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Lecture for 6th year medical students at the King Fahad Medical City Faculty of Medicine on 20th February 2010 by Professor Omar Hasan Kasule Sr.
1.0 CONSENT AND REFUSAL OF TREATMENT FOR COMPETENT ADULTS’
8.1 What is informed consent?
No medical procedures can be carried out without informed consent of the patient except in cases of legal incompetence.
Informed consent means that the patient understands what he or she is consenting to.
1.2 Consent as an autonomy right
The patient has the purest intentions in decisions in the best interests of his or her life. Others may have bias in their decision-making.
As part of his/her autonomy rights, the patient is free to make decisions regarding the choice of physicians and treatments.
1.3 Methods of informed consent
Consent can be direct and immediate or can be prospective by use of proxies, a living will, or power of attorney delegating decision making to someone else.
Decision by a proxy can work in two ways: (a) decide what the patient would have decided if able (b) decide in the best interests of the patient.
Spouses and family members do not have an automatic right to consent for a competent patient. A spouse cannot overrule the patient’s choice.
The device of the power of attorney can be used instead of the living will or advance directive.
The living will has the following advantages:
(a) reassuring the patient that terminal care will be carried out as he or she desires
(b) providing guidance and legal protection and thus relieving the physicians of the burden of decision making and legal liabilities
(c) relieving the family of the mental stress involved in making decisions about terminal care.
The disadvantage of a living will is that it may not anticipate all developments of the future thus limiting the options available to the physicians and the family.
1.4 Competence / capacity, ahliyyat
The patient must be free and capable of giving informed consent. The term competence or capacity is used to indicate capability to consent. A patient who is incapable of consenting is called incompetent or incapacitous. There are specific ways of testing that the patient is competent or capacitous.
Consent is limited to what was explained to the patient except in an emergency.
1.5 Elements of informed consent
The process of informed consent has several elements
(a) disclosure by the physician,
(b) understanding by the patient,
(c) voluntariness of the decision,
(d) legal competence of the patient,
(e) explanation of all alternatives,
(f) recommendation of the physician on the best course of action,
(g) decision by the patient,
(h) and authorization by the patient to carry out the procedures.
1.6 Informed consent in special circumstances
Informed consent is still required for physicians in special practices such as a ship’s doctor, prison doctor, and doctors in armed forces. Police surgeons may have to carry out examinations on suspects without informed consent.
1.7 Refusal to consent
Refusal to consent must be an informed refusal (patient understands what he is doing)
Refusal to consent by a competent adult even if irrational is conclusive and treatment can only be given by permission of the court. Doubts about consent are resolved in favor of preserving life.
Physician assisted suicide, active euthanasia, and voluntary euthanasia are illegal even if the patient consented.
A do not resuscitate order (DNR) by a physician could create legal complications. It is accepted only of there is certainty, yaqeen or ghalabat al dhann, that resuscitation will have no lasting or nett benefits for the patient.
2.0 CONSENT AND REFUSAL OF TREATMENT FOR INCOMPETENT ADULTS and CHILDREN’
2.1 Consent for children
Competent children can consent to treatment but cannot refuse treatment. The consent of one parent is sufficient if the other one disagrees. Parental choice takes precedence over the child’s choice. The courts can overrule parents. Life-saving treatment of minors is given even if parents refuse. Parental choice is final in therapeutic or non-therapeutic research on children.
2.2 Consent for mental patients
Mental patients cannot consent to treatment, research, or sterilization because of their intellectual incompetence. They are admitted, detained, and treated voluntarily or involuntarily for their own benefit, in emergencies, for purposes of assessment, if they are a danger to themselves, or on a court order. Suicidal patients tend to refuse treatment because they want to die.
2.3 Consent for the unconscious
For patients in coma, proxy consent by family members can be resorted to. If no family members are available, the physician does what he as a professional thinks is in the best interest of the patient.
There are many disputes about withdrawing nutrition, hydration, and treatment in a persistent vegetative state since the chance of recovery is low. There is no moral difference between withholding and withdrawing futile treatment.
2.4 Consent in obstetric emergemncies
Labor and delivery are emergencies that require immediate decisions but the woman may not be competent and proxies are used. Forced medical intervention and cesarean section may be ordered in the fetal interest. Birth plans can be treated as an advance directive.