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Informed Consent

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 '''Informed consent''' is a term often used in medical environments in terms of 'patient's rights', but is seldom considered in the Orthodox Christian context of [[Gospel]]'s teaching on freedom and responsibility. In a book, Fr. [[John Breck]] has attempted to struggle with this issue. If you one were to do research on various bioethics issues, you one would most likely come across the term '''''informed consent''''' without there being a definition. It is one of those terms that people often assume everyone knows and understandunderstands. Yet, the sad reality being is that many people do not fully understand informed consent, especially understanding this within an Orthodox Christian context. In his book, ''The Sacred Gift of Life'', Fr. John Breck says, "matters of 'informed consent' and 'patient's rights' need to be evaluated in the light of the Gospel's teaching on freedom and responsibility."{{ref|1}} Our The first step will be to define informed consent and look briefly at the history, and then attempt to struggle with this the issue and what it means for Orthodox Christians, and hopefully come to some conclusion.
== Definition and history ==
What is informed consent? According to the ''Merriam-Webster's Medical Dictionary'', informed consent means "consent to surgery by a patient or to participation in a medical experiment by a subject after achieving an understanding of what is involved."{{ref|2}} Vital to this understanding is that the patient is supplied with the necessary facts but and is also fully capable to understand these facts—in other words, the patient needs to be mentally competent. This brings about legal ramifications which, of course, cloud the issue. When there is an absence of informed consent, ethical issues arise. Legally, certain procedures cannot be allowed to happen. If the patient is unable to give informed consent him- or herself, for example, in the case of a mentally incompetent patient or a child, then someone else is usually in a position to give consent.{{ref|3}}
The American Medical Association (AMA) defines informed consent slightly differently on their website, which has a banner saying "Helping Doctors Help Patients." They say, "Informed consent is more than simply getting a patient to sign a written consent form. It is a process of communication between a patient and physician that results in the patient's authorization or agreement to undergo a specific medical intervention."{{ref|4}} The AMA implores doctors on its website to focus on the communication process and also to document it as well. The AMA provides steps for proper communication with a patient, saying at the end of this list, "this communications process, or a variation thereof, is both an ethical obligation and a legal requirement spelled out in statutes and case law in all 50 states."{{ref|4}} According to the AMA, the legal ramifications of informed consent are recent, although the ethical guidelines have been understood for a long time. Informed consent as such only began appearing on the legal scene in the 1950s, before that it was lumped into the tort law category of battery. The emphasis placed on informed consent by the AMA is not only to protect the doctor legally, but also to protect the rights of the patients.{{ref|4}}
The National Cancer Institute describes two key elements for informed consent in the case of a clinical trial: the document and the process. The document is what the participant actually signs and lists a summary of the clinical trial—"including its purpose, the treatment procedures and schedule, potential risks and benefits, alternatives to participation, etc."{{ref|5}}—and also the rights of the participant. The National Cancer Institute says that the process of informed consent is ongoing and begins long before the trial begins and ends long after the trial is over. "Thus, informed consent is an ongoing, interactive process, rather than a one-time information session."{{ref|5}} I think that this This definition of informed consent is vital also to doctor-patient relationships as well and should not be limited to clinical trials.
The question of mental competency plays a major factor in this discussion. When is it okay for a doctor to question the mental competency of a patient and at what point does the family of the patient begin to question their mental competency? The University of Washington School of Medicine advises that a patient's mental competency is generally clear. In the cases when competency is unclear, they provide the following suggestions for assessment of the situation. Is the patient able to:
* understand his or her situation,
* understand the risks associated with the decision at hand, and
* communicate a decision based on that understanding?{{ref|6}}
If it is hard to assess the patient's competency, it is possible that the doctor will bring in a psychological consult. Often making the discernment of mental competency difficult is that some patients move in and out of competency based on medication and also disease. Doctors are encouraged, in these situations, to try and include the patient in the decision making process when the patient is lucid.{{ref|6}} It is important for the both the patient and the doctor to realize that if the patient refuses treatment, this is not necessarily an indication that the patient is mentally incompetent.{{ref|6}} The patient has the right to say no. I think that many legal struggles over mental competency stem from a differing opinion between the patient and the family as to the course of treatment.
To summarize a definition of informed consent let us look to a listing of the following elements which are necessary for a complete definition of informed consent:
# assessment of patient understanding; and
# the acceptance of the intervention by the patient.{{ref|6}}
This list provides a thorough and complete understanding for the patient and also for the doctor which will in turn provide for the best possible care. Informed consent is not needed in every situation. Generally, when surgery, anesthesia and other invasive procedures are involved, informed consent is needed. In situations where informed consent is not needed, it is still important for the lines of communication to be open and working between the patient and the doctor.{{ref|6}} The patient should not be afraid to ask questions and the doctor should not be annoyed with having to answer them.
== Orthodoxy and informed consent ==
For Orthodox Christians, what does all this mean? The issue seems to be clear cut, why all the fuss? According to Fr. Breck, "Some Christian ethicists today are suggesting that our unity in the Body of [[Christ ]] implies a mutual commitment that in certain cases transcends the need for informed consent and transforms the self-centered notion of personal 'rights' into the self-giving gesture of care offered to others in love.{{ref|1}} It seems that Fr. Breck is saying that there should not be a need for informed consent because we the patients should totally give ourselves themselves over to the doctor's care in love because, ultimately, we the patients are giving ourselves give themselves over to God because as the doctor is working within a Christian framework of caring through love, "ground[ing] personal relationships—between doctor and patient as between the medical team and the patient's family—in the ultimate relationship of love, trust and mutual devotion."{{ref|1}} Personally, I see this This seems as being the ultimate goal, what we need that is needed to strive for in this world, but I do not think that this is our not a current reality or something that we can is feasibly expect expected at this point. If this is the ultimate goal of Orthodox Christians, how do we continually work towards this goal within the world we live in? What is our response to informed consent within the secular framework as followers of Christ?
Unfortunately, not a lot has been written on this topic from an Orthodox standpoint.{{ref|7}} I would venture a guess that this is because there is not a lot to say. The issue appears to be pretty cut and dry. Informed consent is necessary for a proper understanding of a procedure being done and it is the responsibility of doctors to provide the needed information so that patients can understand what is happening. Following the guidelines listed above and others in the cited websites should ensure that the patient is informed. The real issues appear to be revolving around the question of the patient's mental competency. For Orthodox Christians, the answer to that question appears simple. The patient, the patient's family and the doctor all need to open themselves up to hear what God is saying in the situation. The patient's family needs to be sensitive to the needs of the patient and listen to what they are actually saying, not only what the family thinks they are saying. The doctor needs to also be sensitive to the needs of the patient and recognize the patient's concerns and fears. In addition, the doctor must be vigilant in providing the patient with all the possible options in an unbiased manner allowing the patient to make the decision. The patient needs to be open to listening to others, whether the doctor or the family. Inasmuch as they all need to listen to the patient, the patient also needs to listen to them. The patient, patient's family, and the medical team need to work within a framework of "the ultimate relationship of love, trust and mutual devotion shared by the three Persons of the Holy Trinity.{{ref|1}} This may mean the patient or their family needs to "let go," that the doctor needs to accept a difficult decision from the family, or the patient needs to trust the suggestions of the doctor even if this means a difficult surgery.
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