The consent process: Enabling or disabling patients' active participation?

Carole Doherty,Charitini Stavropoulou,Mark Nk Saunders,Tracey Brown

doi:10.1177/1363459315611870

Abstract

Standards expected by doctors’ regulatory bodies in respect of the process of consent to treatment have arguably sought to restructure the nature of the doctor–patient relationship from one of the paternalism to that of shared decision-making. Yet, few studies have explored empirically, from patients’ perspectives, the extent to which the process of consent to treatment enables or disables patients’ participation in medical decision-making. Our article examines patients’ attitudes towards the consent process, exploring how and why these attitudes influence patients’ active participation in decision-making and considering possible consequent medico-legal issues. Data were collected longitudinally using semi-structured interviews and field observations involving 35 patients and 19 of their caregivers, in an English hospital between February and November 2014. These indicate that generally patients defer to the doctor in respect of treatment decision-making. Although most patients and their caregivers wanted detailed information and discussion, they did not necessarily expect that this would be provided. Furthermore, patients perceived that signing the consent form was an obligatory routine principally to protect doctors from legal action should something go wrong. Our study suggests that patients’ predominantly paternalistic perceptions of the consent process can not only undermine attempts by doctors to involve them in decision-making but, as patients are now considered in law as informed actors, their perceptions of the consent form as not being in their interests could be a self-fulfilling prophecy if signing is undertaken without due consideration to the content.

Highlights

Standards expected by doctors’ regulatory bodies in respect of the consent process have arguably sought to restructure the nature of the doctor–patient relationship from paternalism to shared decision-making (AMA, 2009; Charles et al, 1999; Fovargue and Miola, 2010; General Medical Council (GMC), 2008; World Medical Association (WMA), 2006)
Our study suggests that patients’ predominantly paternalistic perceptions of the consent process can undermine attempts by doctors to involve them in decision-making but, as patients are considered in law as informed actors, their perceptions of the consent form as not being in their interests could be a self-fulfilling prophecy if signing is undertaken without due consideration to the content
A recent inquiry into the practice of an English surgeon performing a variation of a mastectomy unrecognised by his peers, argued that if the prevailing culture is one in which the patient is seen as the recipient of whatever is on offer, consent can come to be seen as some perfunctory exercise

Summary

Introduction

Standards expected by doctors’ regulatory bodies in respect of the consent process have arguably sought to restructure the nature of the doctor–patient relationship from paternalism to shared decision-making (AMA, 2009; Charles et al, 1999; Fovargue and Miola, 2010; GMC, 2008; World Medical Association (WMA), 2006). A substantial gap remains between the practice of informed consent and its intended goals (Grady, 2015). Patients’ attitudes and beliefs about the purpose of consent invariably influence how the process is co-constructed in practice. Examining patients’ and their caregivers’ assumptions and beliefs about the consent process in the United Kingdom, our article responds to a call for further research on consent, involving patients and their caregivers, to help guide clinical practice and bridge the gap between the theory and practice of informed consent (Grady, 2015). We explore how and why patients’ attitudes towards the consent process influence their active participation in decision-making and consider the possible consequent medico-legal issues. This research is timely as UK law has changed recently from judgements based on the reasonable practitioner standard to that of a reasonable person in the patient’s position (Montgomery v Lanarkshire Health Board, 2015), this being closer to the medical profession’s (espoused) standard

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