This year the GMC produced its first guidance on obtaining consent Seeking Patients' Consent: The Ethical Considerations.1 Previous guides on obtaining consent include the Medical Defence Union's booklet Consent to Treatment.2
The GMC's booklet has set a standard for us to follow, and coming from our regulatory body it could not speak with greater authority. As with any guide, however, there is always the question: how practical is it?
Consent for treatment is a fundamental part of almost every aspect of medical practice. Although we generally associate it with a surgical procedure or a vaccination, consent to treatment or investigation takes place in every consultation.
On first reading, one gets the impression that the guide is directed at surgical procedures. Do not be fooled by this, however, as it also includes warnings about day-to-day practice, such as not accepting a patient's implied consent to examination simply because he/she lies down on a couch. In addition, there is detailed advice on how to ensure that patients give informed consent to screening procedures.
We are all aware that the assumed consent of previous generations 'doctor knows best' has gradually moved to that of discussion with the patient, enabling him/her to give informed consent; the emphasis has changed from paternalism to patient autonomy a shared or collaborative decision making in place of a directive approach.
Two main problems underlie this process:
- Lack of time the curse of modern medicine. Doctors in TV soaps seem to have hours of time to discuss every possible option with their patients, leading our patients to expect it as the norm. The GMC gives detailed and specific advice on obtaining consent. In the section on providing sufficient patient information, the guide lists 12 specific areas of advice that need to be considered (see figure 1, bottom). At least six of these could apply to everyday consultations.
- The patient's knowledge of basic biology on which any explanation must be based. Judging the level of explanation and detail to give individual patients is an art and will never be easy.
The purpose of the GMC's guide is to clarify areas where there might be confusion or lack of clarity. Indeed, the sections on 'Advance statements', 'Principles of best interest', 'Research' and 'Who obtains consent' are very useful. Some areas covered by the guide may lead us to consider an immediate change in our practice, e.g. screening, where six specific points are recommended (see figure 1).
Where the guide is less helpful is in normal everyday practice. Eight bullet points on how we should present information to patients are helpful, but the addition of 'when practicable', 'wherever possible' and 'when appropriate' does not lead to clarity.
When does the GMC expect us to apply these caveats? We may think the decision will be based on our own common sense, but if our decisions are questioned later, on what basis will we be judged?
The guide is undoubtedly something to be read, re-read and used. It sets a standard to which we must all aspire, and which we would expect if a relative of ours were about to undergo treatment. What we don't know is whether it is what patients want.
When I recently tried to apply the GMC's advice in full, the patient said to me after 15 minutes: 'That's brilliant. I understand everything you told me. But Doc, what do you think I should do?'
|Figure 1: Screen shots from the GMC website Seeking Patients' Consent: The Ethical Considerations*|
|* The full guidance can be downloaded from the website at www.gmc-uk.org. The booklet Seeking Patients' consent: The Ethical Considerations is available from The General Medical Council, 178 Great Portland Street, London W1N 6JE (Tel: 020 7580 7642)|
- Seeking Patients' Consent: The Ethical Considerations. GMC, 1999.
- Consent to Treatment. MDU, 1997.