Consent - An Overview
Following the Nuremberg trials, there was a shift in medical ethics away from a paternalistic model of healthcare to one based on autonomy and consent. Whilst in the past the clinician would dictate treatment and healthcare needs to the patient, this has drastically shifted in the last few decades. Now we have a model of healthcare in which autonomy is paramount and the patient must consent to any treatment. They also have a greater say and involvement when it comes to decisions which relate to their health. In a sense the relationship between patient and clinician has shifted from that of a parent-child relationship to one which more closely resembles an equal partnership.
This idea of having an equal partnership with patients and respecting them as individual’s is reflected in Principle 2 of the General Medical Council’s (GMC) guidelines on consent which you can access at: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/consent
“2. Whatever the context in which medical decisions are made, you must work in partnership with your patients to ensure good care. In so doing, you must:
a. listen to patients and respect their views about their health
b. discuss with patients what their diagnosis, prognosis, treatment and care involve
c. share with patients the information they want or need in order to make decisions
d. maximise patients’ opportunities, and their ability, to make decisions for themselves
e. respect patients’ decisions.”
For consent to be valid it should satisfy the following conditions:
Voluntariness (in deciding)
Consent must be voluntary, in other words the patient’s decision must be their own. Furthermore, in line with respecting their autonomy the decision made by the patient must be free from manipulation, coercion and deceit.
2. Informed
The patient should have all the relevant information which they require to make decisions (see Montgomery vs Lanarkshire Health Board post).
This should take into account what you think the patient should know as well as what you think the patient themselves would like to know. In other words if there are any risks that you have identified as being specific to the patient these should also be disclosed.
In general the GMC recommend in Principle 9 from the document specified above:
“9. You must give patients the information they want or need about:
a. the diagnosis and prognosis
b. any uncertainties about the diagnosis or prognosis, including options for further investigations
c. options for treating or managing the condition, including the option not to treat
d. the purpose of any proposed investigation or treatment and what it will involve
e. the potential benefits, risks and burdens, and the likelihood of success, for each option; this should include information, if available, about whether the benefits or risks are affected by which organisation or doctor is chosen to provide care
f. whether a proposed investigation or treatment is part of a research programme or is an innovative treatment designed specifically for their benefit.
g. the people who will be mainly responsible for and involved in their care, what their roles are, and to what extent students may be involved h their right to refuse to take part in teaching or research
i. their right to seek a second opinion
j. any bills they will have to pay
k. any conflicts of interest that you, or your organisation, may have
l. any treatments that you believe have greater potential benefit for the patient than those you or your organisation can offer.”
3. Capacity
Finally, the patient should have the capacity, or the ability, to make the decision. This is something that we will look at further in posts on the Mental Capacity Act 2005 and in relation to Gillick competency and the Fraser guidelines.
Resources:
https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/consent
https://mdujournal.themdu.com/issue-archive/issue-1/a-question-of-consent
https://www.dentalprotection.org/uk/articles/consent-advice-booklet
https://www.ama-assn.org/delivering-care/ethics/informed-consent
https://plato.stanford.edu/entries/informed-consent/
Reference
Beauchamp, T. L., & Childress, J. F. (2001). Principles of biomedical ethics (5th ed.). New York, N.Y.: Oxford University Press.