Final Report > Chapter 23: Respect and Honesty > Consent to treatment

Consent to treatment

42 We are concerned here with the process of obtaining consent. We do not intend to review the enormously complex legal and ethical issues raised and the extensive literature on them. We touched on some issues relating to consent in the context of post-mortems and the removal, use and disposal of human material in our Interim Report. [33] Here, we intend to make only some very general points.

43 We noted earlier that, when patients are in need of surgery or some other intervention, far too great an emphasis seems to be placed on the isolated act of obtaining written consent to the surgery on a form, rather than on the process of communicating, to which the signing of a consent form is just the end point. By this we mean that too great a regard is paid to the symbolic act of signing a piece of paper, rather than to the real task. The real task is a process which involves explaining what is to take place; setting out what is known about the risks, uncertainties, and possible negative consequences, about the specific performance of the trust, of the specialty and of the consultant unit (as that information becomes available), about any alternatives and about the likely outcome; considering and explaining how the patient will be affected; and seeking and answering questions. Such a process is the only proper way to gain the patient's informed authority to proceed.

44 We were saddened to hear a recently-qualified doctor describe, at one of the Phase Two seminars, how, as part of his training, he was sent `to consent' patients. The very words used illustrate how fundamental is the lack of understanding of what should be going on in the guidance which he had received from those instructing him. A doctor seeks permission. Patients are being asked whether they want to give it. Before doing so they have the right to be told anything that may be material to the decision. The doctor has the duty to do this. Patients are not there to be `consented'. They are there to be informed and asked if they wish to go ahead. Moreover, consent should be seen as an ongoing process of informed decision-making, permeating the whole process of care, rather than a one-off event associated with obtaining formal agreement to specific procedures. This is all the more important when parents are making this decision on behalf of their child. [34]

45 Equally, the process of consent should not be seen as applying only to surgical procedures. It seems extraordinary that a surgical operation is surrounded with the formal trappings of written consent forms, yet when carrying out other clinical procedures, such as a physical examination, or an X-ray, it is not routine to advise a patient of what is going on, far less to seek permission. It is an ethical, as well as a legal, principle that a patient's consent is required for even the most routine of examinations which involve any form of touching. In this way, the patient's (or parents') right to choose is respected. This indeed is the essence of respect. By insisting on this, we would not wish to see a further bureaucracy of form-filling. Indeed forms are something of a distraction. We do not advocate more forms. We advocate more communication. As we have said, forms are of almost secondary importance, merely providing evidence of agreement. What we are emphasising is the primacy of the patient's choice; the right of patients to be asked if they wish to undergo the procedure, to be informed about the procedure and to be asked to agree.

Footnotes

[33] We acknowledge that the Department of Health has published new guidance on consent: `Reference guide to consent for examination or treatment'. London: Department of Health, April 2001

[34] We consider the particular issues arising when parents must give their consent on behalf of their children later in Chapter 29 on Children's healthcare services