Informed consent to treatment

By Dr. Vic Weatherall

A better understanding of the issue of "informed consent" and your rights can help you make wise health care choices and possibly avoid inappropriate care.

What is "informed consent"?

Before undergoing any health care procedure, you have the right to make an informed decision about what the care will involve. Consequently, your doctor (and all other health care providers) must obtain your "informed consent" prior to performing a procedure, writing a prescription, or guiding a course of therapy. The purpose of obtaining your informed consent to a health care intervention (test or therapy) is to empower you to make educated choices in an environment of trust and cooperation.

The Ontario Health Care Consent Act of 1996¹ is a good example of typical informed consent legislation. It states that your consent to treatment is "informed" if you have received information about the matters listed below and you received responses to any request for additional information. "Treatment" is defined broadly as anything done for a therapeutic, preventative, palliative, diagnostic, cosmetic, or any other health related purpose. The Act states that you must be told the

1. nature of the treatment
2. expected benefits
3. material (serious) risks
4. material side effects
5. alternative courses of action
6. likely consequences of not having the treatment

The Act states that consent to treatment may be express (given in writing or verbally) or implied (indicated by an action or behaviour, such as rolling up a shirt sleeve). However, the basic elements of disclosure remain the same.

There are several exclusions to the term "treatment," as defined in the Act, including taking a history, performing an assessment to determine the general nature of a problem, and communicating a diagnosis to a patient. Of special note, it also excludes a treatment that, in the circumstances, poses little or no risk of harm to a patient.

The College of Physicians and Surgeons of Ontario policy Consent to Medical Treatment² states that, in non-emergency situations, the patient must be capable and the consent must be related to the treatment, informed, and given voluntarily. As well, it must not be obtained through misrepresentation or fraud.

The Code of Ethics of the Canadian Medical Association³ states that you should receive the information you need to make informed decisions about your medical care, and that your questions should be answered to the best of your doctor's ability. It also states that doctors should recommend only those diagnostic and therapeutic procedures they consider beneficial. As well, your doctor should respect your right as a competent patient to accept or reject any recommended medical care.

The issue of informed consent is a worldwide concern. Informed Consent for Medical Treatment⁴ written by Dr. Nili Tabak of the Society for Patient's Rights in Israel clarifies the purpose of the informed consent legislation enshrined in the Israeli Patient's Rights Act of 1996. He states that informed consent is needed to

• maintain trust between the medical practitioner and patient
• enable the patient to participate in the decision making process
• avert patronizing attitudes by the medical practitioner
• minimize doubt by maximizing information
• assure control against impingement of privacy

He goes on to specify that the practitioner, not the patient, must take the initiative to provide the information because the patient usually does not know what to ask or may hesitate to request information.

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Making informed decisions

The best to way to get the information you need to make informed decisions is to engage in full and open dialog with your health care providers. Use the following checklist to make sure that you have all of the information you need:

1. Write down in advance any specific questions or concerns about your problem(s)—it's easy to forget during a busy visit.
2. Ask about the published benefits of the proposed intervention—many interventions in all health care fields are poorly supported by the scientific literature.
3. Ask about the risks of the intervention—all interventions have risks—it's up to you, not your provider, to determine if the risks are important.
4. Ask specifically about alternatives and your provider's experience with these alternatives.
5. Similarly, ask if there are alternatives outside of your provider's field of expertise. Be cautious if your provider displays a dismissive or alarmist attitude towards therapies outside of his or her field.
6. Always obtain the results of any test performed—no news is not good news, it's simply no news. Don't be the victim of an administrative error.
7. Always get a second opinion on any serious issue or whenever surgery or hazardous drugs are recommended—they should always be last options.
8. Sign an informed consent form wherever possible—these are becoming more popular with health care professionals because they help ensure that the adequate disclosure has been performed, thereby protecting you and your provider.
9. Don't sign any form without fully reading it and discussing it with your provider—if the person presenting the form does not have the authority or knowledge to answer all of your questions, find someone who can.
10. Always ask for the diagnosis and write it down—this will help ensure that your problem is taken seriously and will help when you do your own research.
11. Always research your problem; however, be careful to use reputable information sources.
12. If the information given by your provider is later found to be incorrect or insufficient, let your provider know.
13. Never acquiesce to an intervention for any reason—it's your decision and you will have to live with the results.
14. Remember that some providers may view your insistence as an annoyance or a threat—don't be put off. It's past time for them to embrace the concept of informed consent and be willing to take the time to give you all of the information you need.

References

1. Ontario Health Care Consent Act 1996. S.O. 1996, c. 2, Sched. A.
2. CMA Board of Directors. Code of Ethics of the Canadian Medical Association. CMAJ 1996;155:1176A-D.
3. College of Physicians and Surgeons of Ontario. Consent to Medical Treatment. CPSO Policy #1-01.
4. Tabak N. Informed Consent for Medical Treatment. The Society for Patients Rights in Israel. 2000.

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