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Consent ... but not as we know it.

View profile for Richard Wood
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As Britain is a mature, stable, democracy millions of us place our trust in our national organisations and institutions every day.

Almost unquestioningly we send our toddlers to nurseries, step on international flights, ride in taxis and dine out because we have a degree of trust, or blind faith, in our fellow citizens.

We are vaguely aware of the risks in these activities but we make a judgment and proceed because modern life has a hectic pace and not everything can be double-checked.

But should patients be expected to undergo a common operation for heart disease without the clearest possible information being laid before them? And, before consenting to a regular screening procedure, such as a colonoscopy, which carry small risks of significant harm, should patients be warned of the benefits and possible adverse consequences?

Debate has been stimulated by a recent medical journal article in which London consultant cardiologist, Dr Aseem Malhotra, said that people with stable angina should be told that angioplasty may relieve some symptoms but will not reduce the risk of death or a heart attack and that this should be made clear on patients consent forms.

People with angina, which is regarded as stable if it is triggered by a known cause such as exercise, suffer pain because of restricted blood supply to the heart. Angioplasty uses a tube called a stent to open up a narrowed artery and helps ensure an adequate blood supply and reduce the pain.

For people who have had a heart attack angioplasty can be a lifesaver. It may also be provided for patients before their condition becomes unstable to relieve symptoms of chest pain.

In the Journal of the American Medical Association Internal Medicine, Dr Amphora said the 30,000 angioplasty patients in the UK each year were rarely told the operation would not help prevent heart attacks or prolong life.

He also quotes a US study which found that 88% of patients having angioplasty thought it would prevent a heart attack and says that he believes the UK figure would be similar.

Another of his concerns is that "payment by activity" for hospitals in England may incentivise such procedures and there may also be some unnecessary treatment carried out by the private sector.

In view of all this, he argues that it should be mandatory to secure patient’s consent to reduce any harm which may be caused by the operations and curb unnecessary costs. He says: “It is imperative to provide patients with all the information before subjecting them to a procedure that still carries a 1% risk of heart attack, stroke or death."

Even though the British Cardiovascular Intervention Society says there is no evidence in the UK that patients have been treated inappropriately and that changing the consent form would not be the best way of ensuring patients understood their treatment, the chairman of the Academy of Medical Royal Colleges, prof Terence Stephenson, has backed the call.

He said: "This is an example of a legitimate debate of appropriate or inappropriate use of clinical procedures or interventions and is an issue of increasing importance to the medical profession. It is primarily about providing appropriate good quality care but is particularly important when resources are limited."

 In our field of providing legal advice to patients suffering as a consequence of medical negligence, issues around informed consent are becoming more prevalent. Clients frequently feel that they haven't been adequately advised, in a fair and balanced way, of the risks and potential benefits of proposed procedures.

It is clear that, in spite of the many important judgments we make in a single day, some doctors and consultants often still adopt a paternalistic approach recommending procedures without properly engaging the patient so they can make an informed decision about their health and appropriate treatment.

As medical treatment moves towards implementing large-scale national screening programmes for conditions such as breast cancer and bowel cancer, which, by its very nature, is less personal, should there be wider debate on how big a role proper discussion and informed consent should play?