By Gordon Bugbee
Patient dignity and self-determination demand consent before treatment. The more consequential or irreversible the treatment, the more informed and explicit the consent should be. But consent, practically and psychologically, rests on trust. (Not necessarily the trustworthiness of the clinician, but how much the patient trusts the physician.)
In the case of major surgery or other consequential, invasive procedure, the surgical consent, affirmed in the moments prior to anesthesia, is at the end of a chain of consents and releases, each of which is predicated on a patient’s trust in the clinician making the request.
The trust a patient places in the surgeon, oncologist or other physician is itself the culmination of a series of trust relationships starting with the patient’s primary care physician (or ER doctor in an emergency). Successive trust relationships, with specialists or a surgeon, are built on and are partly a transfer of trust from one clinician to the next. Institutional affiliation, endorsements by collateral providers, and reputation may also play a role.
The Community Ethics Committee has been wrestling with issues related to informed consent in the context of concurrent surgery (in which the principal surgeon is engaged in operating on two different patients within the same time frame). The CEC's report is expected to be published here this fall.
This brought us to a wider discussion of consent in general and most recently to a consideration of the underlying relationships. (We were led to this in part by “An entrustment model of consent for surgical treatment of life-threatening illness: Perspective of patients requiring esophagectomy,’ by Martin F. McKneally and Douglas K.Martin; Journal of Thoracic and Cardiovascular Surgery, August 2000.)
Here is a list of some of the dimensions or facets that seem to characterize that relationship as seen from a patient’s perspective, in no particular order.
I (patient) trust you (provider). That means I assume:
- That you are well trained and competent to undertake the treatment proposed
- That you will try your best to take good care of me
- That you are honest with me (‘whole truth and nothing but the truth’) about the benefits and risks of the proposed treatment (or at least with yourself if I am unwilling or unable to hear those things)
- That you are aware of and respect your own limits
- That you will have adequate rest and nutrition before beginning any complicated or taxing procedure
- That you will not allow distractions to compromise my care (or will refer me to another competent and trustworthy provider who can focus on my care)
- That you have confidence in your own abilities and training
- That you will ask for help or refer me to other more appropriate providers when it is in my best interests
- That in any conflict between what’s best for you (or the institution) and what’s best for me, you will place my interests first
- That your treatment recommendations are driven by clinical considerations not your financial or professional interests
- That you will not entrust any part of a procedure or my care to anyone you are not convinced is competent and trustworthy
- That you will align your tolerance for risk with mine. That is to say, if I am willing to undergo a risky, unorthodox or experimental treatment, you will not refuse to provide that treatment (within the bounds of responsible medical practice) to protect your reputation or peace of mind. Conversely, if I am unwilling to undertake a particular course because of the uncertainty of the outcome, you will not apply undue pressure or seek to overturn my decision to satisfy research goals or your personal preferences.
- That you remember, no matter how routine a procedure is for you, it is a big deal for me
- That alleviating my suffering is at least as important to you as treating any illness I may have.
- That you know that I am more than the sum of my medical circumstances.
- That you know that the capacities and experiences that you value most may not be the same for me.
- That my values and preferences may be different from yours and that you will learn and respect any differences.
- That you will not presume to make consequential decisions for me without consulting me (or those who know me best)
This list is no doubt incomplete, and perhaps we all have a slightly different list of presumptions. The more constitutionally pessimistic or experientially jaded among us may think many of these assumptions are hopelessly naive. However, they are, I think, what many of us hope are true when we sign those complicated forms in a haze of anxiety, desperation, anticipation, and analgesics.
Gordon Bugbee is a member of the Boston-based Community Ethics Committee.
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