The Essence Of Consent For Medical Or — Surgical Procedure

What does it mean to ask consent for a medical or surgical procedure? I remember over 20 years ago being a medical student in the labour ward, when a woman needed a caesarean section because her labour was not progressing well, the nurse would go up to the woman and say “Maame, we are going to operate you.

Do you agree or not?” or worse still “Maame we are going to operate on you. Bring your thumb and stamp it on this form.”

The nurse would then take hold of the woman's, thumb, press it on the form and presto! - Consent was considered given.

The anaesthetist would sometimes shout across before he started putting the woman to sleep “Has she signed the consent form?” and the answer of course would be “yes”… (Well she had, hadn't she? In a manner of speaking…)

Before any patient undergoes any medical or surgical intervention, the consent of the patient must be sought. Strictly speaking, even small procedures like intra muscular injections should be explained to the patient and his/her consent sought.

It is, however, often assumed that if a patient him/herself walks to a hospital and complains of a headache or a fever he/she is automatically consenting to allowing the healthcare provider access to his/her body to provide a reasonable level of care.

To be valid, consent must be informed. This presupposes that the person administering the consent form must know and be able to explain the reason why the procedure is necessary.

He or she must also be conversant with all the possible risks and side effects that the patient is likely to experience.

He or she must also be in a position to answer all the patient's questions about what is going to happen.

Some of the consent forms still in the system have a place for procedures “where the consent of the husband is needed”.

This is clearly outmoded. A woman certainly can and usually will discuss the decision for a procedure to be done with her husband and he can disagree with her and may even be able to convince her not to consent to have it done.

In that case she alone can refuse to sign the consent form. However, where the husband refuses consent but the woman goes ahead and gives it, the procedure will usually be done.

 This might arise, for example, where a woman has had several children and due to some complication during her last delivery, her doctors have decided that having further children would be injurious to her health.

In this case, even though her husband might refuse the sterilisation as he wants more children, once the woman agrees and gives her consent for the procedure to be done, it generally will be done.

Thus if a pregnant woman refuses to consent to a Caesarean Section, she cannot be forced to have it even if it means that her baby will die.

The situation is different for children, especially when they are clearly too young to participate in decisions concerning their health.

Consent must always be sought from the parents of young children and it is usually given. Doing a procedure without the consent of the parents opens the doctor up to possible litigation.

When the parents refuse however, it is only the courts that can override the refusal of the parents and go ahead to authorise the procedure the parents are not consenting to.

English case law seems to suggest that the unborn baby does not have any legal rights, or that what rights he/she has do not crystallise until he/she is born.

The Children's Act and indeed the Constitution of Ghana both say that parents cannot refuse medical treatment for their children on the grounds solely of religious or other beliefs.

(It is not spelt out what constitutes “other beliefs”!) Health workers have sometimes taken this to mean that they can go ahead to do procedures that the parents have refused permission for.

In recent days, the phrase “expectation management” is being bandied around on radio stations in relation to the oil find. Clearly the expectation of each Ghanaian concerning the “discovery” of oil is different from the other.

Some expect the country to magically improve overnight.

Similarly, sometimes the expectation of the doctor and the patient regarding the outcome of an intervention can be totally different.

If a patient has pain, the surgeon may be doing the operation to prevent the pain from getting worse.

The patient, on the other hand, is expecting that after the surgery the pain will completely go away.

 These issues must be clarified as much as possible before the operation otherwise the patient may be dissatisfied and disappointed. Patients have been known to say “If I had known that this is how it would be I wouldn't have done the operation in the first place.”

In many of our hospitals, especially in our Government hospitals, consent is often sought as a formality, not by the doctor going to do the procedure but by another health worker who actually knows very little detail about the procedure and cannot answer any questions.

It is often assumed that the patient will not have any questions and the truth is, not always but only too often, even when given a chance to ask questions or make a choice about the way things should be done, one gets the response from the patient, “Doctor you know best.

You decide.” Rarely will you find a health worker saying “I am going to give you an injection. The possible risks of this injection include a possible injection abscess or other infection.

There is a small risk of a drug reaction and there is even a tiny risk that you will become paralysed in one leg. Do you still agree to have the injection?”

I suspect many patients would be so frightened that they probably would not accept the procedure. In practice, for simple low risk procedures, consent is usually not asked.

This is not the case in litigation-conscious countries where consent is asked for even the smallest most risk-free procedure, because should the procedure go wrong, the patient is not likely to “give it to God” but will take it up and demand compensation and in this case, the presence of a duly signed consent form can sometimes be a good defence.

Many health workers feel that the presence of a signed consent form in the patients notes is an evidence that informed consent has been given.

There are, however, many court cases on record where the courts did not accept the consent forms on face value but went on to ask the aggrieved patient exactly how the consent was taken.

 I remember once at the ward as a young house officer explaining to a young mother why she had had to have an operation to have her baby whilst her previous deliveries had been normal.

As soon as I finished, all the other women at the ward began to shout across to ask, “Doctor what about me? And what about me.”

I suppose in those days I was so tiny and looked so non-threatening that they felt comfortable to ask.

Who has the right to give or, perhaps more importantly, withhold consent? In theory, any person above the age of 18 can give consent.

They can also withhold it even when it is considered life saving. There is a famous English case where a young Jehovah Witness who had leukaemia was forced to accept blood as he was less than 18 years.

As soon as he turned 18 however, he refused consent to the life-saving transfusions and died.

Health workers who look after children should have a good working relationship with the Social Welfare Department as they can usually help sort such problems out quickly and efficiently.

I have mentioned a few issues concerning consent for medical and surgical procedures.

There are sometimes very complex issues for example when the adult patient is unconscious and there is no one available to give consent and these need to be handled according to good ethical standards.

Patients should always feel confident and ask whenever there is anything that they do not understand about their treatment and not feel intimidated as they have a right to know.

Health workers, likewise, should not feel threatened or become defensive when their clients ask questions.

Article by Dr Gyikua Plange-Rhule