Column

Come clean and be counted

Patient consent is a valuable human right, and it should be extended to cover hospital closures, says David Seedhouse

Before Susan has her operation she has to sign a form declaring that she understands the nature of the proposed treatment, and that she consents to it. Her signature on the form offers some legal protection to her doctors if things go wrong as a result of surgery. But consent is much more than a legal requirement, it is a major moral principle.

Although the British people do not have the benefit of a Bill of Rights certain principles are widely held. In healthcare there is a particularly strong belief that informed consent is almost always necessary before anything is done to a person. We are rightly terrified by the prospect of forcible treatment. We deliberate carefully, and often publicly, before endorsing — or refusing — sterilisation of the seriously mentally handicapped, or brain surgery on those with devastating mental problems.

To give an informed consent to surgery, not only must Susan sign a consent form but her consent must be real. Susan must know what the operation is for, what will take place during it, what the risks are, and what the alternatives are: without understanding and choice talk of consent is meaningless.

So far so good for those who are currently keen to promote individual choice: there seems nothing objectionable about informed consent, on the contrary it appears desirable.

But the principle that consent is essential in health care interventions has not been taken nearly far enough. There is a notable inability, or reluctance, to draw out the wider conclusions that follow from the premise that informed consent is vital. This block exists not only in he minds of health ministers and their staff, but hinders healthcare planning in general. The mental block can be seen clearly by asking this question: If it is necessary that Susan understands the nature of her operation before it can be carried out, then why is her consent not sought before her local hospital decides to opt out of the NHS? In both cases decisions will be made which affect her well-being. Why must she have a say in one while she is not consulted at all about the other? And why was Susan’s consent not sought before the decision was made to close down the hospital which cared for Johnny, her mentally handicapped brother?

One answer is that there are always many considerations to balance: economic pressures, therapeutic possibilities, political sensitivities, regional differences — all play a part in the complex picture of health care provision. But those with power in healthcare cannot fudge forever, dancing from one transient belief to the next fashionable theory. Healthcare hasn’t just happened. Health work came into being because human beings value caring for others.

Healthcare is almost universally believed to be important. And this means that health work is not an arbitrary fashion, but most be inspired by basic principles, even if they are not perceived, and even if they are deliberately ignored. If informed consent is truly a fundamental principle of healthcare, then stated opinions based on understanding of the choices must be sought from all involved whenever decisions are made.

There is no difference in principle between a doctor deciding to go ahead with Susan’s operation and a manager deciding to shut down the ward she is to stay on. Both decisions may be critical for Susan yet she has a say in only one. Those who argue for the principle of choice in healthcare should examine their logic. If they are not prepared to accept the democratic conclusions to which they must be drawn, then will they please stand up — come clean — and be counted?