive resources, and courses of action needed to meet given situational demands" (Wood and Bandura 1989, p. 408). It is "the conviction that one can successfully execute the behavior required to produce outcomes" (Bandura 1977, p. 193). Thus, financial self-efficacy is a consumer's sense of confidence and belief in his/her skill in understanding investments, wealth and income, as well as the ability to make the fight decisions relative to his/her financial well-being. Aging consumers who are financially efficacious will not experience as much vulnerability as one who is not as efficacious. Conversely, aging consumers who lack confidence in their ability to manage financial changes will be more susceptible to vulnerability. However, if they are confident in their ability to manage their finances in a manner that allows them to achieve positive financial outcomes, then vulnerability is mitigated. This is the case in conditions where an aging consumer experiences either positive or negative financial changes. In other words, either type of change can lead to a positive outcome for the consumer, provided they have a suitable level of financial self-efficacy. Thus, financial self-efficacy moderates the impact of positive or negative financial changes on actual vulnerability. We posit that when financial self-efficacy is high, the aging consumer will experience less vulnerability; whereas, when financial self-efficacy is low, aging consumers will experience greater vulnerability.

P5c: Financial self-efficacy will moderate the effects of financial changes on vulnerability.

SENDER AND RECEIVER INTERACTION

Consumer-centered communication must be the fundamental prerequisite in the process of gaining informed consent. Adequate amount of information must be given, accuracy of expectations must be determined and transparency of the risks and alternatives must be disclosed in such a way as to not diminish the autonomy of the aging consumer or heighten feelings of vulnerability. However, personality and attitudinal characteristics of the service representative (sender) can influence the receptivity of the message being communicated to the aging consumer (receiver) and further complicate the process of informed consent in face-to-face interaction. Studies have shown that receivers will judge the motive of the sender in an effort to gain confidence, determine honesty and ascertain accuracy in the message being communicated (Van Swol 2009). Further, to determine trustworthiness receivers make attributions about the sender based on person-related characteristics, and these judgments are likely to remain unaltered throughout the interaction (Burgoon et al. 1996).

Judgment of motive corresponds with theories of causal attributions, which relate to judgments about the cause of self or others' behavior. Attribution theorists suggest that people want to predict the behaviors of others and people assign traits to others because these traits are thought to be useful predictors of future behavior (Erickson and Krull 1999). The request for informed consent may be thought of positively by older consumers, believing the service representative cares, is concerned about the customer's welfare, and wants to ensure that the individual is fully aware of the factors involved (i.e., risks, alternatives, benefits) in the transaction. This positive judgment of motive is referred to here as other-serving. On the other hand, the aging consumer may judge the service representative's motive for requesting informed consent negatively, as not in support of the customer's best interest. Instead, the consent is a means of creating legal standing or grounds for disclaiming responsibility or liability for the service firm and its representatives should the outcome be less than expected. This reflects Deutsch's (1958) individualistic motivational orientation, which is referred to here as self-serving.

In the process of gaining informed consent, the demeanor of the service representative requesting consent can bear greatly on the likelihood of acquiescence, if vulnerable consumers attempt to judge the motivation behind the request. To elucidate this point, we employ the findings of Coulter and Coulter (2002), who identified empathy and politeness as person-related characteristics of the service representative that can impact trust in the consumer-service provider relationship. If a vulnerable consumer is prompted to judge the motive for informed consent, then it is likely that trust has not been established and acquiescence may be unlikely. The authors posited that empathy and politeness are particularly important in the establishment of trust in the early stages of the relationship. Politeness refers to the service representative being considerate, tactful, deferent, or courteous toward the customer. Empathy refers to the service representative possessing a warm, considerate and caring attitude, and engages cognitively and affectively to make an effort to understand and experience the consumer's feelings as their very own (Coulter and Coulter 2002; Dallimore, Sparks, and Butcher 2007; Parasuraman, Zeithaml, and Berry 1988). A service representative with a polite (vs. empathetic) demeanor may generate feelings of a distant professional courtesy which is centered around informing the patient to ensure no possible oversights have occurred that could lead to legal issues for the service provider. Whereas a service provider with an empathetic (vs. polite) demeanor may exude a sincere feeling of concern for the patient while communicating the requisite information to avoid potential legal issues. In the former case, the vulnerable consumer should perceive the service representative as having an other-serving motive and experience increased vulnerability; and in the latter case, the consumer should perceive the service representative as having a self-serving motive and experience reduced vulnerability. Thus,

P6a: Aging consumers who perceive a self-serving (other-serving) service provider motive will experience more (less) vulnerability in acquiescing to informed consent.

P6b: Vulnerable consumers will perceive an empathetic (polite) service representative to have an other-serving (self-serving) motive in requesting informed consent.

Message strategy is another important consideration in how aging consumers interact with service providers. When exposed to information, aging consumers tend to rely on their accumulated intellectual and social resources to partially offset cognitive shortfalls (Phillips and Sternthal 1977). Kardes, Kim, and Lim (1994) found that a consumer's level of knowledge moderates the effectiveness of explicit vs. implicit product claims. Explicit claims are factual and leave little room for error in translation or misinterpretation. Consumers are told explicitly what beliefs to hold about the service provider. In contrast, implicit claims are more subtle and can be misleading, allowing for counterarguments and multiple interpretations (Bonifield and Cole 2007). Consumers are encouraged to arrive at their own conclusions. Unknowledgeable consumers respond more favorably to explicit claims because they have limited knowledge and experience to draw the appropriate conclusion (Kardes, Kim, and Lim 1994). If some aging consumers lack knowledge about the service provider or service requiring consent, they are likely to view explicit claims more favorably. Thus, employing an explicit claim message strategy with older consumers will minimize vulnerability. However, if implicit claims are made by the service representative and the consumer is unknowledgeable, consumer vulnerability will be heightened. For this reason, the method of communication and message strategy of the service provider (e.g., sender) must be considered, as unaddressed statements may increase perception of risks and vulnerability.

P7: Service personnel who use explicit claims (implicit claims) will reduce (increase) feelings of vulnerability and the likelihood of acquiescence to informed consent.

Vulnerability in Consent

Considering vulnerability in the context of the legal parameters in obtaining informed consent, Morgan, Schuler, and Stoltman (1995) offer a typology of vulnerability. (1) Physical competency (i.e., hearing disabilities associated with aging): aging consumers with cognitive limitations (hearing, vision and possibly speech) may lack the competency to provide valid and informed consent; (2) Level of sophistication (i.e., socioeconomics, capacity for understanding the terms of an agreement): in the case of older consumers, financial changes along with sensory issues may decrease their level of sophistication, thereby increasing vulnerabilities; (3) Mental competency (i.e., processing capabilities): vulnerability is an evolving process created and to be understood in terms of cumulative conditions (Webb and Harinarayan 1999). That is to say, consumers may move in and out of situations where they experience vulnerability or are at risk for a defined period of time. When the situation expires, so does the risk and temporary state of vulnerability. For others, individual characteristics and permanent life stage conditions (e.g., physical or mental disability) place them in a state of enduring vulnerability (Mansfield and Pinto 2008). When vulnerable, people are less able to protect their interests and are often less aware of their limitations (Wolburg 2005). The cognitive, sensory and financial changes that create vulnerabilities for older consumers are real and may not improve, but rather worsen with time. As such, it is their experienced vulnerability that must be considered in the context of informed consent.

P8: Actual vulnerability will mediate older consumers' acquiescence to informed consent.

DISCUSSION AND IMPLICATIONS

Understanding variation in acquiescence, as well as factors that may increase the likelihood of aging consumers acquiescing to give informed consent is substantively important because of the ethical and legal implications across services that increasingly require informed consent. This issue is also of importance to policymakers who are responsible for developing and implementing, informed consent standards of procedures and policies to protect consumers' interests.

Implications for Service Providers

Service providers must understand the changing characteristics of the aging consumer market and the impact of these changes on their interaction in the marketplace. The process and protocol for gaining informed consent must reflect the evaluative capabilities of each individual customer. Given that some consumers may be more or less impaired cognitively, consent cannot be gained simply by asking the consumer to read the consent document and sign. Rather, the process of consent must include discussion of what is involved in the service to be administered to the consumer. It should contain tools to assess assurance of learning before the request for signature as an indicator of being informed and the act of consenting. Consideration must be given to those consumers who are more sensory challenged and thus more comfortable with self-paced learning and visual aids to understand complex situations. The manner in which a request for informed consent is delivered; the types of claims used in the message and the personal disposition of the requestor can significantly influence the customer's perception and expectation of a satisfactory outcome.

Relationship marketing can serve as a buffer between aging consumer vulnerability and the service provider. Service providers should attempt to create positive relationships with aging consumers to build trust and mitigate the negative effects of vulnerability. In requesting informed consent, service personnel must recognize that the customer is attempting to adjust or cope with a situation that renders them somewhat powerless, in that they are at the mercy of the service provider for resolution to a problem that they themselves may not have the capacity to understand or resolve.

Oftentimes vulnerable consumers enter into an exchange with an inferior disposition and are reluctant to challenge the service representative or ask for further clarification. This speaks to some aging consumers' need for social desirability and the decision to acquiesce to attain it. Thus, it is important that service providers prepare personnel to be more altruistic and transparent when dealing with aging consumers. Enhancing the consumer's level of comprehension will decrease their feelings of vulnerability; increase their sense of competence, and increase their level of comfort in the decision-making process for informed consent.

Implications for Policymakers

Policymakers are responsible for attending to the needs of vulnerable consumer segments by empowering consumers through education, alternative modes of ascertaining informed consent or mandating the protection of aging vulnerable consumers during the process of informed consent. As aging consumers may be reluctant to acknowledge their deficiencies, policymakers must ensure access to advocates who will assure the well-being of the consumer during the consent process. Similar to health advocates found in medical care services, consumer-service advocates would help to facilitate aging consumers' autonomy. They may serve as interpreters or translators, focusing on simplifying the content and context of the service requirement for informed consent.

The impact of authority figures as influencers of aging consumers' acquiescing has implications in the legal arena as well, where lawsuits alleging coercion, violation of personal and civil fights are numerous. From a medical perspective, asserting the law's interest in protecting patient autonomy, Justice Cardozo declared that "every human adult of years and sound mind has the fight to determine what shall be done with his own body; and a surgeon who performs an operation without his patient's consent commits an assault for which he is liable in damages" (Mawn 1999).

Recognizing the self-determination decision process that is expected from consumers who are not impaired, policymakers should examine the shortcomings existing in the process of informed consent across services, in particular those focusing on aging consumers. They should consider inclusive content in informed consent documents that reflect boundaries of conduct especially for these service providers. Ultimately, there would be legal liability associated with services that fail to follow designated protocol in informing aging consumers of the risks, benefits and consequences or adverse outcomes involved in the service.

Policymakers should recognize the inconsistencies of consent forms across all service sectors (i.e., medical, financial, educational). The content of these documents may be prohibitive for consumers to comprehend the authentic risks that are inherent in the presence of the request, especially among the vulnerable consumer segments. Specifically, in the case of adverse outcomes, the individual is held more legally responsible even though the cause of the unfavorable outcome occurred at the hand of the service provider. From this perspective, policies to increase consumer protection are needed.

CONCLUSION

There are several factors that should be noted when dealing with aging consumers. With the increasing use of informed consent, resolution to the issue of gaining valid informed consent from aging consumers lie in understanding the factors discussed above which impact their decision to relinquish control to a service provider. Factors such as cognitive impairment, financial changes, and sensory changes increase consumer vulnerability. These changes can impede an aging consumer's ability to fully interpret informed consent. Aging consumers have a strong need to have trust in the relationship with service providers. Therefore, the commitment-trust relationship between the service provider and the consumer is important because increased vulnerability can have a negative effect on acquiescence to informed consent. Thus, service providers should be sure to establish the appropriate guidelines to help decrease the vulnerability encountered by aging consumers.

Our propositional inventory and integrative framework represent efforts to build a foundation for addressing older consumers' vulnerability during the informed consent process. To fully understand aging factors that affect older consumers' acquiescence to informed consent, empirical studies to validate the model should be undertaken. Such studies will undoubtedly offer additional insights regarding the conditions under which these and other factors influence older consumers' decision to acquiescence during the informed consent process. Furthermore, empirical studies and simulations can provide marketers and policymakers with a better understanding of the steps that can be taken to reduce vulnerability for older consumers.

With the increasing use of electronic communication medium, the process for informed consent in an online format eliminates the face-to-face interaction with service representatives. The experiences of vulnerability are likely to differ and the challenges may or may not influence acquiescence behaviors. These differences should be addressed in future research. Further, exploration must also involve post-acquiescence outcomes like regret and dissonance, as well as mechanisms adopted for coping with the vulnerability experienced during decision making.

Extending this work, there are psychological concepts that are relevant to gaining consent that would further extend our understanding of the concept of consumer acquiescence. These include reciprocation, consistency, social validation, authority, scarcity and liking, known as the principles of persuasion (Cialdini et al. 1997; Cialdini, Schaller, and Houlihan 1987; Cialdini and Trost 1998). Finally, exploring how aging consumers conceptualize informed consent, the salience of risks involved in the undertaking, and their perception of responsibility will offer further insight in understanding aging consumers' interaction with services in the marketplace.

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Merlyn A. Griffiths (magriff3@uncg.edu) is an Assistant Professor at the University of North Carolina-Greensboro's Bryan School of Business and Economics. Tracy R. Harmon (tracy.harmon@udayton.edu) is an Assistant Professor at the University of Dayton School of Business Administration. The authors would like to thank Carol Kaufman-Scarborough for feedback on an earlier version of this manuscript.
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Date:Sep 22, 2011
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