Issue 18 / 16 May 2016

IT’S hard to argue with the idea that informed consent is a good thing.

Surely it has to be better than the “doctor knows best” attitude that could infect medical practice in the past.

But can it sometimes be a cop out?

Researchers writing in the Journal of Medical Ethics argue that the general reliance on informed choice to resolve ethical problems in clinical treatment is a “fake fix”.

“Rightly, many doctors now reject paternalism if the patient does not specifically ask for it,” they write.

“However, the rise of preventive medicine, the transformation of risk factors and common life experiences into diseases, and the lowering of diagnostic thresholds have changed the ethical premises of informed choice by pushing responsibility on to often ill prepared citizens.”

Mass screening programs, for example, force people with no symptoms of disease to make a choice about an examination they did not request.

In an ideal situation, they will be offered balanced information on the risks and benefits of screening to help them make that choice.

“But who considers the ethics of presenting such a complex choice in the first place?” these authors ask.

That’s a particularly vexed question, given that we know, as I’ve written before, that patients tend to underestimate the risks of screening while overestimating the benefits.

On top of that, these authors suggest that the information provided about screening programs is not always balanced, “giving weight to the potential benefits and downplaying the risk of harm from false positive results and overdiagnosis”.

It’s not just screening programs that pose a challenge to the principle of informed consent.

The authors describe a hypothetical case study of a middle-aged man who visits his GP with a mild headache, dizziness and “a feeling of strong heartbeats”.

Among other things, the doctor takes his blood pressure and finds it moderately raised.

Although this is unlikely to have caused the symptoms, “many doctors will feel pressure from guidelines or quality measures to proceed to medical action”, the authors write.

After assessment of his cardiovascular risk, the patient is given information on the potential harms and benefits of treatment for hypertension and hyperlipidaemia and is encouraged to make an informed choice about initiating “potentially lifelong preventive drugs”.

The GP also diagnoses the patient with moderate depression and a similar conversation ensues about the risks and benefits of treatment with selective serotonin reuptake inhibitors, perhaps combined with cognitive therapy.

“As doctors, we are taught to feel proud of ourselves in this situation,” the authors write. “We took the time to make sure that the person was informed and to explore personal preferences.

“However, we see major ethical problems arising from this approach, which in this case might smoothly transform a person in temporary distress into a lifelong patient, or at least someone who for the rest of their life has ‘previous, medically treated depression’.”

One of the difficulties, I suspect, is that when doctors raise the possibility of a certain course of treatment, many patients hear that as a recommendation, even if the doctor is trying to remain scrupulously neutral.

After all, why would a doctor tell us about this drug, or surgical procedure, or scan, if they didn’t think it was a good idea?

And how many patients are truly equipped to assess the risks and benefits of, say, prostate-specific antigen testing? Let’s face it, that’s not an easy task even for those with the benefit of a medical degree and many years of clinical practice.

The issue of informed choice is becoming even more complex, these authors suggest, as diagnostic thresholds continue to head lower in many conditions, leading to more people being identified as having a clinically significant disease.

Recent controversies have questioned lowered thresholds for diagnosis and risk factors across a range of conditions, including osteoporosis, chronic renal disease, hypertension and gestational diabetes, they write.

That’s an ever-growing number of people being labelled as ill and having to make informed decisions on what to do about it.

Nobody is arguing for a return to paternalism, but perhaps we need to think more about what informed choice really means and how it can best be incorporated into medical care.

Jane McCredie is a Sydney-based science and medical journalist.

3 thoughts on “Can informed choice be a cop out?

  1. Linda Beaver says:

    Your article is of particular interest to me as I investgate the health literacy issues in our adult population and the way in which that very element would impact on the process of informed consent.

    Having the doctor advise a course of treatment, medication, investigation or surgery is indeed a traditional role and previously one of acceptance by the patient. The increasing responsibility for  a shared decision making process being placed on the consumer necessitates greater consultation and discussion and potentially, access to resourses to enable patient investigation and consideration, away from the consulting room.

    As the ABS statistics published in 2006 state that one in two adults (59%) has a less than average ability to understand their health issues and management, the ability for the person to fully grasp the implications or recommendations is a further complication. When I hear or read that the situation was expalined,  my immediate reaction is to question how it was explained, was it understood and how was the content of the conversation reinforced to enable the recipient an opportunity to take away support material to consider and formulate questions to help in the decision making process. 

    Informed choice and informed consent are huge issues that cross all levels of health care and must be highlighted as being inextricably linked to the recognition of health literacy capacity within our community

    Linda Beaver

     

     

  2. Lynette Reece says:

    This article is very important. as a surgeon I explain operations and mangement strategies all day. I a calm environment I know the patients probably understand some of what we talk about and there is time to ask questions and come back for further discussion. Even then I know they often rely on my judgement and cannot understand all the nuances of care that have taken me 30yrs of medical training to understand. In an emergency situation the time is not available and the stressa lot higher and the informed consent much less.

    Paternalistic medicine is not good but expecting the patient to make the decision is not always possible either.

  3. Joe Kosterich says:

    What you are talking about here is the medicalization of life which comes from lowering thresholds and wideneing diagnostic critirea. This is a majpr problem.

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