consent and autonomy

week 2 vle

informed consent

• starting point for protecting rights and interests of individuals

• consent is very powerful

• informed consent is a legitimacy requirement for certain actions:

  • consent is needed to make certain actions legally and ethically permissible

  • lack of consent can turn a well-intended medical intervention into assault or battery

autonomy

• complex and debated philosophical concept

• self rule that is free from both controlling interference by others and from certain limitations such as inadequate understanding that prevents meaningful choice

• respecting autonomy is part of respecting rights and interests of patients

deontology

• rules govern actions and we have a duty to abide by them regardless of cost

• contrasted with emphasis on outcomes

• “the right is prior to the good”

• often seeks to respect autonomy

• it’s the only way to respecting an individual’s right to determine their own life

4 principles of biomedical ethics

• respect for autonomy

• beneficence

• non-maleficence

• justice

consent in healthcare

• treatment

• investigation

• examination

• disclosure of information

• research

• education

battery- English law and consent

• to avoid a charge of battery, a doctor must have valid conset

• for a pt to give consent, they must understand the broad nature of the procedure

• the pt need not be harmed by procedure to claim damages if battery is proved

GMC guidance

• encourages a proportionate approach to consent

• emphasises that obtaining consent doesn’t need to be a formal, time consuming process

• need to exercise your own judgement

3 basic elements of consent

1. competence/capacity

2. information

3. voluntariness

• attempts should generally be made to maximise quality of consent

capacity

• assessment of a person’s capacity must be based on their ability to make a specific decision at the time it needs to be made

• a person is unable to make a decision if they can’t do one or more of the following:

  • understand the information given to them that is relevant to the decision

  • retain that information long enough to be able to make the decision

  • use/weigh up information as part of the decision-making process

  • communicate their decision

working on capacity

• assume: every adult patient has capacity to make decisions

• do not assume that because of someone’s age, disability or communication difficulties that they lack capacity

• they may simply need extra support to help make/communicate decisions

• capacity can be decision-dependent and can change: a pt may be able to make simple decisions (but not complex ones) at a particular moment

• special considerations apply to adult who lack capacity and to children

capacity and autonomy

• capacity is a legal concept

• autonomy is an ethical/philosophical concept

• may overlap, but not exactly the same

information

• consent needs to be sufficiently informed, but information provision should be tailored to specific patient and situation

• you must give pts the information they want or need to make a decision

what information may include

• diagnosis/prognosis

• uncertainties about these

• options for treating/managing condition

• nature of each option, what would be involved, desired outcome

• potential benefits/harms/likelihood of success

you should not rely on assumptions about

• information a patient might want or need

• factors a patient might consider significant

• importance a patient might attach to different outcomes

voluntariness

• consent should be freely given without coercion

• some patients may be under pressure from employers, relatives or insurers to make particular decisions

• if there are suspicions of external pressures, efforts should be made to speak to the patients by themselves to establish whether their decision is voluntary

voluntariness involves

• explicit coercion

• implicit coercion

• power differentials in the pt/doctor relationship

• pressure from family

different forms of consent

• implied consent via compliance

  • a pt may roll up their sleeve to have their blood pressure taken

• oral consent

  • appropriate for low risk procedures/treatments

• written consent

  • generally sought for complex or higher-risk interventions

  • also if there are significant consequences for pt’s employnent, social or personal life

  • if clinical care is part of a research study

  • some specific treatments, such as fertility treatment, legally require written consent

written consent form

• a signed consent form doesn’t mean that consent is valid 

• if pt:

  • lacked capacity

  • was not provided with sufficient info

  • did not give consent voluntarily

their consent will not be valid

• written consent is evidence, rather than evidence of valid informed consent

• therefore important to also document significant aspects of consent conversation