| dc.description.abstract | Surgery today has become extremely complex to the
extent that the oath we took "To do no harm" needs
to be re-enforced in practically everything we do in
the management of patients. It is therefore necessary
and mandatory to document the process of informed
consent which is a freely shared decision between the
attending doctor and the patient, arrived at voluntarily
and without coercion(1-3). The prerequisite and
requirements which must precede the signing of this
legal document are many and have been necessitated
by ethical, social and medico legal dimensions cognisant
of the patient's legal rights and his right to information
and the surgeon's duty not only to do no harm but to
carry out the surgical procedure responsibly and
competently in order to achieve the expected and
promised outcome(1,3,4).
Many questions arise regarding the issues involved
in the pre-operative consent. First and foremost there
must be a crystal clear indication for the surgical
procedure which can only be arrived at after thorough
medical history, medical examination and thorough
investigations using all the available investigative
techniques(5-7). The surgeon must make sure that the
patient understands the nature of the disease, the
planned surgical intervention including the risks and
benefits and any other implications of the surgical
procedure. This must be done in a language the patient
understands, using interpreters if necessary, and all
reasonably foreseeable consequences of the decision to
carry out the surgery as well as decision not to carry
out surgery must be made clear to the patient. The
patient must also be made aware of any available
alternatives to the operation and the reasoning why the
operation is better than the alternative(4,5). It is the
duty of the surgeon/consultant who is planning to carry
out the operation to ensure that the process of obtaining
informed consent from the patient is carried out by him
or somebody of his level of training. This should be
the gold standard although in many teaching institutions
it is very often necessary to indicate that the procedure
might be carried out by an alternative surgeon. The
language used in the pre-operative consent form should
be simplified and easy for an ordinary person to
understand; even when dealing with the educated
people explanations of the details of the operation are
always mandatory.
The issues of litigation for medical malpractice
have become enormous and it is today unthinkable for
anybody who carries out surgical procedures to work
without insurance cover for malpractice. To strengthen
the understanding of the issues related to informed preoperative
consent, it is necessary in this day and age
for all medical schools to include in their curricula
forensic medicine and medical jurisprudence(5-7).
For consent to be informed, free and voluntary
as well as valid one has to consider cultural, social,
economic characteristics and literacy level of the
person giving that consent. Additional consent should
be obtained for any unexpected procedures that are
in the interest of the patient but not mentioned in the
standard hospital consent form. Special considerations
must be given for certain types of patients who may
not be able to legally fulfill the above mentioned
criteria(1,3,4,6):
• Consent for emergency treatment as a life saving
procedure for an unconscious patient or a patient
who due to severe physical distress may not be
able to communicate could be obtained from next
of kin, legal guardian or an independent senior
doctor.
• Consent for those under 18 years of age has to
be obtained from parents or legal guardians as
required by the law though the patient in most
of these cases should also be involved in the
discussions regarding the planned surgical
procedure and in this situation the doctor should
carefully counsel both the under age patient and
the parents.
• Consent for the elderly and other dependent
patients who traditionally might be under the care
of their sons and daughters should nevertheless be
obtained from the patients themselves unless he
or she is mentally incapacitated.
• Although the law makes no legal requirement to
inform or seek consent from husband for the wife
to have family planning services and vice-versa,
this is an issue which could bring conflict and legal
proceedings later on so it is wise for the doctor
to counsel couples together.
• In case of to give consent because of religious and
other reasons, the patient should be asked to sign a
disclaimer exonerating the doctor thus making the
refusal legally valid in case of future litigation. Public
health and legal consideration should override individual
religion and other beliefs. In case of persons under
18 years of age where the parents have refused to
sign consent on religious reasons, a resident magistrate
should be requested to sign a consent in which case
the state temporarily acts as a guardian for the underage
patient in need of surgery.
• For the mentally incompetent consent should be
provided by the next of kin or the legal guardian.
However the doctor should scrutinise each case in
detail and if necessary involve other members of
the family. All issues involved in the pre-operative consent for
surgery must be treated with utmost confidentiality
which means keeping all information received from the
patient confidential between the doctor and the patient
only or within members of the group of medical and
dental practice. Doctors must therefore understand and
acknowledge the special position in which they are
when they receive such information and always be
guided by ethical considerations | en |
