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BMJ No 7102 Volume 315 Letters Saturday 26 July 1997 Informed consent`Blanket' consent to trials would be a good ideaEditor,In his editorial on informed consent, Richard Smith discusses the contrasting views of Len Doyal and Jeffrey S Tobias.(1) He highlights Tobias's suggestion that a patient could give `blanket' consent when admitted to a hospital where several randomisation studies are in progress.(2) I supported this idea some years ago, but also suggested that much work would have to be done explaining the need for it and gaining public trust.(3) lt could be a useful third option, added to the options of requesting and not requesting informed consent; thorough safeguards and approval of an ethics committee would be necessary. In all walks of life, when one person seeks help from another, consent based on trust is surely just as valid as consent based on information. There is always a blend of the two, but the proportions vary. Lord Scarman, a judge with liberal views, said, `It may be sensible to trust your doctor and feel that the risks are for him to assess.'(4) We all know that `fully informed' consent is often nothing of the kind; there may well be more trust than information. With blanket consent the average amount of trust would have to be even greater, but there would be many advantages. Those who want the BMJ to take a rigid view that might overrule the opinion of ethics committees should spend a day in a ward full of elderly people. They would probably find many who, though far from being mentally incompetent, are at times confused and forgetful. What could be more unrealistic than to refuse to recognise this for fear of being called patronising or paternalistic? Suppose a doctor approaches such a patient, who perhaps feels ill and wants only sensitive care, with a view to gaining his or her fully informed consent to, say, two studies-the randomising of the patient's sleeping tablets and the randomising by the surgeon of a new suture material. Who can be sure that concern or confusion will not follow? Where is the sense in this? Some people underestimate both the danger of not comparing treatments in a reliable way and the harm that can be done to many sick patients when fully informed consent for every trial is sought, no matter how tense or difficult the situation. There are many grey areas, but we should start thinking seriously about the idea of some general form of consent to the fact that a treatment is being randomised. The result would be fewer misconceptions, less fundamentalism, more trust, less detail, and more time to attend to patients' real needs. Thurstan Brewin
References 1 Smith R. Informed consent: the intricacies. BMJ 1997;314:1059-60. (12 April.) 2 Tobias JS. BMJ's present policy (sometimes approving research in which patients have not given fully informed consent) is wholly correct. BMJ 1997;314:1111-4. (12 April.) 3 Brewin TB. Valid comparison is the key. In: Razis DV, ed. Medical ethics and/or ethical medicine. Paris: Elsevier, 1989. 4 Scarman, Lord. Consent, communication and responsibility. J R Soc Med 1986;79:697-700.
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