Dr Mike Ewart SmithDivision of Psychiatry, University of

Witwatersrand

The Ethics of Informed Consent: Revisiting the

Doctor Patient Relationship

Paternalism

Making of decisions by professionals on behalf of patients

Dirty word – OUT – AUTONOMY is IN

Liberty, dignity, individuality, independence, accepting responsibility, self assertion, knowledge of one’s own interests, privacy, voluntariness, freedom from coercion or deception

HPCSA Guidelines Booklet 9 May 2008

SEEKING PATIENTS’ INFORMED CONSENT: THE ETHICAL CONSIDERATIONS

Informed consent

The process by which a fully informed patient can be an informed participant in her health care decisions

Ethical obligation to inform patients on

DiagnosisTreatment PlansSide effects of medication

Patient must be informed of :

Nature and purpose of the interventionReasonable alternativesRelevant risks, benefits and uncertainties

of each alternative

Patients must

have knowledge of the nature or extent of the harm or risk

appreciate and understand the nature of the harm or risk

consent to the harm or assume the risk

andThe consent must be comprehensive,

including consequences

Exceptions : patient incompetent to participate

ComaAltered state of consciousnessMentally illDementiaChild

“Try to find out whether”

The patient has previously mandated someone else in writing to make decisions on their behalf

Have indicated preferences in an advance statement (“living will”, “advance directive”)

Or take into account “patient’s known wishes”

Living Will

Living Will is binding in law, and a doctor who disregards it is legally in the wrong

To disregard a Living Will is an assault against the patient and doctor can be sued

It is the patient’s informed consent and not the doctor’s motive which makes the doctor’s intervention lawful

McQuoid-Mason

Hierarchy of persons able to consent for incompetent patients

Person authorised by court eg curatorSpousePartnerParentGrandparentMajor childBrother or sister

“Best interests” principle

Clinical indicationsPrevious expressed preferencesPatient’s background..cultural, religious,

employmentThird party’s views of the patient’s

preferencesWhich option least restricts patient’s future

choices

Emergencies

Provide treatment but limit to what is necessary to save life or avoid significant deterioration in patient’s health

But respect valid advance refusal by the patient

Give patient information as soon as she is sufficiently recovered

Children & Informed Consent

Age of consentMedical treatmentSurgeryReproductive

Parental role Differences between wishes of child and those

of the parents (or between parents)Refusal of treatment based on religious grounds

- adult/child

“TRUTH” and Benificence and Non-maleficence

Are doctors obliged to always tell patients the truth?

Must it be the “whole” truth?Have patients the right not to be told the truth?Cultures where individual autonomy is not the

driving principle

Giving patient bad news

TimePlaceMethod

Beneficence-centred Approach

Quality of life is main concernVaries from person to personDegree of impairment is vital factor in decisionDifficult decisions in patients who are conscious but

seriously compromised eg MS, MNDThis suggests we should maintain life only if reasonable

chance that patient will have meaningful lifeie we compare with our concept of the “norm”

Only if continued life is in patient’s “best interests”ie Is expected life better than absence of life?

eg positive experiences outweigh pain & suffering

Sanctity of life (Trump card Rule)

Strive to preserve life in all situations, regardless of degree of impairment

Often based on specific religious belief systemThe person’s “worth” does not depend on ability to

lead certain life style

Exceptions to rule may open door to withholding treatment from people of less “worth”

And then to even take their lives Very limited evidence of this (Nazi Germany, China)

Factors Affecting Quality of Life

Ability to relate to othersDegree of cognitive impairmentAbility to carry out plans and daily

activitiesExtent to which patient experiences

pleasure and painNB These are all based on degree of

impairment

Who should decide?

Regulatory bodies external to institution enforcing substantive principles rules apply to all easier approach

Ethics committees within institution can be more flexible in individual cases useful advisory body

Patient’s family guided by doctor best qualified to judge what is best for patient