Ethical considerations

Published on 03/03/2015 by admin

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Last modified 03/03/2015

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3 Ethical considerations

William M. Drake

Introduction

The cornerstone of a good relationship between doctor and patient is trust. In primary care, this relationship (often in the context of caring for the whole family) may be built up over several years, but in hospital practice or in an emergency, the patient and the doctor may be meeting for the first time. Patients expect a high standard of behaviour and care when they seek medical help. This includes the following expectations:

They will be consulted about decisions bearing on their treatment.

They will be informed about their illness.

They will be informed about the likely outcome of any treatment offered.

Their right to confidentiality will be respected.

Always assume that a patient is able fully to understand the nature of the medical problem and its implications, regardless of your impression of their educational level. Some patients like to discuss what they would like to know early in a consultation, and many will say clearly what information they would like to be given to the family. Occasionally, family members may feel that the patient would not be able to comprehend medical information; or ask that they are ‘protected’ from the full details of a serious illness. Patients may insist that they do not wish the family to know about their medical problems or, sometimes, that they themselves do not wish to know the diagnosis. In all such instances, the needs and rights of each individual patient should be considered paramount, over and above those of the family, in the event of conflict.

Autonomy

The fundamental principle underlying medical ethics is autonomy: the patient has the right to decide his or her own medical destiny. This gives rise to the concept of seeking the patient’s consent for medical interventions, for research and for teaching. Only in the case of a minor or a mentally disturbed person may consent be sought from the patient’s lawful parents or guardians. Assent, but not consent, may be sought from relatives, for example in the case of an unconscious patient in an intensive care unit. The doctor therefore has a duty not only to advise, but also to explain. This principle crosses all religious and cultural boundaries.

Consent

The patient’s consent should be sought for any treatment, however minor, even when that consent might appear implicit as, for example, by attendance at an emergency unit with injury. Sometimes assessment of a minor symptom discloses a separate, more serious issue. In such circumstances, consent to investigate the new problem is required.

In order to give consent, a patient must have sufficient, accurate information about the illness in order to make an informed judgement about whether its investigation and treatment are justified. There are four requirements of the doctor discussing an intervention with a patient:

1 The procedure itself must be described, including the technique and its implications, and the intended benefit of doing it.

2 Information about the risks and complications must be given, which usually means all the risks, as well as some information about the consequences of the complication (e.g. perforation at colonoscopy is a rare occurrence but, if it happens, a laparotomy and colostomy may be needed).

3 Associated risks (e.g. from anaesthesia or from other drugs that may be necessary) should be described.

4 Alternative medical or surgical investigations or treatments should be discussed, so that the reasons for the specific advice given are clear. In addition, the implications of the ‘do nothing’ option should be discussed.

Obtaining consent

The amount of information divulged will vary according to the context of the discussion and according to the needs of the patient as they emerge in the consultation. The objective is not to place the patient in the situation of having to decide between conflicting medical data, but to explain why a particular investigation or treatment is being recommended. The patient must not feel under duress.

Setting the scene

Discussions regarding consent for investigation and treatment should be conducted in a suitable environment that is quiet, free of interruptions and away from unnecessary observers, such as other patients or unfamiliar nurses or students. Make time for the discussion and turn off pagers or mobile phones which, if they interrupt a discussion, can give the impression that you are rushed and fitting the patient into a busier, more important schedule. Use simple language that the patient can understand. Be patient. If necessary, and with the patient’s permission, involve relatives. If there is likely to be a language problem, make sure that an interpreter (not a relative) is available. At the end of the discussion, check that the patient has actually understood. A written summary of the information supplied should be given to the patient for later consideration.

Implications of consent or refusal

Some patients, after detailed discussion, decline the recommended investigation or treatment. This should not result in the doctor being any less committed to their welfare. Discussions regarding alternative strategies should commence within the framework of what has been agreed and what is acceptable to the patient.

If explicit consent is given, the patient and doctor should both sign an appropriate consent form. This procedure should be followed for all serious interventions. In hospital, this will be a standardized form, and a similar form should be used in family or private practice to verify that the discussion took place. The act of both parties signing the form does not constitute proof that consent has been lawfully given but merely documents that a discussion took place. It is good practice to make a separate, contemporaneous note describing what was discussed.

Legal requirements for consent

There are three aspects of consent that are required in law:

1 The patient must be mentally and legally competent to give consent.

2 The patient must have been sufficiently well-informed to be able to give consent.

3 Consent must have been given voluntarily, and not under duress.

Competence and capacity for consent

The definition of mental capacity is given in Box 3.1. If the patient does not have capacity to make a decision, the doctor must involve the relatives, although the doctor is still taking the final decision. If the patient does not have capacity and has no relatives, in the UK the doctor must involve an independent mental capacity advocate (IMCA) to help with decision-making, particularly if consenting for surgery or for decisions about change of living circumstances.

Box 3.1 Criteria for having mental capacity

The patient can understand what has been explained