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Journal of Postgraduate Medicine, Vol. 49, No. 3, July-Sept, 2003, pp. 287-288 Letter to Editor Informed Consent in Clinical Practice Sheth A
Plastic and Reconstructive Surgeon, 1/7, Ellora, Daftary
Road, Malad, Mumbai - 400 097 Code Number: jp03081 Sir, The article on assessment of subjects asked to participate in a proposed clinical trial by Gitanjali et al,[1] has, as a corollary, scientifically confirmed what I have found in non-research clinical practice. Most patients cannot be expected to truly understand an informed consent. As a practising Plastic Surgeon, I have to explain the implications of a proposed clinical manoeuvre (surgery, procedure, etc) to patients on a daily basis. A consent, informed true to the letter, whether oral or written, would be very difficult to get. Most patients do not (and cannot be expected to) understand the nuances of anesthesia and surgery and its long-term implications. Giving too much information (e.g. the uncommon complication associated with a clinical manoeuvre) has a grave potential of making the patient refuse it, even when told with the best of intentions! The key here is to understand human psychology. How can one expect an uninitiated mind to understand the 'fine print'? Indeed such information is often not understood even by doctors when they come as patients! And I don't suppose this quality of the mind would change either with gender or even with educational status in most patients, even across continents. The authors state (in context of clinical trials) that the quality of consent needs to be balanced against a backdrop of scientific, social and cultural needs. I find this applicable equally to the clinical setting. Often patients rely upon the clinician to do what is best for them and, many times, refuse to listen to detailed explanations of a proposed clinical course. It is a matter of trust and integrity. I think the spirit of consent is much more important than the 'fine print'. In many hospitals, a blanket consent is taken on a pre-printed form immediately on admission from the patient. It is left for the physician to fill in the relevant details later. Whether such a signed blanket consent would stand the scrutiny of the law or not, it is certainly against the true spirit of 'informed consent'. One must no doubt explain the relevant pros and cons of a procedure adequately. But one must often be prepared to make decisions for the patient, especially for the uninitiated. This must be done with the best interests of the patient in mind, and free of any extraneous influences. It is a bit like prescribing a particular drug to a patient. Several alternatives are often available for a particular condition, all of which have described advantages and disadvantages. But the decision to choose the right one rests with the physician and must be done in good faith. It would be ridiculous to discuss all the possibly applicable drugs with the patient and leave him to choose. Why, in spirit, it might even be a breach of the trust the patient has in the physician! Last month I took my car to the garage for servicing. The service person mildly recommended a fuel 'decarboniser' to be fitted to the engine. I tried to understand why this was necessary, to which he gave some esoteric reasons which I could not penetrate. I finally told him that I had faith in him and was willing to leave the decision to him in the good trust that he would install the gadget only if strictly warranted in the best interests of the car. The next day, when I went to collect the car, he told me that it would be alright to drive on for a further six months without the decarboniser. My trust in him has only increased. I have seen this happen to my patients too when they have left their clinical decisions to me. REFERENCES
Copyright 2003 - Journal of Postgraduate Medicine. Online full-text also available at http://www.jpgmonline.com/ |
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