Over the past two decades there has been a shift within health care from an expectation that patients with medical problems should entrust themselves passively to the care of physicians to an expectation that they should cooperate in their own care, and even have some responsibility for the outcome of medical procedures they undergo. These changes are reflected in the terms we use: for instance, the word patient, which means someone who endures, is increasingly replaced by terms such as client or consumer, which suggest a more active and discriminating participant in the medical process.
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Consent
Informed consent was not an issue in medical practice before the 1970s. 1 Today, it forms a central issue through a series of ethical codes applied to medicine, from the Nuremberg to the Helsinki Codes. It may seem immediately clear what informed consent is, but a moment’s reflection should dispel this illusion. For example, in a study volunteers were given varying amounts of information about the drug’s properties and expected side effects. The more information the volunteers were given, the less likely they were to take the drug, despite being offered money. 2 When they found out that the drug being investigated was aspirin, most subjects said that what they now knew would not change their attitude to aspirin when they went home if faced with a headache or fever.
Despite its name, therefore, there seems to be a sense in which informed consent cannot be about being fully informed. Too much information can prejudice valid consent just as readily as too little. Rather than meaning fully informed consent, it would seem that informed consent must mean something more like valid or voluntary consent. There are two key issues. One is whether the consent is voluntary. Another is the issue of adequate or appropriate information, which, in practice, cannot be separated from the question of comprehension on the part of the person being informed. Finally, there is an issue of legal competence.
VOLUNTARY CONSENT
When an individual attends for a consultation, there is an implicit assumption that they are seeking help and will take the advice offered by the doctor, psychologist, community nurse or social worker. In this regard, a prescription often seems to function in two ways: on the one hand as a treatment for a particular condition and on the other as a symbol of the advice being offered. Taking a little piece of paper away with them from the surgery may give the person the feeling that they are not alone in trying to sort the problem out.
Arguably, however, the question of informed consent has come to prominence in recent years precisely because we no longer accept this as a proper and fitting way of going about things. We do not voluntarily consent to current practice. There is a problem in that a surgery or outpatient setting is not one that is conducive to any of us being able to articulate our concerns. We may be worried by the condition that has led us to seek help. We may be anxious when faced with the doctor, nurse, psychologist, or whoever. We may be aware of the queue of others after us, who need to be seen. Once the allotted appointment time of 10–15minutes is up, it is often very clear that the doctor is wondering whether they are likely to get to lunch or to get home if all consultations during this session are going to take as long.
For these and other reasons, we often take the prescription. However, available evidence suggests that most people being treated with antidepressants, for instance, do not take them for longer than 4 weeks, despite recommendations that they be taken for 3–4 months. One reason for this may be that the pill prescribed does not suit them, but another reason that seems likely is that many people being treated do not voluntarily consent to the treatment and, once away from the pressures generated in clinical settings, they withdraw consent.
The lack of consent involved here probably does not reflect an opposition to drug treatment so much as an opposition to a style of treatment delivery in which an authoritarian doctor decides what is best for a patient and issues instructions. Implicit in this authoritarian approach is the idea that medical science has developed to such an extent that there is something approaching certainty regarding the proper management of most conditions, and the doctor is an authority on – or at least knows better than the patient – what they should be doing.
In contrast, a cogent case has been argued by a number of commentators in recent years that medical care should involve a greater acknowledgement of ignorance or uncertainty on the part of the practitioner and an invitation to collaboration. 3, 4 and 5 According to this approach, treatment would be a matter of negotiation rather than one of instruction – a negotiation that would recognise that an illness is one event within the drama of someone’s life and that, for a variety of reasons, rigid adherence to a treatment regimen, with all the side effects that may be entailed, may not be that person’s top priority.
From this perspective, the issue of voluntary consent becomes a matter of good clinical practice. This is not something that can be properly defined at law. Even signed consent forms, in certain circumstances, may not be interpreted by a court as indicating valid consent, while on the other hand the lack of a signed consent will not necessarily be taken to indicate a lack of consent should someone apply for legal redress for a claimed injury.
The law is only a blunt instrument. Ideally a profession should give some indications about what it thinks on certain key issues. In this case, what would seem to be required are a set of statements about what psychotropic drugs do and what their role is in the management of nervous disorders. The problem in mental health work lies in getting the different professionals comprising a mental health team to come to some agreed form of words regarding the treatments they deliver. On a national scale it would be even more difficult to get all psychiatrists, for example, to agree among themselves on a common form of words for what the antipsychotics do. In the absence of such agreements, patients exposed to different mental health professionals are all too likely to be given quite different, even contradictory, views on the nature or purpose of their treatment. The possession of a book such as this can perhaps in some way redress this problem, by offering a clear set of statements with which their therapist may agree or disagree, and in the process reveal something of their approach to therapy.
A clinical style that is more likely to result in valid consent to taking the risks involved in any act of health care hinges, in my opinion, on an ability of health-care professionals to live with explicit ignorance about the likely outcome of their interventions in the circumstances of their patient’s life. The acknowledgement of ignorance and the sharing of knowledge and power that such an approach advocates is not one that all health-care professionals agree is appropriate or one that all can live with easily, even in limited circumstances. Indeed it is not the approach that all patients want – sometimes we just want someone who knows what they are doing to take over responsibility for us.
INFORMATION AND COMPREHENSION
How much information do people need about the risks and benefits of treatments? Most commentators come down in favour of informing the taker of a drug of the significant risks associated with treatment rather than making them aware of every possible risk. There are a number of issues here.
