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BMJ No 7105 Volume 315 Editorial Saturday 16 August 1997
Consent for transfusionA duty of careAll patients have the legal and ethical right before they agree to treatment to receive adequate information on the aims, benefits, and risks of the treatment. In Britain this is firmly stated in the patient's charter, as well as being highlighted by the Medical Defence Union(1) and the Medical Protection Society(2) in their publications. It is also emphasised as a doctor's duty by the General Medical Council: "In particular as a doctor you must give patients information in a way they can understand; respect the rights of patients to be fully involved in decisions about their care."(3) During most transactions between patients and doctors consent is implied, but when a procedure is likely to carry a substantial or material risk the right is usually interpreted as asking patients to provide express written consent. In the United Kingdom, unlike the United States, consent for the transfusion of blood and blood products is not independently sought and remains part of general consent. Specialists in haematology and blood transfusion have, during the past two to three years, argued about the necessity of following the American lead and obtaining formal express consent for the transfusion of blood and blood products. The controversy does not hinge on the need to inform patients adequately - that is accepted - but centres on two issues. The first is whether consent in this instance is appropriate - that is, does transfusion of blood and blood products carry a material risk? The second is whether the consent obtained would be valid. How is material risk defined? In the case of Sidaway versus Bethlem Royal Hospital(4) the Law Lords, Britain's supreme court of appeal, made it clear that it was for the medical profession to define material risk. In reaching a decision, consideration should be given not only to the quantity but also to the nature of the risk. Minor clinically insignificant reactions to transfusion occur fairly commonly, whereas the risks of complications with serious or fatal long term consequences are low and therefore could be said to obviate the need for express consent. But should the profession avoid its traditionally paternalistic stance and consider the problem more from the point of view of the prudent patient? As stated in Canterbury versus Spence: "A risk is ... material when a reasonable person, in what the physician knows or should know to be the patient's position, would be likely to attach significance to the risk or cluster of risks, in deciding whether or not to forego the proposed therapy."(5) In imparting any information to patients, care must be taken also to discuss the balance of risks - the risk of receiving a transfusion against the risk of not being transfused. Are the difficulties related more to the consideration of whether consent obtained would be valid? True or valid consent does not need to be written, but it must be based on adequate information that the patient can understand, and it must be obtained without coercion. Would these requirements be satisfied in the likely situation of the task being delegated to the least experienced member of the team, often working in difficult circumstances? The profession's anxieties therefore centre on the logistics and mechanics of obtaining the consent - who should obtain consent and when.(6) In any instance, it is essential that a patient does not decide against a transfusion inappropriately. How is the question to be resolved? Blood and blood products are a human resource, and, despite the best efforts of the transfusion service, they continue to carry an unknown and indeed an unknowable risk. The answer might lie in a combination of initiatives that have already begun but are slow to progress. These include better audit of transfusion practice, better information about clinically significant risk, and better education of the nursing and medical professions in the use of blood and blood products. Consideration should also be given to delegating the supervision of blood transfusion, including obtaining consent, to specially trained nurse transfusionists. Finally, there should be better communication between the legal and medical professions.(7) These initiatives would permit a greater knowledge and understanding of the issues, the evolution of a reasoned decision, and the fulfilment of all doctors' unchallenged duty of care to their patients. F G Williams Director Welsh Blood Service, References 1 Medical defence Union. Consent to treatment. London: MDU, 1992. 2 Medical Protection Society. Consent and confidentiality. London: MPS, 1991. 3 General Medical Council. The duties of a doctor. guidance from the General Medical Council. London: GMC, 1995. 4 Sidaway v Bethlem Royal Hospital.1985 [2WLR 480] 5 Canterbury v Spence.1972 [464 F 2d 772-80] 6 Le Parc G. Informed consent for blood transfusion. Journal of the Florida Medical Association 1991;78:423-5. 7 Brazier M. Medicine, patients and the law. London: Penguin, 1992.
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