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Lecture for
4th year medical students Salman bin Abdulaziz University Kharj on
May 7, 2013 Professor Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH
(Harvard)
1.0 DEFINITION OF INFORMED CONSENT
No medical procedures can be
carried out without informed consent of the patient except in cases of legal
incompetence. The patient has the purest intentions in decisions in the best
interests of his or her life. Others may have bias their decision-making. The
patient must be free and capable of giving informed consent. Informed consent
requires disclosure by the physician, understanding by the patient,
voluntariness of the decision, legal competence of the patient, recommendation
of the physician on the best course of action, decision by the patient, and
authorization by the patient to carry out the procedures. The patient is free
to male decisions regarding choice of physicians and choice of treatments.
Consent can be by proxy in the form of the patient delegating decision making
or by means of a living will.
2.0 PROCESSES OF INFORMED CONSENT
Valid consent must be voluntary,
informed, and by a person with capacity to consent. It involves explaining the
procedure contemplated, making sure the patient understands, and offering the
patient a choice.
Consent is limited to what was
explained to the patient except in an emergency.
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.
Spouses and family members do not
have an automatic right to consent. A spouse cannot overrule the patient’s
choice.
Advance directives, proxy
informed consent by the family are made for the unconscious terminal patient on
withholding or withdrawal of treatment.
Physician assisted suicide,
active euthanasia, and voluntary euthanasia are illegal even if carried out
with patient consent.
3.0 ADVANCE DIRECTIVES/LIVING WILL
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.
4.0 PROXY DECISION
The device of the power of
attorney can be used instead of the living will or advance directive.
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.
5.0 CONSENT OF CHILDREN
Competent children can consent to
treatment but cannot refuse treatment. The consent of one parent is sufficient
if the 2 disagree. Parental choice takes precedence over the child’s choice.
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.
6.0 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.
7.0 CONSENT IN OBSTETRICS
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 by a court in the fetal interest. Birth plans can be treated as an
advance directive.