Obtaining consent for examination and treatment
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7290.810 (Published 07 April 2001) Cite this as: BMJ 2001;322:810
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Information is not given to patients, to quote Roger Goss, according
to the "collective judgement and wisdom of the medical profession". It is
given according to the individual patient's wishes and the individual
doctor's judgement. I think, but I am not sure, that Mr Goss implicitly
acknowledges the importance of the doctor's judgement when he writes, "A
patient-centred NHS means providing as much information as the [patient]
wants". In that sentence lies the difficulty: how does the doctor judge
how much the patient does want?
I do not tell every patient everything, but I always ask, "Is there
anything else you want to know?" If I know the answer, I will then tell
them; if I don't know the answer, I will tell them that I don't know. But
sometimes I get it wrong. I tell some patients more than they wanted to
know; I tell some patients less than they wanted to know. There is no way
of avoiding these misjudgements completely.
Being guided by the principle that the whole truth should always be
told may be good ethics but it is poor medicine, as Thurstan Brewin
eloquently wrote. (1) He noted that the patient's respect for their doctor
'is not usually enhanced by asking him, "Do you want us to be frank about
all the risks or not?" ' Part of being a doctor is making professional
judgements about treatment. As a patient said to me during a preoperative
visit this week when I was about to start my explanations, "You're the
professional; you do what you think's best. And if you came to me asking
my professional advice, I'd want you to do the same."
Reference
(1) Brewin TB. Truth, trust, and paternalism. Lancet 1985;ii:490-492.
Competing interests: No competing interests
Editor - Professor McCall Smith's response to courts' willingness to
pronounce on what is a reasonable amount of information to give to
patients is very sad. (1) It exposes the gulf that still exists between
what some doctors consider it appropriate to disclose in seeking agreement
to examination or treatment and what patients increasingly expect and
want.
His answer is not only simple and unfashionable but also wrong. A
patient-centred NHS means providing as much information as customers want.
If for some patients this includes data on every possible risk of an
intervention, practitioners' experience (or lack thereof) and track
record, so be it.
The result of leaving how much information to provide to the
collective judgement and wisdom of the medical profession did not impress
the parents of children treated in Bristol or Alder Hey. Nor does it seem
to have worked particularly well at the Royal Brompton or Harefield
hospitals. (2) So long as doctors remain reluctant to offer all the
information that prudent patients might wish to know, more high profile
setbacks to mutual trust are inevitable. Public confidence in medical care
will continue to suffer unnecessarily. Even worse, recruiting participants
for trials may become more difficult. For this reason alone, surely it is
time for a change of attitude to sharing information?
Roger M. Goss
Director-Patient Concern
P.O. Box 23732,
London SW5 9FY
1. McCall Smith A. Obtaining consent for examination and treatment.
BMJ 2001; 322: 810-811 (7 April)
2. Kmietowicz Z. Down's children received "less favourable" hospital
treatment. BMJ 2001; 322: 815 (7 April)
Competing interests: No competing interests
Informed consent and disclosure
Editor:
Despite the DoH excellent new booklet on consent the main grey area
that remains is how much information to disclose to the individual in each
case. All of us as Doctors feel that we have some idea of how much we
should discuss with the patient verbally in each case but we are often
inaccurate in these judgements.
Informed consent is a process not a single conversation or a piece of
paper. The patient must be allowed some ownership of how much information
they would like to have. We should not entirely rely on our own judgemnts,
giving out only the information we feel is relevant to that person but
should in addition pass on a full and frank account in written form for
the patient to read and digest at their leisure. This still allows
therapeutic privalege but enables the patient and doctor to share this
privilege. That is the choice to read or not read the information given
but it is all there should they wish to do so.
The Doctor caring for the patient should then be available for any
questions after digestion of the accompanying literature. If this is done,
there can be no doubt that the patient has been afforded a full disclosure
of all aspects of the procedure in question.
This is a simple but effective solution to the problem of disclosure.
Competing interests: No competing interests