TRUE PROFESSIONAL’S AND DOCTRINE OF INFORMED CONSENT IN SHARED DECISION MAKING

Author: Dr. Shoeb Ahmed Ilyas BDS, MPH, EMSRHS, M.Phil (HHSM),

MHRM, MHA, MS (PSY), MS(BIOTECH), FHTA. Health Care Quality Management Consultant

Ruby Med Plus, Telangana State, India

Abstract The clinical practices around informed consent in healthcare settings have undergone a

revolution for the better over recent decades. However the way doctor obtains informed

consent still remains problematic. A number of factors have contributed to the continued

dominance of the traditional dentist-patient imbalance of power, but, demands for more

patient autonomy are increasing. The reasons for this ambiguity are varied. The complexity

of communication in clinical encounter, the role of autonomy and the changing nature of the

doctor-patient relationship, have also contributed to this uncertainty which still remains in

many clinical settings. The uncertainty is partly due to the conceptual dullness of important

core concepts.

Introduction Many health care practices face difficulties of implementing the doctrine of informed consent

and fail to protect patients’ rights and dignity. This happens because of doctor’s cynicism

about the existence of the right to informed consent, patients' reluctance to make decisions,

the existing busy health care centres, and the absence of clear guidelines about implementing

informed consent. Shared decision-making is increasingly advocated in health care but, is not

widely adopted in clinical practice may be due to professional resistance, lack of skills, lack

of time, and barriers. The traditional concept of the doctor-patient relationship places the

patient in a passive, compliant role. The patient's only obligation is to seek competent help

and cooperate with the doctor. A number of factors have contributed to the continued

dominance of the traditional doctor-patient imbalance of power, but, demands for more

patient autonomy are increasing.

Doctors ought to make all things considered value judgments about what is best for their

patients. If doctors are properly to respect patient autonomy and to function as moral agents,

they must make evaluations of what their patients should do. Still it is not clear that why

doctors avoid making value judgments about what patients should do or what it is best for

them to do. Sometimes these value judgments are difficult to spot, because rarely peer group

evaluates professional work of doctors working in private settings, hence, difficult to controls

the manner in which professional work is accomplished in clinical settings. The major issue

for evaluating the autonomy of doctors is not whether they control diplomacy, but whether

they control the goals that the patient seeks.

Doctrine of Informed Consent The doctrine of informed consent, defined as respect for autonomy, is the tool used to govern

the relationship between doctors and patients. Its framework relies on rights and duties that

mark these relationships. The main purpose of informed consent is to promote human rights

and dignity and it is the requirement, which favours patient to participate in clinical decision

making. In health care, esteem for autonomy obligates doctors to involve their patients "to

disclose information, to probe for and insure understanding and voluntariness, and to foster

adequate decision makingi. The argument for the development of informed consent is based

on the assumption that the professional doctor exercises control over the professional-client

decision making process, and that normal rules of contracting are not sufficient to protect the

patient's rights.

Informed consent places obligations on doctor to supply information to patients so that they

can form their own views and make decisions concerning the nature of their health care.

Informed consent also gives power to patients to implement their decisions, a power or right

to reject medical treatment.

Informed consent is inappropriate for all "true" professionals, because professionals say they,

adhere to a set of internalized norms that include commitment to a patient best interests and

quality services, as the treating doctor has the major role in empowering patients. By

questioning there professional motives, informed consent may decrease the likelihood of

these internalized norms developing because they will no longer be part of the professional's

self- definition. To be autonomous, one must be informed. For example, a doctor, in

attempting to convince his patient that he is wrong in choosing the proposed alternate

treatment may threaten patient autonomy. To consider the choice of patient for given

treatment, patient must be informed of the facts, but also consider its valueii.

Autonomy The principle of respect for autonomy is a prima facie principle. Autonomy has been the

essential value of medical ethics and is "the single most important value for informed

consentiii

.” Professional autonomy is defined as control over how work is performed and

evaluated. This autonomy is thought necessary because the services delivered by the

professional involve the application of specialized knowledge. The patients lack specialized

clinical knowledge and therefore they cannot evaluate the services nor determine how they

should be performed. The professional is required to communicate some of his or her

specialized knowledge with the patient to facilitate in the decision making process and in

determining how the professional work is to be performed.

Philosophers sometimes, pigeonhole the principle of respect for autonomy as a positive or

negative obligation. As a negative obligation, this principle states that "Autonomous action

should not be subjected to controlling constraints by others.” Positive obligations, the

principle of respect for autonomy requires “respectful treatment in disclosing information and

fostering autonomous decision makingiv

”.

The distinctiveness of an autonomous person includes capacities of self-determination such

as understanding, deciding, reasoning, and independent choice. A self-directed action

requires only "a substantial degree of understanding and freedom from constraint, not a full

understanding or a complete absence of influence. The principle of beneficence requires that

moral agents take positive steps to help others, not merely to avoid harming others as the

principle of non-malfeasance requiresv.

To insure that patients' autonomy and free choice are a part of every doctor-patient

interaction, doctors and patients need actively to promote them as values that are absolutely

indispensable in doctors' offices, clinics, and hospitals. The right to self-determination refers

to “the right of individuals to make their own decisions without interference from othersvi

.”

The Nurnberg code states four characteristics of an informed consent that are required for the

consent to be adequate: it has to be informed, competent, voluntary and comprehending. An

informed consent will only be regarded as morally acceptable if it is genuinely voluntary.

One of the main threats to autonomy, which makes informed consent in health care a

necessity, is people's illness, or “wounded humanity,” as some call itvii

. Brody transparent

model proposes following aspects: First, doctors are to arrange only “the typical patient-

management thought process” and convey it to patients in a language they can understand.

Second, what is involved and when the process is sufficiently completed. Third, doctors

avoid hyper-informing the patients about the proposed medical treatment or about their

medical condition. Instead they offer a specific communication of the essential components

and pertinent issuesviii

.

Decision Making In decision making, competence (defined as "the ability to perform a task") and autonomous

decision making, as well as the validity of informed consent, are closely connected. This is

important because incompetent individuals cannot give valid informed consentix

.Like in any

clinical treatment disclosure is a duty of doctors because their expertise and commitment are

to the welfare of the patient. Consequently, the courts reckon only expert testimony from

members of the profession as evidence that someone has violated a patient's right to

informationx. The purpose of disclosure is to make convinced that patients understand the

relevant information regarding their medical conditions and thus give valid consent. Another

squabble is that some patients have very limited knowledge bases, which makes

communication about new or unfamiliar procedures extremely difficult, particularly if new

information includes new concepts or cognitive constructsxi

.

Disclosure and Manipulation:

Disclosure generally include the following elements: an explanation of the purpose of the

clinical treatment; a description of the treatment; a description of the risks and potential

benefits to patient from proposed treatment; a description of alternatives available to patient

should they choose not to take treatment; a description of confidentiality protections; and,

information on whom they may contact with questions. Manipulation refers to several types

of influence that include all intentional and successful influence of others by non-coercively

modifying the actual available alternatives or by non-persuasively changing other people's’

perceptions of those alternativesxii

. Mostly doctors and patients who often do not share the

same values jeopardised the therapeutic nature of the patient-doctor relationship. On the other

hand, promoting patient autonomy does not mean that doctor expertise should be ignored or

disregarded.

Conclusion Informed consent standard must encourage open communication, shares input and

responsibility between doctor and patient.

References i Beauchamp, Principles 64.

ii Beauchamp, Principles 284.

iii Faden, History 18.

iv Beauchamp, Principles 64.

v Beauchamp, Principles 165.

vi Jay Katz, The Silent World of Doctor and Patient (New York: Free Press, 1984) 105.

vii Wear, Consent 42; Edmund D. Pellegrino, "Toward a Reconstruction of Medical Morality: The Primacy of

the act of Profession and the Fact of Illness," Journal of Medicine and Philosophy 4 (1979): 35.

viii Brody, "Transparency" 5-9.

ix Beauchamp, Principles 69.

x “Necessity and Sufficiency of Expert Evidence and Extent of Physician’s Duty to Inform Patient of Risks of

Proposed Treatment.” American Law Reports 3d, 52 (1977): 1084. “Physician’s duty to Inform of risks.”

xi Beauchamp, Principles 89.

xii Faden, History 261