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.
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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.