Informed consent in public hospitals
Informed consent is a commendable concept: it gives patients the power of participating in decisions concerning their own management, to a greater degree than ever before. The qualifying adjective is superfluous (1), for the word consent (cum, together; sentire, to feel, perceive) clearly implies sharing of information. Patients do have problems understanding the nature of their illness and management plans. It is the duty of the doctor to ensure that the patient is helped to make a rational decision.
What do patients want? The priority is honest, unbiased, up-to-date information about their illness, its likely outcome, and the risks and benefits of different interventions. They also want help to identify and secure their treatment preferences. When uncertainty exists they want a full and frank discussion, no omissions or glossing over, and an advice explicitly supported by the best available evidence (2).
What doctors feel about informed consent
I asked several doctors what informed consent meant to them. Most strongly disliked the very concept of informed consent and considered it an obligatory legal formality forced on them by the Consumer Protection Act. Their arguments were:
- Informed consent breeds suspicion and mistrust.
- Patients are uncomfortable with doctors who merely give them options and ask them to choose one. Our patients want us to take responsibility and not shift it onto their sagging shoulders. If we do not act on their behalf, we might be accused of dodging duty.
- Patients fail to understand our misplaced emphasis on consent forms. Our patients have full faith in our knowledge, skills and competence. Aren’t we capable of choosing the best treatment for them?
- Informed consent seriously erodes the doctor and patient relationship. An openness and frankness makes patients anxious, reluctant and distressed.
- How do we share information during an emergency? Can patients respond appropriately during a crisis? Can patients weigh pros and cons of the treatment and make a logical decision?
- Informed consent is an intellectual exercise for armchair ethicists. Emphasis on autonomy and equality is misplaced and lacks knowledge of practical difficulties.
Doctors love to patronise and dominate. Their arrogance and indifference to the philosophy of informed consent is widely known. Medical and public fora have passionately debated these arguments — and disproved them. Surprisingly, most residents and doctors in teaching public hospitals tacitly endorse such reservations against information sharing. To most of them getting informed consent is a needless nuisance, to be delegated to a raw resident whose sole responsibility is to get the patient’s signature on the dotted line.
A few exceptions apart, public hospitals sorely lack good quality information leaflets or audio-visual material to disseminate information to their patients. Residents, working under tight time constraints, find it impossible to explain procedures to the patient. Nor are they sufficiently motivated to do so, for providing explanations and sharing information bring no tangible rewards. No attempt is made to ensure that the appropriate type and amount of information has been provided and the patient has understood the procedure.
Any query or request for an explanation meets stern disapproval and arouses a characteristic, callous response from the resident: “If you don’t trust us, you had better leave the hospital.” The resident, always in a tearing hurry, lists all possible risks (death gets cruelly emphasised) and disappears before the patient can absorb the blow.
Consent forms in most hospitals are either too brief or sketchy or full of incomprehensible medical and legal jargon. They carry hastily scribbled, badly worded, at times illegible text. The text is seldom read aloud to illiterate patients, who, being unable to decipher the draft, simply leave their thumbprints on the case sheet. Seldom do they get the opportunity, and time, to understand the intervention. The nagging fear that not signing the consent form might amount to incurring the displeasure of the treating doctor weighs heavily on their mind.
I reproduce below a consent form obtained in a busy surgery ward of a teaching public hospital:
“I am suffering from a strangulated intestinal hernia. I need an immediate surgery to save my life. I also have mild hypertension. I shall be operated on under general anaesthesia. I run a high risk for surgery. I might develop life-threatening complications during anaesthesia. My surgery might lead to some complications, which could kill me. After surgery I might run into problems, which are well beyond the surgeon’s control. In spite of all these risks, which have been fully explained to me, I agree to undergo surgery. Should anything go wrong, neither doctors, nor nurses shall in anyway be responsible for an adverse outcome. The responsibility shall be entirely mine.”
What makes consent so insensitive and crude? I picked up, at random, several residents from a teaching public institution and asked them if they were ever taught how to get an informed consent. Most sheepishly admitted their ignorance. To some of them, consent was a legal vaccine that reduced the risk of litigation. Many residents were conscious of their lack of communication skills: an inability to use simple words in patient’s regional languages left many of them tongue-tied at the patient’s bedside. They were not getting across to their patients, but could do nothing about it.
Dr Franz Ingelfinger’s two-decades-old description (3) seems to come straight from one of our busy wards:
“Even if a physician takes pains to use appropriate language, he may still lack empathy if he is not acutely sensitive to the emotional needs of the patient seeking consultation. Distraught by anxiety, fear and perhaps suspicion, the patient hears the sounds but not the meaning of words; reassurances that cancer is an unlikely diagnosis and a barrage of tests to prove this point may convince the patient that the opposite is true. ‘We shall not need an another operation’ is recorded in the patient’s mind as ‘another operation.’ Advice that anti-hypertensive drugs or insulin are in order, possibly for a lifetime, may give the patient an idea of incurability. Even advice on smoking and overeating may elicit negative instead of positive results in the susceptible.”
Today’s role models
To whom should residents turn to pick up the art of communication? Teachers? (4) Most residents expressed gratitude to their teachers for teaching them the art and science of modern medicine, but said that, a few exceptions apart, their teachers were poor role models for learning the ethics of the doctor-patient relationship. Medical teachers, said several residents, are generally stiff-lipped and discourteous when patients seek information. Students tend to imbibe their teacher’s arrogance and ill manners during their impressionable years and subconsciously emulate them in their professional practice. And where are good role models left in medical colleges now? asked a resident in exasperation.
Residents welcomed the idea of learning communication skills and behavioural sciences. Several suggestions emerged during discussion: Had we been taught how to talk with patients and what to say (5) during our clinical postings, we would have felt more comfortable with our patients. Many thought that introduction of medical ethics in the undergraduate curriculum (6) would help them emerge more humane, sensitive and responsive to patients’ needs. Few thought that they should’ve been also taught how to discard a patronising attitude and get more interactive with patients.
There were some discordant notes too. A resident asked me: “Most rural patients attending public hospitals do not insist on an intensive, informative discussion. Their main priority is to get cost-effective treatment. Could we make use of their trust in us and practice a bit of paternalism and dominance? What is the evidence that published (western) guidelines for getting informed consent are equally valid in our setting? Could we find ways to make consent more accessible, acceptable, tangible and practical? More patient-friendly and less legal?”
A senior medical teacher, who is deeply respected in the rural community for his compassionate and committed approach, shared his residents’ concerns. A patient must know his disease and management plans, he agreed, but should entrust the responsibility of taking the final decision to his doctor. How can a doctor-patient relationship flourish in an atmosphere where autonomy and equality overrule trust and faith? he wondered. A quest for information might make patients more knowledgeable, but would render them equally insecure and indecisive.
He quoted Charaka: “No gift is greater than the gift of life. The patient may doubt his relatives, his sons and even his parents, but he has full faith in his physician. He gives himself up in the doctor’s hands and has no misgivings about him.”
“I might continue to treat inquisitive and skeptical patients-and their tribe is rapidly increasing thanks to the Internet, but my heart won’t be there in their management,” he honestly admitted.
Teaching tomorrow’s doctors
Neither teachers, nor residents, nor patients seem to know how to handle the issue of informed consent without anguish. Let us concentrate on residents, the future consultants. How could they be helped? Could communication techniques taught in class-rooms ease their burden? Or should students passively imbibe these skills from their mentors and patients as life moves on? There are no easy solutions. Nor can there be cut, copy and paste shortcuts for information sharing and obtaining the consent. As Dr Ingelfinger (3) summed up years ago: “In medical schools, a student is told about the perplexity, anxiety and misapprehension that may affect the patient as he enters the medical-care system, and in the clinical years the fortunate and the sensitive student may learn much from talking to those assigned to his supervision. But the effects of lectures and supervision are ephemeral and are no substitute to actual experience.”
- Laurence D, Carpenter J: A dictionary of Pharmacology and Clinical Drug Evaluation. London: VCL Press, 1994
- Entwistle VA, Sheldon TA, Sowden AJ, Watt IA: Supporting consumer involvement in decision-making: what constitutes quality in consumer health information? Int J Quality in Healthcare 1996;8:425-37
- Ingelfinger FJ: Arrogance. N Eng J Med 1980; 303:1507-11
- Gupta P: Bedside Case Presentations: Thin ice? Natl Med J India 1997;10(4):182
- Calnan J. Talking with patients-a guide to good practice. London: William Heinemann Medical Books, 1983
- Ravindran GD, Kakam T, Lewin S, Pais P. Teaching Medical Ethics in a medical college in India. Natl Med J India 1997;10 (6): 288-89