Intended for healthcare professionals

Rapid response to:

Letters

Incomprehensible consent forms:Plain English is important

BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7505.1450 (Published 16 June 2005) Cite this as: BMJ 2005;330:1450

Rapid Response:

Informed consent is not possible.

The debate relating to consent forms instigated by Pothier's letter,
and responses by Dingwall, Curtis and Roberts, appear to be arguing the
wrong point. The consent form itself should not be focus of consent -
indeed, consent may be adequately undertaken verbally. The document
provides a more robust source of evidence that consent has been aquired,
but not proof of it. It also enshrines a routine within the system to
ensure appropriate efforts are undertaken to aquire consent, and serves as
a reminder of this obligation. Doctors continue to treat consent in the
"functionalist" and administrative way described by Alderson and Goodey(1)
as "a polite ceremony". Surely we need to concentrate more on
communication skills? Perhaps not: Schneider and Farrell(2)
describe their study of forty patients upon each of whom was lavished 1-2
hours of time and considerable effort to obtain informed consent in
relation to having or not having prostate cancer screening. It was clear
to the researchers that proper understanding of the issues was not
achieved and that decisions made were often instantaneous, illogical (such
as reference to a film star who had had a successful treatment of another
cancer or dismissal of statistics because they were more unlucky than
others), or with a clear misunderstaning of the facts. Numerous studies
exist that show, despite best efforts in terms of information provision
and explanation, many patients still cannot remember much of the
information imparted to them. Yet, doctors are under obligation in law(3)
and professional guidelines to ensure, amongst other things, patients have
(a)the capacity to consent (b)enough relevant information to consent and
(c) to have understood this information and be able to come to a
conclusion.

The anecdotal and real evidence suggests that to achieve this
consistently is impossible. It is time for the medical and legal
professions to understand that it is not the failings of doctors that
limits informed consent. The requirements of informed consent have been
derived in the absence of the evidence which shows that these apparently
reasonable stipulations are, perhaps unexpectedly, not possible. Indeed, I
am not aware of any evidence that proves informed consent is consistently
attainable. Perhaps spending an hour for each patient may work, but would
cut clinics down to a few patients and add five years to waiting lists (or
require ten times more staff).

What is required, therefore, is an open debate on resolving this
issue. The first step is to separate ideologically and physically the
consent process from the documentation of that consent. However, informed
consent may be, as many of us suspect, an impossible ideal.

Alderson P, Goodey C. Theories of consent. BMJ, 1998; 317: 1314.

In "Law and Medicine (Current Legal issues vol.3)", Oxford, 2000,
pp107-126

Chatterton v Gerson [1981] 1 All ER 257

Competing interests:
Currently a final year student in medical law undertaking thesis on consent.

Competing interests: No competing interests

20 June 2005
Kayvan Shokrollahi
Specialist registrar, Burns and Plastic Surgery
Welsh Centre for Burns and Plastic Surgery