Informed consent is required in research, in treatment and for the storage use, disclosure or sharing of personal information. For this discussion, we shall consider consent to treatment as part of the delivery of health care. The concept came to the fore in the UK at a series of high profile inquiries into adverse events at Bristol and Liverpool. Those inquiries described situations where the health care professionals were deemed to have acted paternalistically and failed either to obtain valid consent or provide sufficient information to enable patients to make informed decisions. This was responsible for a shift in public opinion and reduced trust in doctors amongst some patients, although the longevity and extent of this shift remains to be proven.
In guidance to patients, published in response to these inquiries, the Department of Health states that:
“It does not matter so much how you show your consent: whether you sign or say you agree. What is important is that your consent is genuine or valid.
1. you must be able to give your consent
2. you must be given enough information to enable you to make a decision
3. you must be acting under your own free will and not, say, under the strong influence of another person”
The influence of this guidance is seen in every UK hospital, where strenuous efforts are made to ensure patient consent. However, it still appears problematic. Consider a patient journey of my own to illustrate some of the issues. A few years ago, I was afflicted with kidney stones. Before arriving at hospital, I demonstrated my incompetence to make informed decisions. In spite of being in extreme pain, I DROVE myself to hospital placing myself and other road users at risk. On arrival, my first priority was pain relief. My options were explained to me. I was unable in reality completely unable to reach an informed decision. My actual thoughts were,
“I don’t care. Just stop the pain. If you offered to stop the pain at the moment by chopping off my head with an axe, I would not only say “yes!”, I would grab the axe with both hands and chop my own head off”
A little later, morphine having been administered, I was asked if I would like more. Does the junkie refuse their next fix? No, and neither did I, although I had absolutely no idea if I needed it.
There can be other unintended side effects. Later in the same episode of care, I found myself awaiting surgery and was visited by a doctor seeking my consent for the procedure I was about to undergo. The first problem is that as in many cases, I had no real choice to make, there was no viable alternative. In such cases, too much information can harm the patient. If I have to undergo a procedure, is it helpful for me to know that the operation is low risk, but the required general anaesthetic is much more likely to kill me?, And if it is, is it helpful to me to reinforce this message with a second conversation shortly before entering the operating theatre? In this case, it seems to have more to do with watching the hospital’s back than looking after my welfare as a patient.
Informed or valid consent is a noble ideal, but appears a noble myth nevertheless.
Filed under: Informed consent