The Ethical Principles Underlying a Particular Aspect of Informed Consent - Case Study Example

Discuss the Ethical Principles Underlying a Particular Aspect of Informed Consent “Better a friendly refusal than an unwilling consent” -Spanish proverb- “qui tacet consentire videtur (He who keeps silent is assumed to consent; silence gives consent)” -Pope Boniface VIII- How different these 2 quotes are. Today, with the boom of the healthcare industry and also information technology for example the internet, gone are the days where healthcare personnel made decisions solely based on what they thought was best for the patients. Patients today want to have more information, they want to be given options and they want to be updated on everything from diagnosis to management. And when this is not fulfilled, patients become less compliant to management and may also opt to change the team which manages their health. One of the issues which are widespread today which nurses and other healthcare personnel should be well aware and is gaining the interest of the public/patients is the area of informed consent. Informed consent basically is the process where the healthcare personnel gives the patient a certain type of information which in this case usually means an investigation i.e. blood test, imaging; or management i.e. surgery, drugs. The healthcare personnel also at this time goes through the information given to make sure that the patient understands what was explained. The patient should also be informed of any side effects of the management choices. For example, with all surgeries come the risk of bleeding and anaesthesia itself has multiple risk factors. In addition to this, there are hardly any drugs which do not have any side effects. After this exchange of information takes place, the patient then decides whether he/she would want to accept the procedure or treatment and gives the consent. In some situations, a verbal consent is not enough and it would be good practice if the consent is written out. Thus, we can see that the concept of informed consent is for the patient to express what they feel and prefer. This opportunity to be in control of their own life makes them happier, more compliant to treatment and it is also protective of not only the patient but also the healthcare personnel’s ethical principles. Johnstone (1999) noted that within informed consent itself, there are many issues and it has been found that amongst nurses, some of the issues were patients who signed consent forms without any understanding of what they were told or were consenting to, nurses assuming wrongly that a doctor has already educated and explained to the patient about the procedure or treatment plan before the consent was obtained, consents from non-English speaking patients without the help of a translator, patients consenting to a procedure and treatment plan without knowing negative side effects and at times, there was no consent at all. (Johnstone, 1999 p. 2-8) Why this is so important is that many times, nurses are the ones who spend the most amount of time with the patient and they are also the people whom the patient and the patient’s family members see first. Thus, when a patient requests for information and the doctor is unavailable, nurses must be ready to take the right course of action. In certain circumstances, the nurse might even have to step in to prevent something which was done unjustly, for example the case where consent was not even taken before a procedure. The larger role played by the nurse has indirectly caused nurses to face moral dilemmas as they start to worry whether the decision made was correct and if it was not, the effects from that causes distress. (Johnstone, 1999, p. 1) Certain bioethical standards can be applied in this context. These standards include creating respect for the patient which indirectly also increases the health personnel’s respect at the same time. The patient is regarded as a client and consumer of the health care system, thus he/she would have the benefits and rights when it comes to health care. Everyone on the team which delivers the service, nurses included, should then maintain and advocate the best service which they can offer the patient or their “client” and to minimize certain issues which have given the healthcare profession a negative image. Informed consent itself is made up of a few aspects which include that the consent must be informed, the patient has to have the appropriate decision making capacity and the consent must be given freely, specific and current. Before we go on further about informed consent, there are certain ethical principles which underlie informed consent itself which would make it easier to explain why certain things can be done and vice versa. According to Gillon (1994), there are basically 4 ethical principles which can be used in a wide range of situations and also in different countries, cultures and healthcare systems and these principles are autonomy, non-maleficence, beneficence and justice. (Gillon 1994, p. 184) By using these principles, health care personnel can use them as a basis for making decisions which may need moral judgment. However, there are no strict rules about how these principles guide decisions. They merely offer moral considerations on common moral situations. (Massiomo, Wiley & Casari, 2004 p. 384) Autonomy means recognizing the rights of a person to determine what type of option he/she would take and respecting the choice that was taken. It also needs us to obtain the agreement from the person before something is done to and for that person. Thus, autonomy is sometimes referred to as respect for autonomy. The concept of autonomy applies in everyday life as we make informed decisions about matters both personal and non-personal. (Nessa & Malterud, 1998 p. 394) In healthcare, autonomy has allowed the patients to choose what they want best which would give them the best quality of life rather than what the healthcare personnel thinks it is best. For example, in a patient who has end stage breast cancer, she may rather not undergo any surgery or chemo/radiotherapy which was recommended but choose to only have analgesia so that she can spend the last 2 months of her life with her family, rather than to have a possibility of survival for 6 months but have to undergo pain, nausea, vomiting and hair loss as side effects of treatment. The healthcare profession has always been “paternalistic” traditionally meaning that patients would do as what they are told to do and sometimes, choices made are not always in the best interest of the patient and the rise of autonomy has decreased this form of practice. Respect for autonomy is one of the main pillars of informed consent. However, the down side to autonomy is that sometimes, autonomy goes against beneficence. This is when the patient does not agree with what the healthcare professional believes is in the best interest of the patient and the patient instead chooses a less beneficial and at times, even dangerous option. An extension of autonomy is proxy decision makers where the patient chooses another person whom they trust to make choices for them for example in cases of accidents or when they are too ill to even talk or function. In regards to how we as healthcare personnel can practice a respect for autonomy, we have to learn to communicate well not only with the patient but also with the other members of the health care team. We have to also listen to the patient and making sure that the information which we present to them is understandable and not filled with medical jargon. Sometimes, patients do not want a lot of information and thus, we have to respect this autonomy. Beneficence as mentioned above is basically the moral obligation to act in order to benefit others. In regards to medical ethics, this means that the medical professional makes the decisions which are the best for the patient but this has to be done without any self interest. Usually, when beneficence is discussed, non-maleficence is also discussed together. Basically, it can be also known in Latin as “primum non nocere” or “first, do no harm.” This means that ethically, health care personnel in should not harm the patient in any way and this covers areas of investigation and even treatment as some drugs may be more harmful to a patient rather than good and some more invasive investigations for example arteriography have significant risks. Thus, we have to make sure that before we can even provide help to others, we have to be well versed and trained in a particular field in order to offer the patient the best and to prevent any mistakes. Every patient should also be told about the risk of a particular procedure or drug versus the benefits and today, with the advancement and availability of clinical research, the things which we offer our patients should be backed up by reliable literature. The fourth ethical principle would be justice. This means that when we act, we should be acting on a basis of fair judgment. In the aspect of health care, we have to be careful about how we distribute our resources to meet the needs of everyone. In certain cases, we might have to distribute our resources to people who are high on the priority list but we still have to maximize the benefits. As health care depends on a country’s resources and tax payers’ money, we have to always justify these decisions. (Solomon, 2006 p. 735) Now, with knowledge of these ethical principles, we can now understand the aspects of informed consent better. Consent must be taken in a form and language which the patient best understands and this information should include the procedure/treatment itself, why this method was chosen, what this would do, the short and long term benefits and side effects, who is performing the procedure and if there are any alternatives. The patient should also have the appropriate decision making ability where not only can he/she understand what was being explained but also understand the nature of the decision and what would happen if a decision was not made. There are some exceptions to the ability to give consent and this includes children below certain ages, those with severe brain damage and those who have severe psychiatric illnesses. It cannot be assumed that anyone who has a psychiatric condition cannot give an informed consent as many of them actually are able to. Consent must also be voluntarily given so that the patient is not manipulated or forced by anyone and if there is time, the patient should be given adequate time to make the decision. The consent should also be specific and current. This means that it would be ethically wrong, for example to use the consent obtained for Drug X today for Drug Y tomorrow or a single consent for all antihypertensive drugs. With these in mind, the patient should always be told that they have the option of changing his/her mind at anytime. (Usher & Arthur, 1998 p. 695) In conclusion, we can see that not only the issue of informed consent but also many other aspects of nursing have a significant ethical component and it can be complicated not only by the process of giving out information but also by the complexities of the medical field. It is more than just giving out information as it also involves us having to use our own experiences, moral values and even compassion and empathy. (Johnstone 1999, p. 429) We too have to be updated on the legal, social, political and cultural aspects of this issue. Despite all these, we can do best by following the main ethical principles and strive to give the patient the best that we can. "Of all the patients' rights which might be claimed in a given health care context, none is perhaps more threatening to the power and authority of attending professionals (including nurses) than the patient's right to make informed choices about their care and treatment," -Megan-Jane Johnstone- References: 1. Gillon, R. (1994). Medical Ethics: Four principles plus attention to scope. BMJ 1994;309:184 (16 July). 2. Johnstone, M (1999). Bioethics a nursing perspective, 3rd edn, W. B. Saunders, Australia 3. Massiomo LM, Wiley TJ, Casari EF (2004), ‘From informed consent to shared consent: a developing process in paediatric oncology’, The Lancet Oncology 2004, vol. 5, pp. 384-387. 4. Nessa J, Malterud K. (1998), Tell me what’s wrong with me: a discourse analysis approach to the concept of patient autonomy, Journal of Medical Ethics, 24(6): 394- 402. 5. Solomon RC. (2006) Ethical issues in medical malpractice, Emerg Med Clin North Am. 2006 Aug;24(3):733-47. 6. Usher K, Arthur D (1998), ‘Process consent: a model for enhancing informed consent in mental health nursing’, Journal of Advanced Nursing, vol. 27, pp. 692-697. Read More