Beyond The Consent Form: Informed Consent, Patient Autonomy, And Choice-Centred Surgical Care In Ghana

Signing without understanding: The Reality of Surgical Consent in Many Healthcare Facilities in Ghana.

In many healthcare facilities in Ghana, patients scheduled for surgical procedures such as caesarean sections, laparotomies, and others are presented with consent forms and asked to sign. In many cases, the process is reduced to a simple instruction: "Sign here."

As healthcare providers, we must ask ourselves some difficult questions:

Do we know that the era of "doctor knows best" is gradually giving way to the era of "patient and clinician decide together"?

Do we know that "sign here, sign there" without adequate explanation is professionally deficient, ethically questionable, and potentially legally problematic?

Do we truly ensure that patients understand what they are consenting to before obtaining their signatures?

This article highlights the importance of informed consent, patient autonomy, and choice-centred care in surgical practice, and professional obligations of healthcare providers in Ghana.

To begin with, there is the need to understand key concepts.

INFORMED CONSENT
World Health Organization (WHO), defines informed consent as a process by which a patient voluntarily confirms willingness to undergo a particular medical intervention, after having been informed of all the risks, benefits, alternatives, and consequences associated with it.

A valid informed consent requires:
Disclosure – providing information about the patient’s condition, purposed procedure, benefits, risks, potential complications, alternatives and consequences of refusing procedure.

Understanding - the patient must understand the information provided.

Voluntariness - the decision must be made freely without force, pressure, or manipulation.

Competence - the patient must be mentally capable and legally competent to make decision.

Consent – only after receiving and understanding this information can a patient make a truly informed decision verbally, in writing or impliedly depending on the situation.

CONSENT
According to Beauchamp and Childress (2019), consent is an autonomous authorization of an intervention by individual patients. Indicating a patient’s voluntary agreement to a proposed examination, treatment, or procedure.

A patient who signs a consent form without understanding has given consent, but not necessarily informed consent. A signature may serve as evidence of consent, but understanding is evidence of informed consent.

CHOICE-CENTRED CARE
Choice-centred is a healthcare approach that ensures patients actively participate in decisions regarding their treatment, with healthcare choices guided by the patients values, preferences, and informed decisions (World Health Organization, 2016).

It requires healthcare providers to:
Provide accurate information.
Encourage questions.
Address patient concerns.
Respect cultural and religious beliefs.
Support patients in making informed choices.

Choice-centred care recognizes patients as active participants rather than passive recipients of healthcare. The goal is not merely to obtain permission for treatment but to facilitate informed participation in healthcare decisions.

THE LEGAL AND PROFESSIONAL FRAMEWORK IN GHANA

Informed consent is supported by both law and professional ethics.

To begin with, the 1992 Constitution of Ghana protects the dignity and privacy of individuals. Article 15 protects human dignity, while Article 18 protects the right to privacy. Performing medical procedures without proper consent may violate this constitutional rights.

Additionally, the Public Health Act, 2012 (Act 851), through the Patient's Charter guarantees the patients the right to full information regarding their condition, treatment, possible risks, alternatives, receive healthcare in a manner that respects their dignity and have their concerns addressed appropriately.

The Data Protection Act also recognizes health information as sensitive personal data and emphasizes the rights of individuals to control information relating to them.

The Professional Code of Ethics of the Nursing and Midwifery Council of Ghana requires nurses and midwives to:

Respect patient autonomy.
Protect patient dignity.
Promote patient welfare.
Support informed decision-making.
Medical practitioners as well are expected to ensure that patients understand the implications of treatment before consent is obtained.

Respect for autonomy is one of the foundational principles of healthcare ethics. Ignoring patient choice undermines professionalism and erodes trust.

Despite these legal and ethical requirement, several barriers continue to affect informed consent practices in health facilities. These barriers include:

High patient workload.
Inadequate staffing
Limited consultation time.
Language barriers.
Low health literacy.
Emergency situations.
Inadequate communication skills.
Institutional cultures that prioritize signatures over understanding.

As a result, many patients consent to procedures without fully understanding the nature of the procedure, its risks, or available alternatives.

EVIDENCE FROM GHANAIAN SURGICAL PRACTICE

Research conducted at Korle Bu Teaching Hospital found significant deficiencies in the informed consent process. Many patients knew their diagnosis but could not explain the actual procedure performed on them after surgery. The study concluded that informed consent practices were unsatisfactory and required improvement.

Legal scholar E. Adwedaa further argues that although Ghana lacks extensive reported case law specifically on informed consent, Ghanaian courts are likely to adopt a patient-centred approach when addressing disputes involving consent and disclosure of information, emphasizing patient autonomy and adequate communication.

WHY PROPER INFORMED CONSENT MATTERS
Informed consent:
Protect patient’s right.
Promote patient autonomy.
Built trust between patient and healthcare providers.

Improves patient satisfaction.
Enhances treatment adherence.
Reduces complains and litigation.
Strengthens professional accountability.

Improves the quality of healthcare delivery.

Most importantly, it enables patients to participate meaningfully in decisions concerning their health.

Is a Signature Enough?
The critical question is not: - “Did the patient sign the form?"

The critical question is: - “Did the patient understand what they were signing?"

The signature is not always a defence. A signed consent form is evidence that consent was given, but it is not conclusive proof that informed consent was obtained.

A patient may later argue:
The procedure was not explained.
The risks were not disclosed.
They did not understand what they were singing.

They would have made a different decision if properly informed.

In such circumstances, healthcare providers may still face legal, professional, and ethical consequences despite having a signed consent form.

Whose duty is it to obtain informed consent?

The responsibility for obtaining informed consent should not be viewed merely as an administrative exercise. For major surgical procedures, informed consent is best obtained by the healthcare professional who will perform the procedure or by a suitable qualified member of the team with sufficient knowledge of the procedure, its risks, benefits, and alternatives. This ensure that patients receive accurate information and have the opportunity to ask question before making decisions regarding their care.

In many primary health facilities in Ghana, obtaining consent for surgical procedures is often delegated to nurses and midwives. While they play an important role in patient education and advocacy, they may not always have detailed knowledge of the procedure, its risks, possible complications, or available alternatives. As a result, the processes may focus on obtaining a patient’s signature rather than patient’s full understanding of the proposed intervention.

CONSEQUENCES OF FAILING TO OBTAIN PROPER INFORMED CONSENT

Failure to obtain informed consent may result in:

Legal liability.
Professional disciplinary action.
Ethical violations.
Loss of patient trust.
Difficulty defending adverse outcomes or complications.

RECOMMENDATIONS
To strengthen informed consent practices, healthcare institutions should:

Provide regular training on informed consent and communication skills.

Promote patient-centered and choice-centered care.

Strengthen documentation of consent discussions.

Ensure that informed consent is obtained by the healthcare professional performing the intervention or by a qualify team member who has adequate knowledge of the intervention.

Foster institutional cultures that prioritize patient understanding over obtaining signatures.

Beyond intuitional reforms, healthcare providers must:

View informed consent as a process, not a form.

Encourage question and prioritize patient understanding.

Respect patient autonomy and avoid coercion.

Delegated members should know their limit - avoid obtaining consent for procedures they do not fully understand.

Document consent discussion adequately.
CONCLUSION
Informed consent is far more than obtaining a signature on a form. It is a process of communication, education, understanding, and voluntary decision-making.

Whether performing a caesarean section, laparotomy, hernia repair, or any other surgical intervention, healthcare providers must ensure that patients understand their diagnosis, the proposed procedure, its benefits, risks, alternatives, and possible outcomes.

Healthcare providers must therefore move beyond obtaining signatures and embrace meaningful conversations that empower patients to make informed choices about their care.

When patients are informed, respected, and involved, healthcare becomes safer, more ethical, and more patient-centered.

By Gloria Boateng
(NURSE MANAGER, PMO, RESIDENT MID. GCNM WELL WOMAN CARE)

REFERENCES
Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Constitution of the Republic of Ghana, 1992.

Data Protection Act, 2012 (Act 843). Republic of Ghana.

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies press

International Council of Nurses. (2021). The ICN Code of Ethics for Nurses. Geneva, Switzerland: International Council of Nurses.

Nsaful, J., Umuago, R., Dedey, F., Adjei, F., & Clegg-Lamptey, J.N.A. (2022). An Audit Of The Informed Consent Process At The Surgical Department Of Korle Bu Teaching Hospital, Accra. Postgraduate Medical Journal of Ghana, 7(1), 24-28. https://doi.org/10.60014/pmjg.v7i1.138

Nursing and Midwifery Council of Ghana. (2018). Code of Professional Conduct and Ethics for Nurses and Midwives in Ghana. Accra, Ghana.

Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2021). Fundamentals of Nursing (11th ed.). St. Louis, MO: Elsevier.

Public Health Act, 2012 (Act 851). Republic of Ghana.

World Health Organization. (2023). Quality of care and patient rights. Geneva, Switzerland: World Health Organization.

World Health organization. (2016). Framework on integrated, people-centered health services. Geneva, Switzerland: World Health Organization.

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