It is well over two decades since Ian Kennedy published “Unmasking Medicine” based on his Reith lectures.¹ He launched an inspired attack on medical paternalism in the UK which in many important respects has now been won—at least in principle. Clinical practice is now expected to embody the duty both to protect life and health and to respect individual autonomy—the right of competent patients to make informed choices about their medical options. Indeed, it is now both legally and professionally clear that, when these two duties are in conflict, the latter trumps the former. Ultimately, the competent adult patient has the final say about whether or not to accept or reject proposed treatment, even when refusing may mean death.

There is now a well articulated body of statute and case law designed to reinforce the right of patients to consent to or refuse treatment on the basis of appropriate information. Guidance from the GMC and professional organisations—particularly the BMA—does the same.^2,3 The Department of Health has issued specific instruction about the standard of obtaining consent to which Trusts are expected to conform, including the structure and content of consent forms.⁴ In relation to medical education, courses abound in ethics and law applied to health care that emphasise the moral and legal importance of obtaining consent to a reasonable standard. Similarly, courses in communication skills are now offered to engender in young doctors the abilities required to meet this standard. Despite some continuing problems of organisational sensitivity—those of the sort highlighted in the Bristol Inquiry—we should not underestimate just how far the NHS has come with regard to respect for the autonomy of patients.⁵ This should be recognised and applauded.

IS CONSENT TRULY INFORMED?

Study by Habiba et al⁶

In this issue of QSHC, however, a timely, interesting, and particularly well referenced paper by Habiba et al suggests the danger of too much optimism in this regard.⁶ The appearance of obtaining formal written consent may reflect a reality that is far removed from the moral goal of respect for individual autonomy. In a qualitative study based on a population of 25 women who had experienced either elective or emergency O&G surgery, they conclude that the process of obtaining informed consent can become a ritualised formality that has little to do with either effective communication or even the confirmation of real choices when consent forms are signed. With regard to elective care, many of the women interviewed felt that that the process of obtaining consent often had little to do with the goals of educating them to make a truly informed choice. Further, other women receiving emergency care did not see the point of the consent process at all and sometimes did not refuse care when they said that they really wanted to. Among other things, the authors conclude that, if informed consent is going to live up to its moral ambitions, the complexity of the consent process should receive greater attention in conventional bioethics literature.

One of the most useful aspects of this study is its narrative methodology. In articulating it, the authors implicitly stress the importance of Trusts auditing the quality of consent obtained by staff and point out that, for this to be effective, it must include more than checking whether or not basic formalities of consent and signing consent forms are being observed. Institutional rituals of obtaining consent must not be confused with truly informed choice, and ways need to be found of monitoring the degree to which staff are achieving anything like the latter. The methodology of such audits should always include some element of triangulation through in depth discussion with a reasonable sample of patients about the quality of their experience.

General view

It is important, however, to place this particular research into a wider context. On the one hand, many discussions within the literature on consent also stress the importance of the quality of the learning processes of patients and of the relative insignificance of consent forms in this regard. For example, recent guidance from the Department of Health states that: “When a patient formally gives their consent to a particular intervention, this is only the end point of the consent process. It is helpful to see the whole process of information provision, discussion and decision-making as part of ‘seeking consent’.”⁴ (page 18) The GMC makes similar points in their guidance on consent, as do the BMA and others. Therefore, the question that is posed is why, in light of our understanding of these dangers, does this ritualisation of consent continue in so many settings?

The general answer is partly reflected in the moral maxim: “ought implies can”. There is little point insisting that someone ought to do something in principle when they are incapable of doing so in practice. Clearly, as the authors suggest, the experience of the process of communication prior to the signing of consent forms should be a rich and textured one. However, for this to be achieved much remains to be done. Despite undergraduate courses in ethics, law and communication skills, the fact remains that many healthcare professionals have not had such learning experiences. Without a common denominator of basic skills, it is difficult to know what can reasonably be expected of staff.

Furthermore, against the background of a health service increasingly driven by targets, it has become commonplace that consultation time has fallen. Without sufficient time for an empathetic relationship to develop between clinician and patient, along with sufficient time to communicate even minimum amounts of appropriate information, it is hardly surprising that patients may sometimes feel that interactions are abrupt and lack meaning. This would be the case irrespective of the ethical and legal understanding and the communication skills of their clinicians. Of course, this problem may be mitigated by the effective use of published information about surgical and medical procedures. However, the development and design of such literature is not easy, especially regarding the communication of understandable information about risks.⁷ Effectiveness entails the consumption of scarce NHS resources. These may not be available because of the need to use what resources are available simply to optimise the quality and safety of clinical interventions. In short, good ethics costs money and the NHS has some way to go in creating hospital or primary care environments that are consistent with optimal success in obtaining truly informed consent.

CONCLUSION

It is difficult to know how representative the study by Habiba et al is about the quality of consent within O&G. On the one hand, we know nothing of the communication training and skills of the staff who obtained consent from the women who were interviewed or the time and other resources that they had to do so. On the other hand, and this is always a problem with in depth interview techniques, it is hard compare a process that has engendered complaints with the level of complaints there would be if there were no such process at all, even a substandard one. The fact remains that the doctrine of informed consent is one of the most important bricks in the edifice of what Kennedy calls “right” medical treatment.⁸ Without it, patients would be little better than slaves to whom doctors could use their “clinical discretion” to treat as they pleased. We want the communication and negotiation associated with informed consent to be as effective as possible and to recognise and correct low standards where they exist. But we do not want to throw out the moral baby with the critical bath water when and if we discover it. Certainly, some of the women having elective O&G care who were interviewed understood this. They indicated that having to sign a consent form reminded them that only they could ultimately determine whether or not they would receive treatment. Indeed!